Objective To explore the effect of preoperative hypothyroidism on postoperative cognition dysfunction (POCD) in elderly patients after on-pump cardiac surgery. Methods Patients who were no younger than 50 years and scheduled to have on-pump cardiac surgeries were selected in West China Hospital from March 2016 to December 2017. Based on hormone levels, patients were divided into two groups: a hypo group (hypothyroidism group, thyroid stimulating hormone (TSH) >4.2 mU/L or free triiodothyronine 3 (FT3) <3.60 pmol/L or FT4 <12.0 pmol/L) and an eu group (euthyroidism group, normal TSH, FT3 and FT4). The mini-mental state examination (MMSE) test and a battery of neuropsychological tests were used by a fixed researcher to assess cognitive function on 1 day before operation and 7 days after operation. Primer outcome was the incidence of POCD. Secondary outcomes were the incidence of cognitive degradation, scores or time cost in every aspect of cognitive function. Results No matter cognitive function was assessed by MMSE or a battery of neuropsychological tests, the incidence of POCD in the hypo group was higher than that of the eu group. The statistical significance existed when using MMSE (55.56% vs. 26.67%, P=0.014) but was absent when using a battery of neuropsychological tests (55.56% vs. 44.44%, P=0.361). The incidence of cognitive deterioration in the hypo group was higher than that in the eu group in verbal fluency test (48.15% vs. 20.00%, P=0.012). The cognitive deterioration incidence between the hypo group and the eu group was not statistically different in the other aspects of cognitive function. There was no statistical difference about scores or time cost between the hypo group and the eu group in all the aspects of cognitive function before surgery. After surgery, the scores between the hypo group and the eu group was statistically different in verbal fluency test (26.26±6.55 vs. 30.23±8.00, P=0.023) while was not statistically significant in other aspects of cognitive function. Conclusion The incidence of POCD is high in the elderly patients complicated with hypothyroidism after on-pump cardiac surgery and words reserve, fluency, and classification of cognitive function are significantly impacted by hypothyroidism over than other domains, which indicates hypothyroidism may have close relationship with POCD in this kind of patients.
Objective Historically, perioperative hemoglobin monitoring has relied on calculated saturation, using blood gas devices that measure plasma hematocrit (Hct). Co-oximetry, which measures total hemoglobin (tHb), yields a more comprehensive assessment of hemodilution. The purpose of this study was to examine the association of tHb measurement by co-oximetry and Hct, using conductivity with red blood cell (RBC) transfusion, length of stay (LOS) and inpatient costs in patients having major cardiac surgery. Methods A retrospective study was conducted on patients who underwent coronary artery bypass graft (CABG) and/or valve replacement (VR) procedures from January 2014 to June 2016, using MedAssets discharge data. The patient population was sub-divided by the measurement modality (tHb and Hct), using detailed billing records and Current Procedural Terminology coding. Cost was calculated using hospital-specific cost-to-charge ratios. Multivariable logistic regression was performed to identify significant drivers of RBC transfusion and resource utilization. Results The study population included 18 169 cardiovascular surgery patients. Hct-monitored patients accounted for 66% of the population and were more likely to have dual CABG and VR procedures (10.4% vs. 8.9%, P=0.006 9). After controlling for patient and hospital characteristics, as well as patient comorbidities, Hct-monitored patients had significantly higher RBC transfusion risk (OR=1.26, 95%CI 1.15-1.38,P<0.000 1), longer LOS (IRR=1.08, P<0.000 1) and higher costs (IRR=1.15, P<0.000 1) than tHb-monitored patients. RBC transfusions were a significant driver of LOS (IRR=1.25, P<0.000 1) and cost (IRR=1.22, P<0.000 1). Conclusion tHb monitoring during cardiovascular surgery could offer a significant reduction in RBC transfusion, length of stay and hospital cost compared to Hct monitoring.
ObjectiveTo investigate the application of ascending aorta cannulation and brachiocephalic trunk cannulation in acute type A aortic dissection.MethodsWe screened 183 patients with acute type A aortic dissection from January 2017 to January 2020 in our hospital. They were divided into 2 groups according to the cannulation strategy: ascending aorta cannulation and brachiocephalic trunk cannulation (a DAC group, n=42, 33 males and 9 females with a median age of 50 years) and the single axillary artery cannulation (an AAC group, n=141, 116 males and 25 females with a median age of 51 years). The general clinical data, intraoperative data and early postoperative results of the two groups before and after matching with propensity scores were compared.ResultsBefore propensity-score matching, the operation time, cardiopulmonary bypass time, aortic occlusion time and ICU stay in the DAC group were all shorter than those in the AAC group (P<0.05). The early postoperative mortality, and rates of brain complications, renal failure and pulmonary complications in the DAC group were significantly lower than those in the AAC group. After propensity-score matching, the operation time in the DAC group was significantly shorter than that in the AAC group (P<0.05). The early postoperative mortality, and rates of brain complications and pulmonary complications in the DAC group were significantly lower than those in the AAC group.ConclusionAscending aorta cannulation and brachiocephalic trunk cannulation can provide a safe, fast and effective method of establishing cardiopulmonary bypass for some acute type A aortic dissection patients, and significantly shorten the operation time without increasing surgical complications.
ObjectiveTo compare the impact of cardiopulmonary coronary artery bypass grafting (CCABG) and off-pump coronary artery bypass grafting (OPCAB) on the incidence of postoperative acute kidney injury (AKI) in the elderly patients (age≥70 years). MethodsThe clinical data of the isolated coronary artery bypass grafting (CABG) patients (age≥70 years) in our center from January 1, 2009 to December 31, 2017 were collected and retrospectively analyzed. The patients with long-term dialysis, missing serum creatinine data, emergent surgery or CABG combined with other cardiac procedures were excluded. Totally there were 3 346 patients undergoing isolated CABG, and finally 1 405 patients (age≥70 years) entered the study. The elderly patients were divided into a CCABG group (956 patients) and an OPCAB group (449 patients) according to whether they used extracorporeal circulation. The incidence and severity of postoperative AKI in the two groups were compared. Results AKI occurred in 306 (32.0%) patients in the CCABG group and in 138 (30.7%) patients in the OPCAB group with no significant difference (P=0.677). According to the acute kidney injury network (AKIN) criteria, the severity of AKI in the CCABG vs. OPCAB was as followings, AKIN stage Ⅰ: 211 (22.1%) vs. 93 (20.7%); AKIN stage Ⅱ: 51 (5.3%) vs. 23 (5.1%); and AKIN stage Ⅲ: 44 (4.6%) vs. 22 (4.9%) with no significant difference (P=0.579, 1.000 and 0.788). There was no significant difference in the new onset of dialysis between the CCABG group (31 patients, 3.2%) and the OPCAB group (10 patients, 2.2%, P=0.376). Conclusion AKI is a common complication in the elderly CABG patients, with AKIN stage Ⅰ accounting for the most proportion, but rate of postoperative renal replacement therapy is low. Compared with CCABG, OPCAB is not associated with a significantly low rate or reduced severity of AKI in elderly patients.
Objective To investigate the risk factors for arrhythmia after robotic cardiac surgery. Methods The data of the patients who underwent robotic cardiac surgery under cardiopulmonary bypass (CPB) from July 2016 to June 2022 in Daping Hospital of Army Medical University were retrospectively analyzed. According to whether arrhythmia occurred after operation, the patients were divided into an arrhythmia group and a non-arrhythmia group. Univariate analysis and multivariate logistic analysis were used to screen the risk factors for arrhythmia after robotic cardiac surgery. ResultsA total of 146 patients were enrolled, including 55 males and 91 females, with an average age of 43.03±13.11 years. There were 23 patients in the arrhythmia group and 123 patients in the non-arrhythmia group. One (0.49%) patient died in the hospital. Univariate analysis suggested that age, body weight, body mass index (BMI), diabetes, New York Heart Association (NYHA) classification, left atrial anteroposterior diameter, left ventricular anteroposterior diameter, right ventricular anteroposterior diameter, total bilirubin, direct bilirubin, uric acid, red blood cell width, operation time, CPB time, aortic cross-clamping time, and operation type were associated with postoperative arrhythmia (P<0.05). Multivariate binary logistic regression analysis suggested that direct bilirubin (OR=1.334, 95%CI 1.003-1.774, P=0.048) and aortic cross-clamping time (OR=1.018, 95%CI 1.005-1.031, P=0.008) were independent risk factors for arrhythmia after robotic cardiac surgery. In the arrhythmia group, postoperative tracheal intubation time (P<0.001), intensive care unit stay (P<0.001) and postoperative hospital stay (P<0.001) were significantly prolonged, and postoperative high-dose blood transfusion events were significantly increased (P=0.002). Conclusion Preoperative direct bilirubin level and aortic cross-clamping time are independent risk factors for arrhythmia after robotic cardiac surgery. Postoperative tracheal intubation time, intensive care unit stay, and postoperative hospital stay are significantly prolonged in patients with postoperative arrhythmia, and postoperative high-dose blood transfusion events are significantly increased.
Objective To summarize the clinical experience of cardiac surgery during pregnancy in a single center for the past 11 years. MethodsThe clinical data of 26 pregnant patients (mean age 28.6±4.9 years) complicated with heart diseases who underwent non-emergency cardiac surgery with cardiopulmonary bypass from 2010 to 2020 in Guangdong Provincial People's Hospital were retrospectively analyzed. Patients were divided into two groups according to the gestational age at the time of surgery: a change group (gestational age<21 weeks) and a stable group (gestational age≥21 weeks). The hospitalization data and follow-up data of the patients were collected. ResultsMean gestational age at surgery was 23.4±4.2 weeks. Eleven patients had congenital heart diseases and fifteen had valvular heart diseases. Meanpostoperative ICU stay was 2.5±2.4 d, and mean total hospital stay was 22.5±9.5 d. There were 5 postoperative fetal losses. There was no maternal death during follow-up. No statistical difference in the maternal postoperative outcomes between two groups. ConclusionThe number of patients undergoing cardiac surgery during pregnancy is increasing. The maternal mortality rate is low and the prognosis is good, but the fetal loss remains concern. Cardiac surgery performed before or after the establishment of cardiopulmonary adjustment in pregnancy does not change the maternal postoperative outcomes.
Cardiac surgery has always been one of the major specialties in the development of “fast track surgery”. Enhanced recovery after surgery (ERAS) has become a widespread topic in perioperative medicine over the past 20 years, and it results in substantial improvements in clinical outcomes and cost savings. This frontier concept has also been increasingly applied and promoted in cardiac surgery. However, compared with other surgical fields, current studies regarding cardiac surgery are still limited in quantity, scale and universality of application. Therefore, this review focuses on current concept and progress of ERAS in adult patients undergoing cardiac surgery with cardiopulmonary bypass, aiming to provide guidance for the establishment of a better framework.
Objective To explore the clinical effect of hemoperfusion (HP) in cardiopulmonary bypass (CPB) on postoperative inflammation in patients with acute type A aortic dissection (AAD). MethodsAdult patients with AAD who planned to undergo total aortic arch replacement from July 2020 to November 2021 were continuously enrolled in our heart center. Patients were randomly divided into a HP group and a control (C) group. The HP group was treated with disposable HP device (Model: HA380, Zhuhai Jafron Biomedical, China) in CPB during the operation. ResultsFinally, 70 patients were included with 59 males and 11 females at an age range of 21-67 years. There were 35 patients in both groups. In this study, 3 patients died within 3 days after surgery, 2 in the HP group and 1 in the C group, and the remaining 67 patients survived to the follow-up end point (30 days after surgery). There was no statistical difference in preoperative baseline data, operative method, CPB time, block time, or other intraoperative data between the two groups. Blood product dosage, intubation time, hospital stays, and hospitalization expenses were similar between the two groups. Intraoperative hemoglobin (82.70±2.31 g/L vs. 82.50±1.75 g/L, P=0.954] and platelet concentration [(77.87±7.99)×109/L vs. (89.17±9.99)×109/L, P=0.384] were not statistically different between the HP group and C group. In the HP group, postoperative (ICU-12 h) interleukin-6 (IL-6) [338.14 (128.00, 450.70) pg/mL vs. 435.75 (180.50, 537.00) pg/mL, P=0.373], IL-8 [35.04 (18.02, 40.35) pg/mL vs. 43.50 (17.70, 59.95) pg/mL, P=0.383], and IL-10 [21.19 (6.46, 23.50) pg/mL vs. 43.41 (6.34, 50.80) pg/mL, P=0.537] were slightly lower than those in the C group, and the difference was not statistically different. The incidences of pulmonary infection (0.00% vs. 11.76%, P=0.042) and liver injury (2.94% vs. 20.58%, P=0.027) in the HP group were significantly lower than those in the C group, and the incidence of other postoperative complications, such as arrhythmia, nervous system complications and urinary system complications, showed no statistical difference between the two groups. Conclusion HP therapy in CPB is safe, but its effect on reducing postoperative inflammatory factors, postoperative inflammatory reactions and postoperative complications in the patients with AAD is limited, and it may be of application value to some high-risk patients with lung and liver injury.
ObjectiveTo determine the predictive value of the preoperative prognostic nutritional index (PNI) regarding the development of acute kidney injury (AKI) after non-coronary artery bypass grafting (CABG) cardiac surgery.MethodsThe clinical data of 584 patients who underwent elective non-CABG cardiac surgery with cardiopulmonary bypass (CPB) in our hospital from May to September 2019 were reviewed. There were 268 (45.9%) males and 316 (54.1%) females, with a mean age of 52.1±11.6 years. The mean cardiopulmonary time and aortic-clamp time was 124.8±50.1 min and 86.4±38.9 min, respectively. Totally 449 (76.9%) patients received isolate valve surgery. We developed the risk prediction model of AKI using multivariable logistic regression. The predictive values of preoperative PNI, Cleveland Clinic Score (CCS) and risk prediction model were estimated by the area under the receiver operating characteristic curve (AUC) and Hosmer-Lemeshow goodness-of-fit test. The improvement of preoperative PNI to predictive values of CCS or AKI risk prediction models were defined by the net reclassification index (NRI) and variation of AUC.ResultsThe preoperative PNI could neither effectively predict the occurrence of AKI following non-CABG cardiac surgery (AUC=0.553, 95%CI 0.489-0.617, P=0.095) nor improve the predictive effect of other AKI predictive models. The risk prediction model of AKI structured by our study had high predictive value on AKI or severe AKI (stage 2-3) (AUC=0.741, 95%CI 0.686-0.796, P<0.001) and superior to CCS (AUC=0.512, 95%CI 0.449-0.576, P=0.703).ConclusionThe preoperative PNI can neither predict the occurrence of AKI following elective non-CABG cardiac surgery nor improve the prediction values of other AKI prediction models.
The aortic dissection (AD) carries high mortality which increases by 1%-2% per hour after onset in untreated patients. Fifty percent of patients will die in 48 hours, and 70%-80% patients will die in 2 weeks without treatment. Moreover, acute AD during pregnancy is a rare and much catastrophic disease with high lethality for the mother and fetus simultaneously. At present, AD is so rare that most articles are mainly small cohort studies and case reports. Therefore, we reviewed literatures in order to provide clinical reference for the comprehensive treatment of AD.