Trend, Predictors and Outcomes of Combined Mitral Valve Replacement and Coronary Artery Bypass Graft in Patients with Concomitant Mitral Valve and Coronary Artery Disease; A National Inpatient Sample Database Analysis

Combined mitral valve replacement (MVR) and coronary artery bypass graft (CABG) procedures have been the norm for patients with concomitant mitral valve disease (MVD) and coronary artery disease (CAD) with no large-scale data on their safety and efficacy. Methods The National Inpatient Sample (NIS) database (2002-2018) was queried to identify patients undergoing MVR and CABG. The major adverse cardiovascular events (MACE) and its components were compared using a propensity score-matched (PSM) analysis to calculate adjusted odds ratios (OR). Results A crude population of 6,145,694 (CABG-only 3,971,045, MVR-only 1,933,459, MVR+CABG 241,190), while a subset of matched cohort 724,237 (CABG-only 241,436, MVR-only 241,611 vs. MVR+CABG 241,190) was included in the PSM analysis. The combined MVR+CABG procedure had significantly higher adjusted odds of MACE (OR 1.13, 95% CI 1.11-1.14 and OR 1.96, 95% CI 1.93-1.99) and in-hospital mortality (OR 1.29, 95% CI 1.27-1.31 and OR 2.1, 95% CI 2.05-2.14) compared with CABG and MVR-alone, respectively. Similarly, the risk of post-procedure bleeding, major bleeding, acute kidney injury, cardiogenic shock, sepsis, need for intra-aortic balloon pump (IABP), mean length of stay (LOS) and total charges per hospitalization were significantly higher for patients undergoing the combined procedure. These findings remained consistent on yearly trend analysis favoring the isolated CABG and MVR groups. Conclusion Combined procedure (MVR+CABG) in patients with MVD and CAD appears to be associated with worse in-hospital outcomes, increased mortality and higher resource utilization compared with isolated CABG and MVR procedures. Randomized controlled trials are needed to determine the relative safety of these procedures in the full spectrum of baseline valvular and angiographic characteristics.

Diaphragm Ultrasound in Cardiac Surgery: State of the Art

In cardiac surgery, patients are at risk of phrenic nerve injury, which leads to diaphragm dysfunction and acute respiratory failure. Diaphragm dysfunction (DD) is relatively frequent in cardiac surgery and particularly affects patients after coronary artery bypass graft. The onset of DD affects patients’ prognosis in term of weaning from mechanical ventilation and hospital length of stay. The authors present a narrative review about diaphragm physiology, techniques used to assess diaphragm function, and the clinical application of diaphragm ultrasound in patients undergoing cardiac surgery.

Synthetic recovery of impulse propagation in myocardial infarction via silicon carbide semiconductive nanowires

Myocardial infarction causes 7.3 million deaths worldwide, mostly for fibrillation that electrically originates from the damaged areas of the left ventricle. Conventional cardiac bypass graft and percutaneous coronary interventions allow reperfusion of the downstream tissue but do not counteract the bioelectrical alteration originated from the infarct area. Genetic, cellular, and tissue engineering therapies are promising avenues but require days/months for permitting proper functional tissue regeneration. Here we engineered biocompatible silicon carbide semiconductive nanowires that synthetically couple, via membrane nanobridge formations, isolated beating cardiomyocytes over distance, restoring physiological cell-cell conductance, thereby permitting the synchronization of bioelectrical activity in otherwise uncoupled cells. Local in-situ multiple injections of nanowires in the left ventricular infarcted regions allow rapid reinstatement of impulse propagation across damaged areas and recover electrogram parameters and conduction velocity. Here we propose this nanomedical intervention as a strategy for reducing ventricular arrhythmia after acute myocardial infarction.

Impact of atrial fibrillation on in-hospital outcomes among hospitalizations for cardiac surgery: an analysis of the National Inpatient Sample

The short-term impact of atrial fibrillation (AF) on cardiac surgery hospitalizations has been previously reported in cohorts of various sizes, but results have been variable. Using the 2005–2014 National Inpatient Sample, we identified all adult hospitalizations for cardiac surgery using the International Classification of Diseases, Ninth Revision, Clinical Modification as any procedure code and AF as any diagnosis code. We estimated the impact of AF on inpatient mortality, length of stay (LOS), and cost of hospitalization using survey-weighted, multivariable logistic, accelerated failure-time log-normal, and log-transformed linear regressions, respectively. Additionally, we exact-matched AF to non-AF hospitalizations on various confounders for the same outcomes. A total of 1,269,414 hospitalizations were noted for cardiac surgery during the study period. Coexistent AF was found in 44.9% of these hospitalizations. Overall mean age was 65.6 years, 40.9% were female, mean LOS was 11.6 days, and inpatient mortality was 4.5%. Stroke rate was lower in AF hospitalizations (1.8% vs 2.1%, p<0.001). Mortality was lower in the AF (3.9%) versus the non-AF (5%) group (exact-matched OR or emOR=0.48, 95% CI 0.29 to 0.80, p<0.001; 987 matched pairs, n=2423), with similar results after procedural stratification: isolated valve replacement/repair (emOR=0.38, p<0.001), isolated coronary artery bypass graft (CABG) (emOR=0.33, p<0.001), and CABG with valve replacement/repair (emOR=0.55, p<0.001). A 12% increase was seen in LOS in the AF subgroup (exact-matched time ratio=1.12, 95% CI 1.10 to 1.14, p<0.001) among hospitalizations which underwent valve replacement/repair with or without CABG. Hospitalizations for cardiac surgery which had coexistent AF were found to have lower inpatient mortality risk and stroke prevalence but higher LOS and hospitalization costs compared with hospitalizations without AF.

The Effect of Paracetamol on the Patient-Controlled Pain After Coronary Artery Bypass Surgery: A Randomized Clinical Trial Study

Background: Pain is one of the patients' common problems, and usual morbidity after coronary artery bypass graft (CABG). This study aimed to assess the effect of Paracetamol and fentanyl in reducing post-CABG pain. Methods: This double-blind randomized clinical trial was conducted on 160 patients undergoing elective CABG (80 in group F (Fentanyl) and 80 in group P (Paracetamol)), at the cardiac surgery department of hospitals affiliated with Zahedan University of Medical Sciences. In group F, 50μg of Fentanyl (intravenous (IV)) was injected followed by a solution of 10 μg/cc at a rate of 4 cc/hr. For patients in group P, 15 mg/kg of Paracetamol (IV) was administered followed by a solution of 25 μg/cc at a rate of 4 cc/hr. Patients have been infused with the named drugs within the first 24 hours after the operation. Pain severity was assessed by the visual pain score (VAS) tool at baseline, and two, four, eight, twelve, and twenty-four hours after the surgery. Results: The mean of pain score in 12 (P-value=0.002) and 24 (P-value<0.0001) hours after surgery in group P was significantly less than that of group F. The mean heart rate in patients receiving Paracetamol was significantly (P-value = 0.005) less than that of patients receiving Fentanyl for 4 hours after surgery. The mean of increasing creatinine postoperatively in two groups was significant. The mean of increasing AST and ALT postoperatively in group P was significant with no case of liver function impairment. Conclusion: It seems Paracetamol is a good choice for reducing post-CABG pain with no significant complication, although further and more comprehensive research is needed.

Glycemic Control in Coronary Artery Bypass Graft Surgery: A Different Perspective

Background: Hyperglycemia during coronary artery bypass graft surgery (CABG) strongly predicts intra- and post-operative adverse consequences. Objectives: This study aimed to evaluate the quality of glycemic management during CABG in an academic center regarding peripheral blood and coronary sinus values. Methods: This prospective descriptive study encompassed 55 eligible patients undergoing on-pump CABG surgery in 2020. Peripheral blood glucose (BG) was measured four times, before anesthesia induction (T0), before cardiopulmonary bypass pump (CPB) (T1), during CPB (T2), at the end of CPB (T3), and at the end of surgery (T4). The surgeon also took a sample of the coronary sinus BG. Results: The BG variations from T0 to T4 were statistically significant (P < 0.0001). The higher values detected in the ASA class III compared to ASA classes II were statistically significant at T1 (P = 0.01) and T2 (P = 0.025): patients with the higher BMI showed the higher levels of BG. In this regard, the differences were significant at T0 (P = 0.0001), T2 (P = 0.004), and T3 (P = 0.015). Regarding coronary sinus, the mean BG was 222.18 ± 75.74 mg/dL. It was also observed that the ASA class III (P = 0.001), longer duration of CPB (P = 0.021), higher IV fluid volume administrated during surgery (P = 0.023), higher BMI (P = 0.0001), and less urine volume at the end of surgery (P = 0.049) were significantly associated with the higher BG of the coronary sinus. Conclusions: The existing glycemic management protocols on the CABG patients were acceptable in our hospital. However, the BG level of the coronary sinus was higher than the peripheral one.

Incomplete Removal and Accidental Retention of Temporary Epicardial Pacing Wires in the Chest after Heart Surgery: A Case Report

Temporary pacemaker wires are commonly used for the diagnosis and treatment of arrhythmias in the acute postoperative period. We herein describe a 65-year-old woman with a history of coronary artery bypass graft surgery who was referred to the hospital with a purulent discharge in the lower third of the sternal region while on antibiotics. Two years later, following treatment failure, 2 sternal wires were removed. Several years after the surgery, the patient developed a purulent discharge. On suspicion of rib osteomyelitis, the last left cartilage attached to the sternum was excised and removed together with an infectious tract. During the operation, the right ventricle was torn, and tampons were used to control bleeding. The patient was placed under cardiopulmonary bypass via the cannulation of the left femoral artery and the right femoral vein. The sternum was opened, and the rupture site was repaired. A temporary epicardial pacing wire was found at the site of the right ventricular rupture. Several days later, the patient was taken from the intensive care unit to the operating room due to a pulsatile hematoma in the left groin and a diagnosis of a pseudoaneurysm of the femoral artery. After a week, the purulent discharge at the lower sternum improved, and the patient was discharged. At 1 month’s post-discharge follow-up, the infection was eradicated