Hugh A. Cassiere

Impact of Preoperative Prealbumin on Outcomes After Cardiac Surgery

BACKGROUND Preoperative malnutrition is increasingly prevalent in patients undergoing cardiac surgery. Although prealbumin is a widely used indicator of nutrition status, its use in the preoperative assessment of patients undergoing cardiac surgery is not well defined. The purpose of this study is to determine the impact of preoperative prealbumin levels on outcomes after cardiac surgery. MATERIALS AND METHODS Data were prospectively gathered from February 2013 to July 2013 on 69 patients undergoing cardiac surgery. Prealbumin levels were obtained within 24 hours of surgery. Patients were divided into 2 groups based on a prealbumin cutoff value of 20 mg/dL. RESULTS Of the 69 patients, 32 (46.4%) had a preoperative prealbumin ≤ 20 mg/dL. There was no correlation between prealbumin levels and body mass index (r = -0.13, P = .28). Likewise, there was no correlation between preoperative albumin and prealbumin levels (r = 0.09, P = .44). Nine of 32 (28.1%) patients with low preoperative prealbumin levels had postoperative infections compared with 2 of 37 (5.4%) patients with high prealbumin levels (P = .010). Patients with low prealbumin levels also had increased risk of postoperative intubation for > 12 hours (P = .010). CONCLUSIONS Patients undergoing cardiac surgery with preoperative prealbumin levels of ≤ 20 mg/dL have an increased risk for postoperative infections and the need for longer mechanical ventilation. If feasible, nutrition optimization of such patients may be considered prior to cardiac surgery.

P2Y12 platelet function assay for assessment of bleeding risk in coronary artery bypass grafting.

The use of platelet function testing has been advocated to individualize the time needed between discontinuation of P2Y12 inhibitors and coronary artery bypass grafting (CABG). However, the use of specific point‐of‐care assays to predict bleeding risk in patients on P2Y12 inhibitors prior to CABG has not been fully validated.

Propensity-matched analysis of the effect of preoperative intraaortic balloon pump in coronary artery bypass grafting after recent acute myocardial infarction on postoperative outcomes

IntroductionThere is substantial variability in the preoperative use of intraaortic balloon pumps (IABPs) in patients undergoing coronary artery bypass grafting post myocardial infarction. The objective of this study is to determine the effect of preoperative IABPs on postsurgical outcomes in this subset of patients.MethodsFrom 2007 to 2012, 877 patients underwent isolated coronary artery bypass post myocardial infarction. Four hundred and six patients were propensity-score matched based on the likelihood of receiving a preoperative balloon pump. Total blood transfusion requirements, composite in-hospital morbidity and/or mortality end point, total hours in the intensive care unit, and length of hospital stay were compared between the two groups.ResultsNo significant differences in demographics, preoperative risk factors, intraoperative variables or length of hospital stay were found between patients with and without balloon pumps after propensity score matching. Compared to patients without balloon pumps, a higher percentage of patients with preoperative IABPs required transfusions. Patients with preoperative balloon pumps were more likely to have the composite end point of in-hospital morbidity (24.1% versus 12.8%, P <0.004), and increased hours in the intensive care unit (median hours: 69.0 versus 46.0, P <0.013) as compared to patients without balloon pumps.ConclusionsThe use of preoperative IABPs in patients undergoing isolated coronary artery bypass grafting after myocardial infarction is associated with increased transfusion requirements, increased in-hospital morbidity and longer postoperative intensive care unit stay as compared to patients without IABPs.

Dose-Dependent Effects of Intraoperative Low Volume Red Blood Cell Transfusions on Postoperative Outcomes in Cardiac Surgery Patients

OBJECTIVE To determine the incremental risk associated with each intraoperative red blood cell transfusion in cardiac surgery patients. DESIGN Retrospective analysis on prospectively collected data. SETTING Single tertiary care hospital. PARTICIPANTS Seven hundred forty-five patients undergoing on-pump cardiac surgery between January 2010 and June 2012 who received between 1 and 3 units of red blood cell transfusion intraoperatively. INTERVENTIONS All patients received between 1 and 3 units of red blood cell transfusions. All transfusions were with leukoreduced blood that had been stored for < 14 days. MEASUREMENTS AND MAIN RESULTS Postoperative complications and length of intubation were associated with the number of red blood cell units transfused. Transfusion of each additional unit of red blood cells was associated with incrementally worse outcomes. Median length of intubation was 11 hours, 12 hours, and 13 hours in patients receiving 1, 2, and 3 units of red blood cell transfusions, respectively (p < 0.005). Similarly, each additional unit of red blood cell transfusion was associated with increasing postoperative septicemia (0% v 0.35% v 2.29%, p < 0.006) and postoperative pneumonia (0% v 0.70% v 2.29%, p < 0.013). CONCLUSIONS There is a step-wise increase in length of postoperative intubation with each red blood cell transfusion in patients undergoing cardiac surgery. Each additional unit of intraoperative RBC transfusion also may increase postoperative infectious complications. Thus, even single-unit reductions in red blood cell transfusions may have significant impact on outcomes.

Outcomes of Patients with Prolonged Intensive Care Unit Length of Stay After Cardiac Surgery.

OBJECTIVE To determine in-hospital and post-discharge long-term survival in patients with prolonged intensive care unit (ICU) stays after cardiac surgery. DESIGN Retrospective, cohort study of cardiac surgery patients from May 2007 to June 2012. SETTING Single-center cardiac surgery ICU. PARTICIPANTS Patients were grouped according to length of ICU stay: between 1 and 2 weeks, between 2 and 4 weeks, and>4 weeks. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Of 4,963 patients, 3.3%, 1.6%, and 2.9% of patients stayed 1 to 2 weeks, 2 to 4 weeks, and>4 weeks in the ICU, respectively. In-hospital mortality was 11.1%, 26.6%, and 31.0% for patients with 1 to 2 weeks, 2 to 4 weeks, and>4 weeks ICU stay, respectively. Patients with ICU stays between 1 and 2 weeks had 6 months, 1 year, and 2 year survival rates of 84.4%, 80.0%, and 75.3% after discharge, respectively. Patients with ICU stay between 2 and 4 weeks had similar 6 months, 1 year, and 2 year survival rates of 84.7%, 79.9%, and 74.1%, respectively. In contrast, patients with>4 week ICU stays had significantly lower postdischarge survival rates of 63.3%, 56.4%, and 41.1% at 6 months, 1 year, and 2 years, respectively. Postoperative stroke conferred the greatest risk of death within 1 year after discharge (odds ratio 7.6, p = 0.0140). CONCLUSIONS In-hospital mortality rates post-cardiac surgery correlate with length of ICU stay but appear to plateau after 4 weeks. However, a>4 week ICU length of stay confers a worse long-term outcome post-hospital discharge, especially in patients with postoperative stroke.

Myocardial Infarction Classification on Outcomes in Nonemergent Coronary Artery Bypass Grafting

BACKGROUND Although patients with ST elevation myocardial infarctions (STEMIs) are known to have worse outcomes than patients with non-ST elevation myocardial infarctions (NSTEMIs), such differences are not well described in the subset of patients undergoing coronary artery bypass grafting. The purpose of this study is to compare postoperative outcomes of patients undergoing nonemergent coronary artery bypass grafting within 1 week after an STEMI versus NSTEMI. METHODS A retrospective study was performed on patients undergoing isolated coronary artery bypass grafting between 1 and 7 days from an MI from 2008 to 2012. Postoperative outcomes, including mortality and composite postoperative morbidity for patients with STEMI versus NSTEMI, were compared within each group. RESULTS Of the 446 patients undergoing nonemergent isolated coronary artery bypass grafting between 1 and 7 days after an MI, 122 patients (27.3%) had an STEMI. The STEMI cohort was younger with less incidence of hypertension than the NSTEMI cohort. However, aside from having a lower incidence of congestive heart failure, STEMI patients had an overall poorer cardiac status than NSTEMI patients. No differences were found in mortality, rates of major complication, length of intensive care unit stay, and length of hospital stay between STEMI and NSTEMI patients. CONCLUSION Despite differences in preoperative characteristics and pathophysiology of patients undergoing coronary artery bypass grafting between 1 and 7 days after NSTEMI versus STEMI, no difference was found in early surgical outcome. The classification of MI should therefore not influence surgical decision making in such patients.

Metastatic meningioma extending into the left atrium through the pulmonary vein.

Left atrial extension of pulmonary tumors through the pulmonary vein is most often associated with primary malignancies and is rarely associated with metastatic disease. We present the first, to our knowledge, reported case of a patient with a history of intracranial meningioma resections presenting with metastatic meningioma to the right lower lobe with extension into the left atrium through the pulmonary vein.

Impact of Postoperative Hypothermia on Outcomes in Coronary Artery Bypass Surgery Patients

OBJECTIVES To determine the impact of postoperative hypothermia on outcomes in coronary artery bypass graft surgery (CABG) patients. DESIGN A retrospective study was performed on patients who underwent isolated CABG between 2011 and 2014. SETTING Single-center study at a university hospital. PARTICIPANTS All patients who underwent isolated CABG with cardiopulmonary bypass between 2011 and 2014. INTERVENTIONS Patients underwent isolated CABG on cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Patients were propensity-score matched based on the likelihood of being hypothermic (<36ºC) or normothermic (≥36ºC) on arrival to the cardiac surgery intensive care unit (ICU) from the operating room. Total transfusion requirements, composite in-hospital morbidity and/or mortality endpoint, total hours in the ICU, and length of hospital stay were compared between the 2 groups. Of the 1,030 patients undergoing isolated CABG, 529 (51.3%) were hypothermic on arrival to the ICU. The hypothermic cohort were older, had more females, had lower body mass indices, had lower starting hematocrit values, were cooled to lower temperatures while on cardiopulmonary bypass, and had longer cardiopulmonary bypass runs compared with the normothermic group. Of the 748 patients who were propensity matched, there were no differences in blood and blood product transfusion requirements, mortality and complication rates, time on the ventilator, length of ICU stay, and length of hospital stay between hypothermic and normothermic patients. CONCLUSIONS Hypothermia at ICU admission after CABG was not associated with increased adverse outcomes, possibly suggesting that complete rewarming before separation from cardiopulmonary bypass may not be essential in all patients.

Utility of Established Risk Models to Predict Surgical Mortality in Acute Type-A Aortic Dissection.

OBJECTIVE The objective of this study was to determine the predictive value of 2 established risk models for surgical mortality in a contemporary cohort of patients undergoing repair of acute type-A aortic dissection. DESIGN Retrospective analysis. SETTING Single tertiary care hospital. PARTICIPANTS Seventy-nine consecutive patients undergoing emergent repair of acute type-A aortic dissection between 2008 and 2013. INTERVENTION All patients underwent emergent repair of acute type-A aortic dissection. MEASUREMENTS AND MAIN RESULTS The receiver operating characteristic curve was compared for each scoring system. Of the 79 patients undergoing emergent repair of acute type-A aortic dissection, 23 (29.1%) were above the age of 70. Seventeen (21.5%) patients presented with hypotension, 25 (31.6%) presented with limb ischemia, and 10 (12.7%) presented with evidence of visceral ischemia. Overall operative mortality was 16.5%. Increasing age was the only preoperative variable associated with increased operative mortality. The areas under the receiver operating characteristic curve for operative mortality was 0.62 and 0.66 for the scoring systems developed by Rampoldi et al and Centofanti et al, respectively. The area under the receiver operating characteristic curve for operative mortality for age was 0.67. The areas under the receiver operating characteristic curve for operative mortality between the 2 scoring systems and for age were not statistically different. CONCLUSIONS Existing predictive risk models for acute type-A aortic dissection provide moderate discriminatory power for operative mortality. Age as a single variable may provide equivalent discriminatory power for operative mortality as the established risk models.

Quantitating Airflow in Sleep-Disordered Breathing: The Nose Knows

SYNOPSIS: The use of a nasal cannula/pressure transducer device to measure airflow during polysomnography (PSG) is more sensitive than the commonly used thermistor at detecting flow limitation. This device will aid in the diagnosis of upper airway resistance syndrome.SOURCE: Hosselet JJ et al. Detection of flow limitation with a nasal cannula/pressure transducer system. Am J Respir Crit Med 1998;157:1461–7.