Multiple approaches in recent years have been implemented to address the persistent shortage of heart donors, including a recent modification of UNOS heart allocation system, expanding donor acceptance criteria, and adoption of novel techniques to utilize hearts from donors with circulatory death. The opioid epidemic has resulted in an exponential increase in deaths in the United States in recent years, particularly affecting younger adults. A recent analysis of UNOS database by Jenser et al. reveals a relative underutilization of heart donors with cardiovascular mechanism of brain death which provide similar long-term survival as donors with other mechanisms of brain death, highlighting the potential role of these donors to provide life saving cardiac allografts and mitigate the persistent shortage of hearts for transplantation.
Background: Ventricular septal defect (VSD) is one of the most common congenital cardiac defects, However, in some cases VSD sites are difficult to expose due to obstruction from chordal attachments and leaflets of the tricuspid valve (TV)(#ref-0006). To systematically review the efficacy and safety of tricuspid valve detachment,( TVD) versus conventional surgical repair ( non-TVD) in the treatment of ventricular septal defect ( VSD) ．This article is aimed to compare the many outcomes from existing studies and provide evidence regarding the necessity of performing TVD. Methods:We searched the following databases: PubMed via NCBI, the Cochrane Central Register of Controlled Trials (no date restriction),Medline via Ovid (from 1966 to May 2020); Embase via Ovid (no date restriction) and China National Knowledge Infrastructure for studies comparing the efficacy of tricuspid valve detachment (TVD) and other surgical techniques in VSD repair. Cardiopulmonary bypass time, Cross-clamp time; postoperative complications including residual defect ,Postoperative atrioventricular block ,Implantation of pacemakers, tricuspid regurgitation ;Length of stay, Length of ICU stay were analyzed． Results: Only 9 studies were included after selection (Table 1), including 7 retrospective cohort studies, 1 respective cohort study and 1 prospective observational stud，a patient pool of 1404 patients with 374 underwent TVD and 1030 underwent non-TVD procedures,met the inclusion criteria．Meta analysis has drawn to the following conclusions. Firstly, TVD prolongs CPB time (MD=7.75, 95% CI=2.60-12.89, p=0.003) and cross-clamp time(MD=7.77, 95% CI=4.76-10.78, p<0.001) compared with non-TVD techniques in VSD repair surgeries. Secondly, no significant difference exists in LOS, length of ICU stay, postoperative atrioventricular block, implantation of pacemakers, incidence of ≥mild TR postoperatively and at discharge, as well as incidence of ≥small residual VSD after surgery and during follow-up( all P ＞ 0. 05). Thirdly, application of TVD increases the risk of TR during follow-up(OR=2.42, 95% CI=1.55-3.76, p<0.001). Conclusion: VSD closure using TVD technique results in longer CPB and cross-clamp time, and increases risk of TR during follow-up. TVD provides equally viable and safe alternative in treating VSD．
The results of a meta-analysis are more than just the reported odds ratio, 95% confidence interval, and P value. Of equal importance is the fine print of the study which should include assessment of risk of bias, certainty in evidence, and heterogeneity in the individual point estimates and confidence intervals. These areas all have influence on the quality of the data in the analysis. Reading and understanding the fine print is important.
Background: Initial clinical evaluation (ICE) is traditionally considered a useful screening tool to identify frail patients during the pre-operative assessment. However, emerging evidence supports the more objective assessment of cardiorespiratory fitness (CRF) via cardiopulmonary exercise testing (CPET) to improve surgical risk stratification. Herein, we compared both subjective and objective assessment approaches to highlight the interpretive idiosyncrasies. Methods: As part of routine pre-operative patient contact, patients scheduled for major surgery were prospectively ‘eyeballed’ (ICE) by two experienced clinicians prior to more detailed history taking that also included American Society of Anaesthesiologists score classification. Each patient was subjectively judged to be either ‘frail’ or ‘not frail’ by ICE and ‘fit’ or ‘unfit’ from thorough review of the medical notes. Subjective data were compared against the more objective validated assessment of post-operative outcomes using established CPET ‘cut-off’ metrics incorporating peak pulmonary oxygen uptake ( V̇O 2PEAK), V̇O 2 at the anaerobic threshold ( V̇O 2-AT) and ventilatory equivalent for carbon dioxide that collectively informed risk stratification. These data were retrospectively extracted from a single-centre prospective National Health Service database. Data were analysed using the Chi-square automatic interaction detection decision tree method. Results: A total of 127 patients examined that comprised 58 % male and 42 % female patients aged 69 ± 10 y with a BMI of 29 ± 7 kg/m 2. Patients were poorly conditioned with a peak pulmonary oxygen uptake almost 20 % lower than that predicted for age, sex-matched healthy controls with 35 % exhibiting a V̇O 2-AT <11 mL/kg/min. Disagreement existed between the subjective assessments of risk with ~34 % of patients classified not frail on ICE were considered unfit by notes review ( P < 0.0001). Furthermore, ~35 % of patients considered not frail on ICE and ~31 % of patients considered fit by notes review exhibited a V̇O 2-AT <11 mL/kg/min and of these, ~28 % and ~19 % were classified as intermediate-to-high risk. Conclusions: These findings highlight the interpretive limitations associated with the subjective assessment of patient frailty with surgical risk classification underestimated in up to a third of patients compared to the validated assessment of CRF. They reinforce the benefits of a more objective and integrated approach offered by CPET that may help improve perioperative risk assessment and better direct critical care provision in patients scheduled for ‘high-stakes’ surgery including open TAAA repair.
Background: Patients who undergo cardiac surgery are at increased risk of stroke, postoperative cognitive decline, and delirium. These neurocognitive complications have led to increased costs, intensive care unit stays, morbidity, and mortality. As a result, there is a significant push to mitigate any neurological complications in cardiac surgery patients. Near-infrared spectroscopy to measure regional cerebral oxygen saturations has gained consideration due to its non-invasive, user-friendly, and relatively inexpensive nature. Aim of Study: To provide a comprehensive summary of cerebral oximetry in cardiac surgery. The review interrogates multiple systematic reviews assessing different outcomes in cardiac surgery to assess if cerebral oximetry is effective. Further, the review analyzes all available interventions for an acute desaturation to determine the efficacy of individual interventions. Methods: A narrative review of randomized controlled trials, observational studies, and systematic reviews with metanalyses were performed through August 2021. Results: There is significant heterogeneity amongst studies regarding the definition of a clinically significant cerebral desaturation. In addition, the assessment of neurocognitive outcomes has large variability, making metanalysis challenging. To date, cerebral oximetry use during cardiac surgery has not been associated with improvements in neurocognitive outcomes, morbidity, or mortality. The evidence to support particular interventions for an acute desaturation is equivocal. Conclusions: Future research is needed to quantify a clinically significant cerebral desaturation and to determine which interventions for an acute desaturation effectively improve clinical outcomes.