Journal of Cardiac Surgery

Background. Surgical mobilization of the internal mammary artery (IMA) can induce graft vasospasm, which is commonly managed by wrapping the IMA in a vasodilator-soaked swab before grafting. However, the choice of the most effective topical vasodilator remains the subject of continued investigation. We carried out a prospective randomized controlled trial to compare the effect of topically applied milrinone, nitroglycerin, and normal saline on IMA free flow. Methods. Forty-six consecutive patients undergoing elective primary coronary artery bypass grafting were enrolled. After the left IMA was harvested, free flow was measured under controlled hemodynamic conditions before any intervention (flow 1) and at a mean of 12.5 minutes after the topical application of one of three agents (milrinone, nitroglycerin, or normal saline) on the IMA (flow 2). Results. All agents induced a significant increase in IMA flow, and flow 2 was significantly higher in the nitroglycerin and milrinone groups compared to the normal saline group, even while controlling for flow 1 as a centered continuous variable. Nevertheless, there was no statistically significant difference in flow 2 between the nitroglycerin and milrinone groups. Conclusions. Topically applied milrinone and nitroglycerin can increase blood flow of the IMA significantly in the early period after surgical mobilization. IMA blood flow was greater after the topical application of milrinone compared to nitroglycerin, but this has failed to reach statistical significance in the present study setting. This trial is registered with NCT06301880.

Objective. Introduction of minimally invasive cardiac surgery anticipated the reduction in postoperative pain but little quantitative data are available on this effect. This study investigated factors influencing pain scores and opioid demand after robotically assisted cardiac procedures. Methods. Using data derived from prospective robotic cardiac surgery and anesthesia databases, we analyzed 75 patients undergoing robotic cardiac surgery between July 2021 and December 2022. Study endpoints were mean cumulative pain scores measured on a 0–10 scale and opioid use on postoperative days (PODs) 1 to 4. Pain scores and oral morphine equivalent (OME) were correlated with perioperative variables. Results. Postoperatively, 39/75 (52%) of patients were extubated in the operating room (OR) and 34/75 (45.3%) were extubated within 24 hours of surgery. Mean pain scores declined from 5.8 (SD 1.5) on POD 1 to 3.8 (SD 1.6) on POD 4 and OME fell from 34.9 (SD 29) mg to 8.2 (SD 11.8) mg. OME use correlated significantly with pain scores (). Higher pain scores on postoperative day (POD) 1 were associated with diabetes (), tobacco use (), and extubation in the OR (). Opioid utilization was higher in younger patients (), heavier patients (), active tobacco users (), longer procedure times (), and those extubated in the OR (). Conclusion. Pain and opioid consumption after robotically assisted cardiac surgery are moderate but decline steadily within the first four postoperative days. Tobacco use and extubation in the OR were associated with increased pain and opioid consumption.

Objectives. Procalcitonin level is generally undetectable from blood sample under normal physiological condition. However, its production can be greatly stimulated by the presence of various inflammatory responses, especially those caused by bacterial infection. We aimed to determine if postoperative procalcitonin level could be used to predict bacterial infection more promptly than bacterial culture results. Materials and Methods. We performed a retrospective case-control study by collecting postoperative procalcitonin as well as white blood cell level of patients undergoing cardiac surgery using cardiopulmonary bypass from electronic medical records of Ramathibodi Hospital between 1st January 2019 and 30th June 2023. Patients with pre-existing inflammatory syndromes or proven bacterial infection, who had been receiving preoperative treatment-dose antibiotics or steroids, who underwent non-elective surgery, and whose medical record data were lost or insufficiently recorded were excluded. Demographic data and operative details were also collected and reviewed. Results. From a total of 146 patients in our study, 42 patients developed proven postoperative bacterial infection. The level of procalcitonin with greatest association to postoperative bacterial infection from our study was 4.13 ng/dl on postoperative day 7. White blood cell level, however, was less predictive of bacterial infection. Conclusions. Procalcitonin level, when utilized alongside clinical presentation, proved to be useful as a predictor of bacterial infection during postoperative day 7. A larger, prospective trial of our continuing series would further strengthen our results.

Objectives. Despite guideline recommendations for use of bilateral internal mammary artery (BIMA) in coronary artery bypass grafting (CABG), a large proportion of patients still receive saphenous vein grafts (SVG). We herein aimed to identify reasons for SVG use at a center with a BIMA utilization rate between 60 and 70% and compare outcomes of patients undergoing CABG with either BIMA or left internal mammary artery (LIMA) plus SVG. Methods. Between 2013 and 2022, 4145 consecutive patients underwent isolated CABG at our center. Of those, 2067 patients received BIMA (group 1) and 1206 patients received LIMA/SVG (group 2). A propensity score-matched analysis was performed to adjust for baseline differences. Results. Group 2 presented with higher age, more female patients, and more patients with acute coronary syndrome including NSTEMI/STEMI with more urgent/emergency CABG. In unadjusted analysis group 2 presented adverse 30-day outcomes compared to group 1 with a higher mortality (18/2067, 0.9% vs. 34/1206, 2.8%; ), higher rate of re-revascularization (52/2067, 2.5% vs. 50/1206, 4.1%; ), more stroke (20/2067; 1.0% vs. 33/1206, 2.7%; ), and more postoperative renal failure (17/2067, 0.8% vs. 27/1206, 2.2%; ). After adjustment for baseline characteristics, 30-day outcomes were comparable. Conclusions. After adjustment for baseline characteristics no differences in outcomes were found between groups suggesting a safe applicability of BIMA even in patients with acute coronary syndrome undergoing urgent/emergency CABG. Reasons for SVG use were higher age, female gender, and acute coronary syndrome with urgent/emergency CABG. Outcomes of both groups were excellent with low rates of primary endpoints.

Background. Infective endocarditis (IE) is considered a life-threatening cardiac infection with a predilection to involve heart valves. One of the most feared complications of IE is the development of new-onset neurological complications (NCs). The aim of this study is to compare the short- and long-term outcomes of surgery in patients with IE presenting with vs. without NCs. Methods. We retrospectively reviewed patient records which were regularly collected in our institutional database. Between January 2002 and August 2020, 438 consecutive patients who underwent open cardiac surgery in our university hospital due to IE were included in the retrospective study. Results. Of the total cohort, 89 patients (20.3%) had preoperative NCs. Patients in the NC group were more likely to be female (33.7% vs. 23.5%; ), had more acute kindly injury at presentation (22.5% vs. 10.0%; ), were more likely to be admitted to ICU (36.0% vs. 18.3%; ), and had significantly more vegetations (84.3% vs. 69.8%; ) and overall higher preoperative embolization (92.1% vs. 11.7%; ). Staphylococcus aureus as causative organism of IE was significantly higher in the NC group (35.2% vs. 16.1%; ). Patients in the NC group had significantly higher affection of the mitral valve. There was no difference in postoperative outcomes between the two groups. The long-term survival was also similar in both groups. Preoperative atrial fibrillation (adjusted odds ratio (aOR): 2.03; 95% CI [1.04–3.93]; ) and Staphylococcus aureus IE (aOR: 2.60; 95% CI [1.4–4.8]; ) were independent risk factors of developing NCs, while previous endocarditis was a protective factor (aOR: 0.33; 95% CI [0.11–0.99]; ). Conclusion. Our study emphasizes the shared risk factors between mortality and developing NCs. NCs are critical in IE’s clinical presentation, but they do not independently predict short- or long-term survival following surgery for IE.

Backgroud. The results of the Fontan operation, depending on the anatomy of the pulmonary arteries, have been studied quite well. Various indices have been proposed to assess the degree of hypoplasia of the pulmonary arterial bed (Nakata, Reddy, and McGoon indexes). At the same time, an obstruction of pulmonary venous blood return may be considered as a contraindication to Fontan operation. Aim of the Study. To present an optimal method for pulmonary venous index (PVI) calculation based on computed tomography angiography (CTA) enhancement of the heart data in patients with a functional single ventricle. Materials and Methods. 63 patients with a functional single ventricle (SV) underwent CTА (Philips, Brilliance iCT) before the Fontan operation. Axial sections were reconstructed to a thickness of 0.75–3 mm using soft tissue and lung filters, followed by postprocessing of the data (Horos and OsiriX software) and construction of multiplanar and 3D images. The diagnoses were presented by various types of SV of the heart. The age of the patients ranged from 3 to 30 years (median 7 years). Comparison of PVI was carried out in patients of two groups: those who survived the intervention (n = 55 patients) and those who died (n = 8). The evaluation of the pulmonary veins (PV) and the calculation of the pulmonary venous index (PVI) were carried out based on the measurement of each pulmonary vein at 2 levels (at the level of the orifices and bifurcation). The calculation of the PVI was carried out according to the formula: the sum of the cross-sectional area of the main pulmonary veins, related to the body surface area. 3 variants of PVI calculation were compared: taking into account the values of the PV areas at the level of the orifices, the bifurcation, and the sum of the minimum areas of each of the PVs. Results. In the group of survived patients, the median PVI at the level of the PV orifices was 292 mm/m², and in the group of deceased, it was 242 mm/m²; at the level of PV bifurcation in the group of survivors, it was 299 mm/m², and in the group of dead patients, it was 281 mm/m²; the minimum PVI was 257 mm/m² in the survivor group and 218 mm/m² in the deceased group . An ROC analysis performed to determine the critical value of the minimum PVI affecting survival after Fontan operation revealed that PVI measured taking into account the minimum dimensions of the areas of the PV is a significant risk factor for death after Fontan operation , with its value (cutoff) <233.5 mm²/m². Conclusion. The value of the minimum PVI can be an important morphological indicator of the state of PV blood return and serve as an additional criterion in determining indications for the Fontan operation.