Search

Enhanced Recovery After Surgery (ERAS) pathways have improved clinical outcomes, cost-effectiveness, and patient satisfaction across multiple non-cardiac surgical specialties. Since the adaptation of ERAS in cardiac surgery is rapidly increasing yet still evolving, herein, we demonstrate early results of our implementation of ERAS cardiac guidelines. We retrospectively reviewed all patients who were managed with our institutional ERAS Cardiac Surgery guidelines between 5/2018 and 6/2019(N = 102). Postoperative primary outcomes (total ventilation times(hours), intensive-care unit(ICU) stay, and postoperative hospital length of stay (LOS)) were compared to 1:1 propensity matched controls from the pre ERAS era between January 2017 and March 2019. A total of 76 propensity-matched pairs were identified. Compared to the matched controls, ERAS patients had significantly shorter median ventilation times(3.5 vs. 5.3 hours, p = .01), ICU stays(median 28 vs 48 hours, p=.005) and postoperative hospital LOS (median 5 vs. 6 days, p = .03). There were no operative mortalities and no significant differences in 30-day readmission rates. There were also no significant differences in post-operative stroke, acute kidney injury, atrial fibrillation, and reoperation rates for bleeding. Two-year survival was also not statistically different between the two cohorts (p = .22). Our initial experience with implementation of ERAS protocols in cardiac surgery appear to demonstrate that these protocols are associated with shorter ventilation times, ICU stay, and hospital LOS without compromising patient outcomes. While these results are promising yet preliminary, further studies are warranted to demonstrate whether ERAS algorithms in cardiac surgery can consistently expedite postoperative recovery and improve outcomes.

Objective Postinfarction ventricular septal defects (VSDs) is one of the serious mechanical complications of acute myocardial infarction and it is associated with high mortality even with surgical repair. Combining surgical patch closure with an Amplatzer septal occluder device (ASOD) is a novel technique that has not been reported before. Deploying an ASOD under direct vision through a left ventriculotomy followed by exclusion patch repair is a novel and dependable surgical technique of a repair for patients with postinfarction VSD. Methods This is a case series of two patients with large inferior postinfarction VSDs who underwent open repair with an ASOD deployed under direct vision through a left ventriculotomy followed by surgical exclusion patch repair. Results There was no immediate intraoperative complication from the repair, no residual VSD, no in hospital mortality. One patient was taken back to the operative room for bleeding on the day of surgery. One patient was discharged to a rehab facility and the other was discharged home. Both patients continue to do well after hospital discharge without any residual VSD. Conclusions Coupling the patch exclusion technique with an Amplatzer septal occluder device for the treatment of post infarction ventricular septal defect is a novel technique with excellent short-term results, but the long-term outcomes of this approach remain unknown.

The cardiovascular system is the first system in the body to reach a functional state, at around the 21st and 22nd day of gestation. As a result, any aortic arch anatomical variant results from the aberrant embryologic migration and/or differentiation of undifferentiated cardiac cell precursors. Initially, six paired aortic channels encircle the embryonic pharynx. They supply the developing pharyngeal arches and arise from the aortic sac. These channels run dorsally, embedded in the mesenchyme of the pharyngeal arches, and terminate in the right and left dorsal aortae.

Functional status is an important predictor of outcomes after infrainguinal bypass surgery. There are little data on the effect of functional status on the outcomes of endovascular lower extremity interventions, especially in the elderly frail population.This is a retrospective analysis of the American College of Surgeons - National Surgical Quality Improvement Program files for the years 2011-2013 to assess the impact of functional status on outcome after endovascular intervention for critical limb ischemia (CLI). Elderly patients (age ≥70) undergoing revascularization for CLI were included. The patients were divided into 2 groups based on functional status prior to surgery: independent (IND) or dependent (DEP), which included partially dependent as well as totally dependent patients. The 2 groups were compared with respect to demographics, comorbidities, complications, length of stay, limb loss, and mortality. Statistical analysis was performed using Student's t-test for continuous variables and Fisher's exact test for categorical variables.There were 1,055 patients (DEP = 253, 24%). There was no difference in gender or race but DEP patients were older than IND (P = 0.008). DEP patients were significantly more likely to have history of congestive heart failure (P = 0.003), hypertension (P = 0.042), and diabetes (P 0.001). There was no difference in emergent surgeries between the 2 groups (P = 1.00). DEP patients had more tibial interventions compared with IND (P 0.001). DEP developed more pneumonia (P 0.001) and septic shock (P = 0.016) and had a trend toward more urinary tract infections (P = 0.051) after endovascular revascularization. There was no significant difference in operating time (P = 0.232) or major amputation (P = 0.092). DEP had significantly longer length of hospital stay (P = 0.0068). DEP had significantly higher mortality (5.98% vs. 2.01%, P = 0.002). On multivariate analysis, DEP status, emergency procedure, congestive heart failure, cardiac arrest requiring cardiopulmonary resuscitation, myocardial infarction, sepsis, and septic shock were independently associated with 30 days of mortality. Irrespective of age, DEP functional status was the most significant preoperative predictor of mortality with an odd ratio of 5.16 [1.93-13.83], P = 0.001 (parsimonious model).Functional status should be carefully assessed when considering endovascular revascularization in the elderly as DEP has significantly higher morbidity and mortality.

Cardiac surgery for radiation-induced valvular disease is associated with adverse outcomes. Transcatheter aortic valve replacement (TAVR) is increasingly used in patients with radiation-induced aortic stenosis (RIAS). The aim of this study was to examine outcomes of TAVR compared with surgical

From the Section of Endocrine Surgery; and Section of Thoracic Surgery, Department of Surgery, Yale School of Medicine, New Haven, Conn. Disclosures: Authors have nothing to disclose with regard to commercial support. Received for publication May 16, 2015; revisions received Aug 22, 2015; accepted for publication Sept 28, 2015. Address for reprints: AnthonyW. Kim, MD, Section of Thoracic Surgery, Yale School of Medicine, 330 Cedar St, BB 205, New Haven, CT 06520 (E-mail: anthony.kim@yale.edu). J Thorac Cardiovasc Surg 2016;151:e33-4 0022-5223/$36.00 Copyright 2016 by The American Association for Thoracic Surgery http://dx.doi.org/10.1016/j.jtcvs.2015.09.105

Kv1.4 channels are Shaker-related voltage-gated potassium channels with two distinct inactivation mechanisms. Fast N-type inactivation operates by a ball-and-chain mechanism. Slower C-type inactivation is not so well defined, but involves intracellular and extracellular conformational changes of the channel. We studied the interaction between inactivation mechanisms using two-electrode voltage-clamp of Kv1.4 and Kv1.4ΔN (amino acids 2–146 deleted to remove N-type inactivation) heterologously expressed in Xenopus oocytes. We manipulated C-type inactivation by introducing a lysine-tyrosine point mutation (K532Y, equivalent to Shaker T449Y) that diminishes C-type inactivation. We used experimental data to develop a comprehensive computer model of Kv1.4 channels to determine the interaction between activation and N- and C-type inactivation mechanisms needed to replicate the experimental data. C-type inactivation began at lower voltage preactivated states, whereas N-type inactivation was coupled directly to the open state. A model with distinct N- and C-type inactivated states was not able to reproduce experimental data, and direct transitions between N- and C-type inactivated states were required, i.e., there is coupling between N- and C-type inactivated states. C-type inactivation is the rate-limiting step determining recovery from inactivation, so understanding C-type inactivation, and how it is coupled to N-type inactivation, is critical in understanding how channels act to repetitive stimulation.