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Permanent pacemaker (PPM) implantation may be indicated post-transcatheter aortic valve implantation (TAVI). The Emory Risk Score (ERS) is a validated predictive risk score of the need for a PPM post-TAVI using a balloon-expandable valve. Our objectives were to determine the validity of the ERS in our local TAVI population with both balloon-expandable and self-expanding valves and to identify additional electrocardiographic (ECG) parameters predictive of the need for a PPM post-TAVI.Retrospective chart and electronic database reviews were performed to collect demographic and procedural information. Two expert readers reviewed all ECGs. Independent factors associated with PPM implantation were examined with multivariable logistic regression via a stepwise selection process with calculation of the area under the receiver operating characteristic curve to assess model discrimination.The overall PPM implantation rate was 11.7%; rates were 9% for the Sapien 3 valves, 10% for the Evolut Pro valves, and 17% for the Evolut R valves. The ERS was found to not be predictive of need for PPM post-TAVI for the entire cohort. Right bundle branch block was the only ERS parameter independently associated with new PPM implant (8.5% vs 25%, odds ratio = 3.59,The poor predictive value of the ERS in determining the need for a PPM post-TAVI in our patient population suggests that further refinement of a formula (or risk-calculator) is warranted. Identification of a precise risk-calculator is likely to facilitate patient mobilization and reduce inpatient healthcare resource utilization.L’implantation d’un stimulateur cardiaque permanent (SCP) peut être indiquée après l’implantation valvulaire aortique par cathéter (post-IVAC). L’Emory Risk Score (ERS) est un score de prédiction du risque validé de la nécessité d’un SCP post-IVAC au moyen d’une valve expansible par ballonnet. Nous avions pour objectif de déterminer la validité de l’ERS auprès de notre population ayant eu une IVAC soit par valve expansible par ballonnet ou valve auto-expansible, et de déterminer d’autres paramètres électrocardiographiques (ECG) prédictifs de la nécessité d’un SCP post-IVAC.Nous avons réalisé des revues rétrospectives de dossiers et de bases de données électroniques pour collecter les données démographiques et interventionnelles. Deux experts ont lu et interprété tous les ECG. Les facteurs indépendants associés à l’implantation du SCP ont été examinés en effectuant la régression logistique multivariée par processus de sélection pas-à-pas au moyen du calcul de la surface sous la courbe caractéristique d’efficacité du récepteur afin d’évaluer la discrimination du modèle.Le taux global d’implantation d’un SCP était de 11,7 % ; les taux étaient de 9 % pour les valves Sapien 3, de 10 % pour les valves Evolut Pro et de 17 % pour les valves Evolut R. Nous avons observé que l’ERS ne permettait pas de prédire si l’implantation d’un SCP post-IVAC était nécessaire pour la cohorte entière. Le bloc de branche droit était le seul paramètre de l’ERS indépendamment associé à la nouvelle implantation d’un SCP (8,5 %La faible valeur prédictive de l’ERS à déterminer la nécessité d’un SCP post-IVAC au sein de notre population de patients montre que des améliorations de la formule (ou calculateur de risques) sont justifiées. L’identification d’un calculateur de risques précis devrait favoriser l’adhésion des patients et réduire l’utilisation des ressources en soins de santé en milieu hospitalier.

In 2019, the Society for Enhanced Recovery After Cardiac Surgery (ERAS-CS) published perioperative guidelines to optimize the care of patients undergoing cardiac surgery. For centers with limited capacity, a sequential approach to the implementation of the full guidelines may be more feasible. Therefore, we aimed to explore the priority of implementation of the ERAS-CS guideline recommendations from a patient and caregiver perspective.Using a modified nominal group technique, individuals who previously underwent cardiac surgery and their caregivers ranked ERAS-CS recommendations within 3 time points (ie, preoperative, intraoperative, and postoperative) and across 2 to 3 voting rounds. Final round rankings (median, mean and first quartile) were used to determine relative priorities.Seven individuals (5 patients and 2 caregivers) participated in the study. Patient engagement tools (2, 2.29, and 1.50), surgical site infection reduction (2, 1.67, and 1.25), and postoperative systematic delirium screening (1, 2.43, and 1.00) were the top-ranked ERAS-CS recommendations in the preoperative, intraoperative, and postoperative time points, respectively.Exploration of patient and caregiver priorities may provide important insights to guide the healthcare team with clinical pathway development and implementation. Further study is needed to understand the impact of the integration of patient and caregiver values on effective and sustainable clinical pathway implementation.

The recent American College of Cardiology/American Heart Association/Society for Cardiovascular Angiography and Interventions Guidelines for Coronary Artery Revascularization have raised concerns on the survival benefits of coronary artery bypass grafting (CABG) over guideline-directed medical therapy (GDMT) in stable coronary artery disease (CAD) and appropriate conduit selection for CABG. This review summarizes the evidence supporting CABG for stable CAD and use of the radial artery as a conduit for CABG.CABG has consistently demonstrated a survival benefit over GDMT for patients with stable multivessel CAD. These benefits were more pronounced in patients with diabetes and/or anatomically complex coronary artery disease. The recently published International Study of Comparative Health Effectiveness with Medical and Invasive Approaches trial was not designed to and did not include an appropriate patient population to compare revascularization with CABG to GDMT. These results should thus be viewed in the context of previously published studies. Furthermore, increasing evidence suggests that use of a radial artery in CABG is associated with reduced myocardial infarction and repeat revascularization. This should be considered when selecting the appropriate conduits based on underlying patient factors.Readers should be cautious when applying these guidelines broadly. Appropriate consideration of patient and anatomic factors, and in consultation with a multidisciplinary heart team, is important to achieve the best outcomes for patients.

The coronavirus disease 2019 (COVID-19) pandemic continues to disrupt the provision of cardiac procedural services due to overwhelming interval surges in COVID-19 cases and the associated crisis of cardiac intervention deferment. Despite the availability of widespread testing, highly efficacious vaccines, and intensive public health efforts, the pandemic is entering its third year, where new severe acute respiratory syndrome-coronavirus-2 variants have increased the likelihood that patients scheduled for a cardiac intervention will contract COVID-19 in the perioperative period. The Society of Thoracic Surgeons (STS) Workforce on Critical Care, the STS Workforce on Adult Cardiac and Vascular Surgery, and the Canadian Society of Cardiac Surgeons have developed this document, endorsed by the STS and affirmed by the Society of Cardiovascular Angiography and Interventions and the Canadian Association of Interventional Cardiology, to provide guidance for cardiac procedure deferment and intervention timing for preoperative patients diagnosed with COVID-19. This document is intended for the perioperative cardiac surgical team and outlines the present state of the pandemic, the impact of COVID-19 on intervention outcome, and offers a recommended algorithm for individualized cardiac procedure triage and timing.

Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery.Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival.There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79).A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery.

Although multidimensional frailty scales have been proven to predict mortality and morbidity in cardiac surgery, there is a need for rapid tools that could be easily administered at the point of care. Handgrip strength (HGS) is an attractive option that can be measured in acutely ill and bed-bound patients, although it has yet to be validated in a large cardiac surgery cohort.This is a post hoc analysis of a multicentre prospective study in older patients undergoing coronary artery bypass grafting and/or valve surgery from 2011 to 2019. HGS was measured before surgery and classified by sex-stratified cutoffs. The primary outcome was 1-year mortality and secondary outcomes were 30-day mortality, discharge disposition, and prolonged length of stay.There were 1245 patients included in the analysis (mean age 74.0 ± 6.6 years; 30% female). Weak HGS was associated with advanced age, heart failure, kidney disease, malnutrition, and various frailty scales. In those with weak vs normal HGS, respectively, 1-year mortality was 17% vs 6%, 30-day mortality was 10% vs 3%, prolonged length of stay was 34% vs 19%, and discharge to a health care facility was 45% vs 26% (all P0.001). After adjustment, HGS was predictive of 1-year and 30-day mortalities, with odds ratios of 2.44 (95% confidence interval [CI] 1.39-4.29) and 2.83 (1.38-5.81), respectively. HGS cutoffs of26 kg in men and16 kg in women had the highest predictive performance.HGS is a simple and effective tool to identify patients at higher risk of mortality and protracted recovery after cardiac surgery.

Background: Current intensive care unit physician-staffing (IPS) models for postoperative cardiac surgery have not been previously investigated in Canada. The purpose of this study was to determine current IPS models at 2 time points and describe the evolution of Canadian cardiac surgery IPS models. Methods: A survey of 32 Canadian cardiovascular intensive care units (CVICUs) was undertaken in 2012 and 2017 to determine IPS models of care during “daytime” and “after-hours” in each unit. Data were collected regarding surgical volume, base specialties, and style of IPS management (“open”; “semi-open”; “closed”). In addition, we collected the overnight experience level of the bedside healthcare provider for in-house intensive care units. Results: Survey responses were received from 27 of 32 CVICUs (87%). As of 2017, the style of 1 (4%) was open, 7 (26%) were semi-open, and 19 (70%) were closed in their unit IPS strategy. Base specialties of CVICU physicians varied. A medical doctor provided after-hours coverage in 81% of CVICUs. Senior residents (37%) or critical care certified attending staff (25%) typically provided after-hours coverage for in-house CVICUs. Linked Canadian Institute for Health Information data did not indicate a difference among CVICU models in mortality or rehospitalization for coronary artery bypass graft or valve procedures. Conclusions: Considerable heterogeneity is demonstrated in CVICU staffing patterns. No consensus was identified regarding the appropriate level of training for “after-hours” coverage. In-house overnight physician staffing in CVICUs varies widely. Finally, semi-open and closed style models did not demonstrate differences compared to Canadian Institute for Health Information data. Variability among CVICUs does exist; however, benefits of one model over another have not been identified. Résumé: Introduction: Les modèles actuels de dotation en médecins aux soins intensifs (DMSI) postopératoires de chirurgie cardiaque n’ont pas fait l’objet d’études antérieures au Canada. L’objectif de la présente étude était de déterminer les modèles actuels de DMSI à deux points temporels et de décrire l’évolution des modèles de DMSI de chirurgie cardiaque au Canada. Méthodes: Nous avons entrepris une enquête auprès de 32 unités de soins intensifs cardiovasculaires du Canada (USICC) en 2012 et en 2017 pour déterminer les modèles de soins DMSI « pendant la journée » et « après les heures normales » dans chaque unité. Nous avons collecté les données relatives au volume d’interventions chi- rurgicales, aux spécialités de base et au style de gestion de la DMSI (« ouvert », « semi-ouvert », « fermé »). De plus, nous avons collecté les données sur le niveau d’expérience de nuit des prestataires de soins au chevet des patients des unités intégrées de soins intensifs. Résultats: Nous avons reçu les réponses à l’enquête de 27 des 32 USICC (87 %). Depuis 2017, le style de 1 (4 %) USICC était ouvert, de 7 (26 %) était semi-ouvert et de 19 (70 %) était fermé dans leur stra- tégie de DMSI à l’unité. Les spécialités de base des médecins de l’USICC variaient. Un docteur en médecine offrait ses services après les heures normales dans 81 % des USICC. Les résidents chevronnés (37 %) ou les médecins titulaires agréés en soins aux patients en phase critique (25 %) offraient habituellement leurs services après les heures normales aux USICC intégrées. Les données liées de l’Institut canadien d’information sur la santé n’indiquaient pas de différence entre les modèles des USICC en ce qui a trait à la mortalité ou à la réhospitalisation en raison de pontages aortocoronariens ou d’interventions valvulaires. Conclusions: Les modèles de dotation en personnel aux USICC démontrent une importante hétérogénéité. Aucun consensus n’a été établi quant au niveau approprié de formation pour les services offerts « après les heures normales ». Le personnel médical de nuit à l’interne des USICC varie grandement. Finalement, les modèles de styles semi-ouverts et fermés ne démontraient pas de différence par rapport aux données de l’Institut canadien d’information sur la santé. Une variabilité existe entre les USICC. Toutefois, les avantages d’un modèle par rapport à un autre n’ont pas été définis.

Background: Recently, anecdotal evidence suggested an increase in infective endocarditis (IE) in Manitoba driven by an increasing proportion of patients with intravenous drug use (IVDU)-associated endocarditis. This study aimed to characterize the observed changing incidence and epidemiology of IE. Methods: This retrospective study evaluated consecutive patients >18 years old with an International Classification of Disease–10 diagnosis of IE who presented to a tertiary referral center in Winnipeg, Manitoba between January 1, 2004 and December 31, 2018. Data were obtained by individual review of paper and electronic medical records and entered into the Research Electronic Data Capture database. Mortality and hospital readmission data were acquired by linking Research Electronic Data Capture data to the Manitoba Centre for Health Policy, which prospectively maintains a comprehensive population-based health database. Results: A total of 612 cases of IE were identified. The incidence of IE increased from 2.03 per 100,000 in 2004 to 5.16 per 100,000 in 2018, with IVDU-associated cases increasing from 0.11 to 2.87 per 100,000. Left heart vegetations were most common in the non-IVDU group, whereas right-sided vegetations dominated in the IVDU group. All-cause mortality did not differ between IVDU and non-IVDU IE, despite a significantly younger age in patients with IVDU. The IVDU group showed a higher rate of endocarditis recurrence. Conclusions: In this first study to examine the longitudinal incidence of IE in Manitoba, we showed that the incidence of IE has significantly increased over the last 15 years, with a contribution of IVDU-associated IE that has a high rate of mortality and disease recurrence. Résumé: Introduction: Des données anecdotiques récentes montraient une augmentation de l’endocardite infectieuse (EI) au Manitoba attribuable à la proportion accrue de patients atteints d’une endocardite associée à l’usage de drogues par voie intraveineuse (UDVI). La présente étude avait pour but de caractériser les changements observés dans l’incidence et l’épidémiologie de l’EI. Méthodes: Cette étude rétrospective a permis d’évaluer les patients consécutifs > 18 ans qui avaient un diagnostic d’EI conformément à la Classification internationale des maladies, 10e révision, et qui s’étaient présentés dans un centre d’aiguillage en soins tertiaires de Winnipeg, au Manitoba, entre le 1er janvier 2004 et le 31 décembre 2018. Nous avons obtenu les données par l’examen du dossier individuel et des dossiers médicaux électroniques de la base de données Research Electronic Data Capture. Nous avons obtenu les données sur la mortalité et les réadmissions à l’hôpital par la liaison des données de la Research Electronic Data Capture au Manitoba Centre for Health Policy, qui maintient de manière prospective une base de données exhaustive sur la santé de la population. Résultats: Nous avons trouvé un total de 612 cas d’EI. L’incidence de l’EI est passée de 2,03 par 100 000 en 2004 à 5,16 par 100 000 en 2018, et l’incidence des cas d’EI associée à l’UDVI, de 0,11 à 2,87 par 100 000. Les végétations du cœur gauche étaient plus fréquentes dans le groupe de patients atteints d’une EI non associée à l’UDVI, alors que les végétations du cœur droit dominaient dans le groupe de patients atteints d’une EI associée à l’UDVI. La mortalité toutes causes confondues ne différait pas entre les patients atteints d’une EI associée à l’UDVI ou non associée à l’UDVI, en dépit de l’âge significativement plus jeune des patients atteints d’une EI associée à l’UDVI. Le groupe de patients atteints d’une EI associée à l’UDVI montrait un taux plus élevé de récurrence de l’endocardite. Conclusions: Dans cette première étude, qui portait sur l’incidence longitudinale de l’EI au Manitoba, nous avons montré que l’incidence de l’EI avait considérablement augmenté au cours des 15 dernières années, puisque l’EI associée à l’UDVI a contribué à l’augmentation du taux de mortalité et de récurrence de la maladie.

Background The coronavirus disease 2019 (COVID‐19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID‐19 pandemic. Methods A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed. Results Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID‐19, they were most worried with exposing their family to COVID‐19 (81%), followed by contracting COVID‐19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID‐19 burden, with higher COVID‐19 burden institutions more likely to resort to PPE conservation strategies. Conclusions The present study demonstrates the impact of COVID‐19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.

IntroductionA major complication of cardiac surgery is bleeding which can require surgical re-exploration and the transfusion of allogeneic blood products. Re-operative procedures for bleeding have been associated with higher rates of mortality and morbidity, therefore an intervention to reduce this complication would be important. Previous investigation has demonstrated that low-cost solutions, such as the use of an intraoperative haemostatic checklist may result in the reduction of bleeding and subsequent transfusion. The goals of this scoping review aim to assess the efficacy of the use of intraoperative haemostatic checklists on blood management in patients undergoing cardiac surgery. Specifically, the objective is to understand if the use of intraoperative haemostatic checklists has been associated with a reduction in bleeding and blood product utilisation in patients undergoing non-emergent cardiac surgery.Methods and analysisA scoping review of literature identifying randomised control and observational trials, reporting on haemostatic checklists in cardiac surgery, will be undertaken. The proposed review will be guided by the methodological framework proposed by Arksey and O’Malley. A search will be conducted for published and unpublished (grey) literature. Published literature will be searched in the following electronic databases: Scopus, MEDLINE, EMBASE and the Cochrane Library. Relevant grey literature will be identified through conference abstracts. Outcomes chosen are patient centred to ensure reduced bleeding and overall positive experience that reduces complications intraoperatively.Ethics and disseminationThis study does not require ethical approval as the data used are from available publications. Our dissemination strategy includes peer-review publication, presentation at conferences and relevant stakeholders.

Preoperative anemia is common in patients presenting for cardiac surgery, with a prevalence of approximately 1 in 4, and has been associated with worse outcomes including increased risk of blood transfusion, kidney injury, stroke, infection, and death. Iron deficiency, a major cause of anemia, has also been shown to have an association with worse outcomes in patients undergoing cardiac surgery, even in the absence of anemia. Although recent guidelines have supported diagnosing and treating anemia and iron deficiency before elective surgery, details on when and how to screen and treat remain unclear. The Eighth Perioperative Quality Initiative (POQI 8) consensus conference, in conjunction with the Enhanced Recovery after Surgery-Cardiac Surgery Society, brought together an international, multidisciplinary team of experts to review and evaluate the literature on screening, diagnosing, and managing preoperative anemia and iron deficiency in patients undergoing cardiac surgery, and to provide evidence-based recommendations in accordance with Grading of Recommendations, Assessment, Development and Evaluation (GRADE) criteria for evaluating biomedical literature.

Transplant vasculopathy is an aggressive form of atherosclerosis that manifests uniquely in transplanted hearts, lungs, and kidneys. Recently, immunoengineered transition metal carbides, or MXenes, have demonstrated unique immunomodulatory properties and this can potentially be leveraged to prevent transplant vasculopathy. Here, we present the synthesis, characterization and application of novel zero-dimensional tantalum carbide (Ta 4 C 3 T x ) MXene quantum dots (MQDs) for immunomodulation. A facile hydrofluoric acid-free etching protocol was developed to synthesize zero-dimensional Ta 4 C 3 T x MQDs from Ta 4 AlC 3 MAX phase. The resultant MQDs are 3 to 7 nm in diameter and are surface modified with carboxyl, hydroxyl, and amine functional groups for biological interactions. Immunomodulation was assessed in vitro through co-cultures of human umbilical vein endothelial cells (ECs) and peripheral blood mononuclear cells. We found that MQDs interact with activated human ECs in vitro to reduce activation and pro-inflammatory Th1 polarization of allogeneic CD4 + lymphocytes. Mechanistically, we showed using quantitative PCR that treatment with MQDs significantly increased endothelial surface expression of the T-cell co-inhibitory molecule PD-L1 and decreased the co-stimulatory molecule CD86. Furthermore, exploratory bulk RNA-sequencing of co-cultured lymphocytes showed decreases in the immunologic signatures of naïve T-cells and increases in the immunologic signatures of CD25 + regulatory T-cells, suggesting activation of this suppressive T-cell population. Finally, when applied in an in vivo rat model of transplant vasculopathy, treatment with MQDs reduced lymphocyte infiltration and preserved medial smooth muscle cell integrity within transplanted aortic segments. These findings suggest that these novel MQDs have potential as an effective treatment to ameliorate transplant vasculopathy.

At present, there is a lack of information on patient and caregiver values, and perceived priorities and barriers, to guide successful post-discharge recovery. This was a single center, multiple methods study that investigated patient, caregiver, and health care provider perceptions of the discharge process after cardiac surgery. Themes emerging from focus group discussions with patients and caregivers were used to develop surveys relating to values, barriers, and challenges relating to the discharge process. Thirty-two patients (n = 16) and caregivers (n = 16) participated in four separate focus groups. Four themes emerged from these discussions: (1) a lack of understanding about what the discharge process entails and when discharge is appropriate, (2) issues relating to the information provided to patients at the time of discharge, (3) participant experiences with the health care system, and (4) the experiences of caregivers. Seventy-eight patients, 34 caregivers, 53 nurses and/or other allied health professionals, and 8 surgeons completed the cross-sectional surveys. The most important component of the discharge process for patients and caregivers was "knowing what to do in an emergency." Health care providers less accurately identified what caregivers perceived as the most important aspects of the discharge process.Statements relating to informational barriers to discharge were the most discordant among patient and caregiver respondents. After discharge, patients and caregivers identified the need for longer-term follow up with the surgeon and more support in the community. Incorporation of patient and caregiver values to guide the post-cardiac surgery discharge process is essential to promote successful recovery.

Introduction Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT; www.the4AT.com) is a short ( Methods We searched the following electronic databases through Ovid: MEDLINE, Embase, and PsycINFO. Additional databases were searched: CINAHL (EBSCOhost), clinicaltrials.gov and Cochrane Central Register of Controlled Trials from 2011 (4AT publication) until 21 December 2019. Inclusion criteria: older adults (≥65) across any setting of care except critical care; validation study of the 4AT against a delirium reference standard (standard diagnostic criteria or validated tool). Two reviewers independently screened abstracts and papers and performed the data extraction. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. Results 17 studies (n = 3,701 observations) were included. Various settings including acute medicine, surgery, stroke wards and the emergency department were represented. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). The methodological quality of studies was mostly good. Conclusions The 4AT is now supported by a substantial evidence base comparable to other well-studied tools such as the Confusion Assessment Method (CAM). The strong pooled sensitivity and specificity findings for the 4AT in this meta-analysis along with its brevity and lack of need for specific training provide support for its use as an effective assessment tool for delirium.

Postoperative atrial fibrillation (POAF) after cardiac surgery is associated with longer hospital stay and increased in-hospital death and stroke, but its long-term implications remain incompletely understood. A systematic literature review was undertaken to investigate the impact of POAF on long-term death and stroke in adult patients who undergo cardiac operations.Electronic databases (Cochrane, Embase, Ovid MEDLINE, and PubMed) were queried from inception to October 2018. Included studies compared long-term outcomes after cardiac operations in patients with and without POAF. Adjusted and unadjusted meta-analyses examined death, stroke, and major adverse cardiac and cerebrovascular events. Risk of bias was evaluated with the Newcastle-Ottawa Scale.The inclusion criteria were met by 32 studies describing 155,575 patients who had undergone cardiac operations. POAF occurred in 36,988 patients (23.7%). Meta-analysis of 10 studies (44,367 patients) demonstrated increased 1-year death in patients with POAF (odds ratio, 2.60; 95% confidence interval, 2-3.38; P.01). Aggregate adjusted hazard of death (16 studies, n = 84,295) was also increased in patients with POAF (hazard ratio, 1.25; 95% confidence interval, 1.2-1.3; P.01).This systematic review and meta-analysis identified an association between POAF and long-term death after cardiac surgery. More comprehensive POAF prevention and management, including more stringent follow-up for POAF recurrence after hospital discharge, may be indicated. The included studies used inconsistent definitions of POAF and variable exclusion criteria; however, estimates of heterogeneity are low. Differences in preoperative comorbidities, such as age, ejection fraction, and obesity, may not be fully accounted for in adjusted analyses. Future work is required to delineate mechanisms linking POAF and death in this population.

The Thoracic Surgery Social Media Network (TSSMN) is a collaborative effort of leading journals in cardiothoracic surgery to highlight publications via social media. This study aims to evaluate the 1-year results of a prospective randomized social media trial to determine the effect of tweeting on subsequent citations and nontraditional bibliometrics.A total of 112 representative original articles were randomized 1:1 to be tweeted via TSSMN or a control (non-tweeted) group. Measured endpoints included citations at 1 year compared with baseline, as well as article-level metrics (Altmetric score) and Twitter analytics. Independent predictors of citations were identified through univariable and multivariable regression analyses.When compared with control articles, tweeted articles achieved significantly greater increase in Altmetric scores (Tweeted 9.4 ± 5.8 vs Non-tweeted 1.0 ± 1.8, P.001), Altmetric score percentiles relative to articles of similar age from each respective journal (Tweeted 76.0 ± 9.1 percentile vs Non-tweeted 13.8 ± 22.7 percentile, P.001), with greater change in citations at 1 year (Tweeted +3.1 ± 2.4 vs Non-Tweeted +0.7 ± 1.3, P.001). Multivariable analysis showed that independent predictors of citations were randomization to tweeting (odds ratio [OR] 9.50; 95% confidence interval [CI] 3.30-27.35, P .001), Altmetric score (OR 1.32; 95% CI 1.15-1.50, P.001), open-access status (OR 1.56; 95% CI 1.21-1.78, P.001), and exposure to a larger number of Twitter followers as quantified by impressions (OR 1.30, 95% CI 1.10-1.49, P.001).One-year follow-up of this TSSMN prospective randomized trial importantly demonstrates that tweeting results in significantly more article citations over time, highlighting the durable scholarly impact of social media activity.

Background Cardiac surgery is becoming increasingly common in older, more vulnerable adults. A focus on timely and complete medical and functional recovery has led to the development of enhanced recovery protocols (ERPs) for a number of surgical procedures and subspecialties, including cardiac surgery (ERAS® Cardiac). An element that is often overlooked in the development and implementation of ERPs is the involvement of key stakeholder groups, including surgery patients and caregivers (e.g., family and/or friends). The aim of this study is to describe a protocol for a scoping review of cardiac patient and caregiver preferences and outcomes relevant to cardiac surgery ERPs. Methods Using Arksey and O’Malley’s et al six-stage framework for scoping review methodologies with adaptions from Levac et al. (Represent Interv: 1–18, 2012), a scoping review of existing literature describing patient- and caregiver-identified preferences and outcomes as they relate to care received in the perioperative period of cardiac surgery will be undertaken. The search for relevant articles will be conducted using electronic databases (i.e., the Cochrane Library, Medline, PsycINFO, Scopus, and Embase), as well as through a search of the grey literature (e.g., CPG Infobase, Heart and Stroke Foundation, ProQuest Theses and Dissertations, Google Advanced, and Prospero). Published and unpublished full-text articles written in English, published after the year 2000, and that relate to the research question will be included. Central to the design of this scoping review is our collaboration with two patient partners who possess lived experience as cardiac surgery patients. Discussion This review will identify strategies that can be integrated into ERPs for cardiac surgery which align with patient- and caregiver-defined values. Broadly, it is our goal to demonstrate the added value of patient engagement in research to aid in the success of system change processes.

Background The influence of renin–angiotensin–aldosterone system (RAAS) inhibitors on the critically ill COVID-19 patients with pre-existing hypertension remains uncertain. This study examined the impact of previous use of angiotensin-converting enzyme inhibitors (ACEi) and angiotensin receptor blockers (ARB) on the critically ill COVID-19 patients. Methods Data from an international, prospective, observational cohort study involving 354 hospitals spanning 54 countries were included. A cohort of 737 COVID-19 patients with pre-existing hypertension admitted to intensive care units (ICUs) in 2020 were targeted. Multi-state survival analysis was performed to evaluate in-hospital mortality and hospital length of stay up to 90 days following ICU admission. Results A total of 737 patients were included—538 (73%) with pre-existing hypertension had received ACEi/ARBs before ICU admission, while 199 (27%) had not. Cox proportional hazards model showed that previous ACEi/ARB use was associated with a decreased hazard of in-hospital death (HR, 0.74, 95% CI 0.58–0.94). Sensitivity analysis adjusted for propensity scores showed similar results for hazards of death. The average length of hospital stay was longer in ACEi/ARB group with 21.2 days (95% CI 19.7–22.8 days) in ICU and 6.7 days (5.9–7.6 days) in general ward compared to non-ACEi/ARB group with 16.2 days (14.1–18.6 days) and 6.4 days (5.1–7.9 days), respectively. When analysed separately, results for ACEi or ARB patient groups were similar for both death and discharge. Conclusions In critically ill COVID-19 patients with comorbid hypertension, use of ACEi/ARBs prior to ICU admission was associated with a reduced risk of in-hospital mortality following adjustment for baseline characteristics although patients with ACEi/ARB showed longer length of hospital stay. Clinical trial registration The registration number: ACTRN12620000421932; The date of registration: 30, March 2020; The URL of the registration: https://www.australianclinicaltrials.gov.au/anzctr/trial/ACTRN12620000421932.

Advances in cardiac surgical operative techniques and myocardial protection have dramatically improved outcomes in the past two decades. An unfortunate and unintended consequence is that 80% of the preventable morbidity and mortality following cardiac surgery now originates outside of the operating room. Our hope is that a renewed emphasis on evidence-based best practice and standardized perioperative care will reduce overall morbidity and mortality and improve patient-centric care. The Perioperative Quality Initiative (POQI) and Enhanced Recovery After Surgery–Cardiac Society (ERAS® Cardiac) have identified significant evidence gaps in perioperative medicine related to cardiac surgery, defined as areas in which there is significant controversy about how best to manage patients. These five areas of focus include patient blood management, goal-directed therapy, acute kidney injury, opioid analgesic reduction, and delirium.

For yet another year, our lives have been dominated by a pandemic. This year in review, we feature an expert panel opinion regarding extracorporeal support in the context of COVID-19, challenging previously held standards. We also feature survey results assessing the impact of the pandemic on cardiac surgical volume. Furthermore, we focus on a single center experience that evaluated the use of pulmonary artery catheters and the comparison of transfusion strategies in the Restrictive and Liberal Transfusion Strategies in Patients With Acute Myocardial Infarction (REALITY) trial. Additionally, we address the impact of acute kidney injury on cardiac surgery and highlight the controversy regarding the choice of fluid resuscitation. We close with an evaluation of dysphagia in cardiac surgery and the impact of prehabilitation to optimize surgical outcomes.

Background While fast track clinical pathways have been demonstrated to reduce resource utilization in patients undergoing cardiac surgery, it remains unclear as to whether they adversely affect post-operative outcomes. The purpose of this study was to determine the impact of fast tracking on post-operative outcomes following cardiac surgery. Methods In a retrospective study, all patients undergoing first-time, on-pump, non-emergent coronary artery bypass grafting, valve, or coronary artery bypass grafting + valve at a single centre between 2010 and 2017 were included. Patients were considered to have been fast tracked if they were extubated and transferred from intensive care to a step-down unit on the same day as their procedure. The risk-adjusted effect of fast tracking on a 30-day composite of all-cause mortality, stroke, renal failure, infection, atrial fibrillation, and readmission to hospital was determined. Furthermore, propensity score matching was used to match fasting track patients in a 1-to-1 manner with their nearest “neighbor” in the control group and subsequently compared in terms of 30-day post-operative outcomes. Results 3252 patients formed the final study population (fast track: n = 245; control: n = 3007). Patients who were fast tracked experienced reduced time to initial extubation (4.3 vs. 5.6 h, p Conclusion Fast track clinical pathways was associated with reduced intensive care unit, overall length of stay and similar 30-day post-operative outcomes. These results suggest that fast tracking appropriate patients may reduce resource utilization, while maintaining patient safety. Graphical abstract

Objective Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 ‘A’s Test (4AT) is a short ( Methods We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model. Results Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8–32.1%; range 10.5–61.9%). The pooled sensitivity was 0.88 (95% CI 0.80–0.93) and the pooled specificity was 0.88 (95% CI 0.82–0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77–0.92) and the pooled specificity was 0.89 (95% CI 0.83–0.93). The methodological quality of studies varied but was moderate to good overall. Conclusions The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection. PROSPERO Registration number CRD42019133702.

Introduction/background Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty. Purpose The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium. Methods A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder. Main outcomes and measures Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview. Results A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI 0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, p=0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, p=0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium. Conclusion This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.