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OBJECTIVES:. Anemia has been associated with an increased risk of both cardiac arrest and stroke, frequent complications of COVID-19. The effect of hemoglobin level at ICU admission on a composite outcome of cardiac arrest or stroke in an international cohort of COVID-19 patients was investigated. DESIGN:. Retrospective analysis of prospectively collected database. SETTING:. A registry of COVID-19 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with cardiac arrest or stroke up to 30 days after ICU admission. Anemia was defined as: normal (hemoglobin ≥ 12.0 g/dL for women, ≥ 13.5 g/dL for men), mild (hemoglobin 10.0–11.9 g/dL for women, 10.0–13.4 g/dL for men), moderate (hemoglobin ≥ 8.0 and < 10.0 g/dL for women and men), and severe (hemoglobin < 8.0 g/dL for women and men). PATIENTS:. Patients older than 18 years with acute COVID-19 infection in the ICU. INTERVENTIONS:. None. MEASUREMENTS AND MAIN RESULTS:. Of 6926 patients (median age = 59 yr, male = 65%), 760 patients (11.0%) experienced stroke (2.0%) and/or cardiac arrest (9.4%). Cardiac arrest or stroke was more common in patients with low hemoglobin, occurring in 12.8% of patients with normal hemoglobin, 13.3% of patients with mild anemia, and 16.7% of patients with moderate/severe anemia. Time to stroke or cardiac arrest by anemia status was analyzed using Cox proportional hazards regression with death as a competing risk. Covariates selected through clinical knowledge were age, sex, comorbidities (diabetes, hypertension, obesity, and cardiac or neurologic conditions), pandemic era, country income, mechanical ventilation, and extracorporeal membrane oxygenation. Moderate/severe anemia was associated with a higher risk of cardiac arrest or stroke (hazard ratio, 1.32; 95% CI, 1.05–1.67). CONCLUSIONS:. In an international registry of ICU patients with COVID-19, moderate/severe anemia was associated with increased hazard of cardiac arrest or stroke.

Abstract Background Extracorporeal membrane oxygenation (ECMO) is a rescue therapy in patients with severe acute respiratory distress syndrome (ARDS) secondary to COVID-19. While bleeding and thrombosis complicate ECMO, these events may also occur secondary to COVID-19. Data regarding bleeding and thrombotic events in COVID-19 patients on ECMO are sparse. Methods Using the COVID-19 Critical Care Consortium database, we conducted a retrospective analysis on adult patients with severe COVID-19 requiring ECMO, including centers globally from 01/2020 to 06/2022, to determine the risk of ICU mortality associated with the occurrence of bleeding and clotting disorders. Results Among 1,248 COVID-19 patients receiving ECMO support in the registry, coagulation complications were reported in 469 cases (38%), among whom 252 (54%) experienced hemorrhagic complications, 165 (35%) thrombotic complications, and 52 (11%) both. The hazard ratio (HR) for Intensive Care Unit mortality was higher in those with hemorrhagic-only complications than those with neither complication (adjusted HR = 1.60, 95% CI 1.28–1.99, p

Background: Postoperative atrial fibrillation (POAF) is a prevalent complication following cardiac surgery that is associated with increased adverse events. Several guidelines and expert consensus documents have been published addressing the prevention and management of POAF. We aimed to develop an order set to facilitate widespread implementation and adoption of evidence-based practices for POAF following cardiac surgery. Methods: Subject matter experts were consulted to translate existing guidelines and literature into a sample turnkey order set (TKO) for POAF. Orders derived from consistent class I or IIA or equivalent recommendations across referenced guidelines and consensus manuscripts appear in the TKO in bold type. Selected orders that were inconsistently class I or IIA, class IIB, or supported by published evidence appear in italic type. Results: Preoperatively, the recommendation is to screen patients for paroxysmal or chronic atrial fibrillation and initiate appropriate treatment based on individual risk stratification for the development of POAF. This may include the administration of beta-blockers or amiodarone, tailored to the patient's specific risk profile. Intraoperatively, surgical interventions such as posterior pericardiotomy should be considered in selected patients. Postoperatively, it is crucial to focus on electrolyte normalization, implementation strategies for rate or rhythm control, and anticoagulation management. These comprehensive measures aim to optimize patient outcomes and reduce the occurrence of POAF following cardiac surgery. Conclusions: Despite the well-established benefits of implementing a multidisciplinary care pathway for POAF in cardiac surgery, its adoption and implementation remain inconsistent. We have developed a readily applicable order set that incorporates recommendations from existing guidelines.

Despite the benefits established for multiple surgical specialties, enhanced recovery after surgery has been underused in cardiac surgery. A cardiac enhanced recovery after surgery summit was convened at the 102nd American Association for Thoracic Surgery annual meeting in May 2022 for experts to convey key enhanced recovery after surgery concepts, best practices, and applicable results for cardiac surgery. Topics included implementation of enhanced recovery after surgery, prehabilitation and nutrition, rigid sternal fixation, goal-directed therapy, and multimodal pain management.

Background: Post-operative pain is a major factor in surgical recovery. There is evidence that pain remains undermanaged. Complications related to the undermanagement of acute pain can increase length of stay and contribute to readmission and the development of chronic pain. It is well acknowledged that pain assessment is critical to pain management and that self-report of pain is the gold standard. As a result, patients play a central role in their own pain management. A preliminary review of the literature failed to provide a clear or consistent description of this key patient role. Objective: A scoping review was conducted with the objective of reviewing literature that described adult patients’ perspectives or highlighted the adult patient's role in post-operative pain management, including assessment. Understanding patients’ attitudes toward their roles in pain management through a scoping review of the current literature is critical for informing research and improvements in post-operative pain management. Design: Scoping review. Methods: The databases searched for the review included CINAHL, MEDLINE, PubMed, and SCOPUS (ending May 2022). Thematic analysis, using the methodology of Arksey and O'Malley, was applied to the records identified Results: Of the 106 abstracts initially identified, 26 papers were included in the final analysis. Two major themes identified through thematic analysis were attitudes toward pain and pain management, with the subthemes of patient expectations and beliefs and desire to treat; and care and communication, with the subthemes of pain assessment and education. Conclusions: This paper provides one of the first known comprehensive scoping reviews of surgical patients’ perspectives of their role in pain management, including assessment, and offers an important global awareness of this patient role. The findings suggest that improved understanding of patients’ perspectives of their roles in pain assessment and treatment is critical to improving post-operative pain management. Engaging patients as partners in their care can facilitate enhanced communication and improving congruence in pain assessment and treatment decisions. The complex nature of patients’ beliefs, expectations, and subjective experiences of pain present challenges for health care practitioners. These challenges can be met with enhanced education for patients, respect for patients’ beliefs and expectations, and the provision of dignified care.

Objective: 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. Methods: 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. Results: 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. Conclusions: 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.

Background: 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. Methods: 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. Results: 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, P = 0.01). No additional ECG parameters met the criteria for statistical significance. Conclusions: 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. Résumé: Introduction: 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. Méthodes: 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. Résultats: 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 % vs 25 %, rapport de cotes = 3,59, P = 0,01). Aucun autre paramètre ECG ne satisfaisait au critère de signification statistique. Conclusions: 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.

Objectives: The coronavirus disease 2019 (COVID-19) pandemic negatively impacted cardiothoracic (CT) surgery, with changes in clinical, academic, and personal responsibilities. We hypothesized that the pandemic may disproportionately impact female academic CT surgeons, accentuating preexisting sex disparities. This study assessed sex differences in authorship of 2 major CT surgery journals during the early part of the COVID-19 pandemic. Methods: All accepted submissions to The Annals of Thoracic Surgery and The Journal of Thoracic and Cardiovascular Surgery between April and August of 2019 and the same period in 2020 were reviewed. Article type and author characteristics were obtained from the journals. Author sex was predicted using a validated multinational database (Genderize.io) and verified with authors' institutional and public professional profiles. Results: In total, 1106 submissions were accepted during the 2019 period, whereas 900 articles (18.6% decrease) were accepted during the same period in 2020. Original research articles comprised 33.3% of the 2019 articles but only 4.9% of the 2020 articles. Female authors contributed to 39.3% (23.1% original research and 16.2% nonoriginal articles) and 29.4% (3.3% original research and 26.1% nonoriginal articles) of articles during the 2019 and 2020 periods, respectively. This represents a marked change in the type of articles that female authors contributed to. Conclusions: Early on during the COVID-19 pandemic, the type of articles accepted, and authorship demographic changed. There was a decrease in contribution of female-authored CT surgery articles submitted to both journals, especially for original research. Future research will elucidate the long-term impact of the pandemic on sex disparities in academic productivity. Video Abstract:

Abstract 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.

Abstract 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

Abstract 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 .

Abstract Healthcare systems need to adapt to better serve an aging population with complex presentations. Frailty assessments are a potential means to address this heterogeneity in aging to identify individuals at increased risk for adverse health outcomes. Furthermore, frailty assessments offer an opportunity to optimize patient care in various healthcare settings. While the vast number of frailty assessment tools available can be a source of confusion for clinicians, each tool has features adaptable to the constraints and goals of different healthcare settings. This review discusses and compares barriers, facilitators, and the application of frailty assessments in primary care, the emergency department/intensive care unit and surgical care to cover a breadth of settings with different frailty assessment considerations. The implementation of frailty-aware care across healthcare settings potentiates better healthcare outcomes for older adults.

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: 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.

Abstract Background The burden of frailty on cardiac surgical outcomes is incompletely understood. Here we perform a systematic review and meta-analysis of studies comparing frail versus pre-frail versus non-frail patients following cardiac surgery. Methods We searched MEDLINE and EMBASE databases until July 2018 for studies comparing cardiac surgery outcomes in “frail”, “pre-frail” and “non-frail” patients. Data was extracted in duplicate. Primary outcome was operative mortality. Results There were 19 observational studies with 66,448 patients. Frail patients were more likely female (risk ratio [RR]1.7; 95%CI:1.5–1.9), older (mean difference: 2.4; 95%CI:1.3–3.5 years older) with greater comorbidities and higher STS-PROM. Frailty (RR2.35; 95%CI:1.57–3.51; p

The importance and value of engaging patients and the public as co-researchers (i.e., “patient engagement in research”) is becoming more evident, and guiding methods must be available for researchers conducting their work at different points along the engagement spectrum. This article provides a virtual workshop model for integrating patient and public stakeholder perspectives in data analysis and interpretation. The model is based upon a critical reflection on the methods that underlaid the consultation stage of our scoping review on patient and caregiver preferences for cardiac surgery. It involves four virtual workshop sessions held on separate days, each achieving the unique goals of (a) establishing participants’ technological literacy within the virtual platform, (b) obtaining responses to the research question, (c) introducing participant perspectives into research analysis and interpretation, and (d) prioritizing research findings or future research agendas. Further, a description of the considerations related to virtual engagement, including those pertaining to equity, diversity, and inclusion; features of the virtual platform; and roles for the research team are provided. This paper contributes toward a methodological toolkit for patient engagement in research, especially as an adjunct to research with otherwise minimal patient engagement. It also adds to the emerging literature on practical approaches to patient engagement in research as more engagement is occurring virtually.

Mobile Health (mHealth) technologies are becoming integral to our healthcare system. This study evaluated the feasibility (compliance, usability and user satisfaction) of a mHealth application (app) for delivering Enhanced Recovery Protocols (ERPs) information to Cardiac Surgery (CS) patients peri-operatively. This single centre, prospective cohort study involved patients undergoing CS. Patients received a mHealth app developed for the study at consent and for 6–8 weeks post-surgery. Patients completed system usability, patient satisfaction and quality of life surveys pre- and post-surgery. A total of 65 patients participated in the study (mean age of 64 years). The app achieved an overall utilization rate of 75% (68% vs 81% for 65 and

Abstract 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.

IntroductionNeurological complications are frequent in patients with coronavirus disease-2019 (COVID-19). The use of non-invasive neuromonitoring in subjects without primary brain injury but with potential neurological derangement is gaining attention outside the intensive care unit (ICU). This systematic review and meta-analysis investigates the use of non-invasive multimodal neuromonitoring of the brain in non-critically ill patients with COVID-19 outside the ICU and quantifies the prevalence of abnormal neuromonitoring findings in this population.MethodsA structured literature search was performed in MEDLINE/PubMed, Scopus, Cochrane, and EMBASE to investigate the use of non-invasive neuromonitoring tools, including transcranial doppler (TCD); optic nerve sheath diameter (ONSD); near-infrared spectroscopy (NIRS); pupillometry; and electroencephalography (EEG) inpatients with COVID-19 outside the ICU. The proportion of non-ICU patients with CVOID-19 and a particular neurological feature at neuromonitoring at the study time was defined as prevalence.ResultsA total of 6,593 records were identified through literature searching. Twenty-one studies were finally selected, comprising 368 non-ICU patients, of whom 97 were considered for the prevalence of meta-analysis. The pooled prevalence of electroencephalographic seizures, periodic and rhythmic patterns, slow background abnormalities, and abnormal background on EEG was.17 (95% CI 0.04–0.29), 0.42 (95% CI 0.01–0.82), 0.92 (95% CI 0.83–1.01), and.95 (95% CI 0.088–1.09), respectively. No studies investigating NIRS and ONSD outside the ICU were found. The pooled prevalence for abnormal neuromonitoring findings detected using the TCD and pupillometry were incomputable due to insufficient data.ConclusionsNeuromonitoring tools are non-invasive, less expensive, safe, and bedside available tools with a great potential for both diagnosis and monitoring of patients with COVID-19 at risk of brain derangements. However, extensive literature searching reveals that they are rarely used outside critical care settings.Systematic Review Registration:www.crd.york.ac.uk/prospero/display_record.php?RecordID=265617, identifier: CRD42021265617.

Abstract This study examined whether immediate post-exercise systolic blood pressure (SBP) is associated with arterial compliance in middle-aged and older normotensive females. A total of 548 normotensive, non-frail females aged 55 years and older with no previous history of cardiovascular disease (CVD) participated in this cross-sectional study. Large and small arterial compliance were assessed by pulse wave analysis. Reduced arterial compliance was defined based on age and sex cutoffs. SBP was measured at rest and immediately following a 3-min moderate step-test. CVD risk factors were also assessed (e.g. resting systolic and diastolic BP, fasting glucose, triglycerides, cholesterol, body mass index). A total of 15.1% and 44.0% of the participants showed reduced large and small artery compliance, respectively. Immediate post-exercise SBP was associated with reduced large (OR 1.02 per 1 mmHg increase in post-exercise SBP, 95%CI 1.01–1.04; p = 0.010) and small (OR 1.02 per 1 mmHg increase in post-exercise SBP, 95%CI 1.00–1.03; p = 0.008) arterial compliance. Participants with highest immediate post-exercise SBP (quartile 4; i.e. ≥ 165 mmHg) showed increased odds ratios for reduced large (2.67, 95%CI 1.03–6.94; p = 0.043) and small (2.27, 95%CI 1.22–4.21; p = 0.010) arterial compliance compared to those with the lowest immediate post-exercise SBP (quartile 1; i.e. ≤ 140 mmHg), independent of other established CVD risk factors. Immediate post-exercise SBP following a brief moderate step-test seems to be able to discriminate reduced arterial compliance in middle-aged and older normotensive females.

Background: There is growing evidence that SARS-Cov-2 infection is associated with severe neurological complications. Understanding the nature and prevalence of these neurologic manifestations is essential for identifying higher-risk patients and projecting demand for ongoing resource utilisation. This review and meta-analysis report the neurologic manifestations identified in hospitalised COVID-19 patients and provide a preliminary estimate of disease prevalence.Methods: MEDLINE, Embase and Scopus were searched for studies reporting the occurrence of neurological complications in hospitalised COVID-19 patients.Results: A total of 2,207 unique entries were identified and screened, among which 14 cohort studies and 53 case reports were included, reporting on a total of 8,577 patients. Central nervous system manifestations included ischemic stroke (n = 226), delirium (n = 79), intracranial haemorrhage (ICH, n = 57), meningoencephalitis (n = 13), seizures (n = 3), and acute demyelinating encephalitis (n = 2). Peripheral nervous system manifestations included Guillain-Barrè Syndrome (n = 21) and other peripheral neuropathies (n = 3). The pooled period prevalence of ischemic stroke from identified studies was 1.3% [95%CI: 0.9–1.8%, 102/7,715] in all hospitalised COVID-19 patients, and 2.8% [95%CI: 1.0–4.6%, 9/318] among COVID-19 patients admitted to ICU. The pooled prevalence of ICH was estimated at 0.4% [95%CI: 0–0.8%, 6/1,006].Conclusions: The COVID-19 pandemic exerts a substantial neurologic burden which may have residual effects on patients and healthcare systems for years. Low quality evidence impedes the ability to accurately predict the magnitude of this burden. Robust studies with standardised screening and case definitions are required to improve understanding of this disease and optimise treatment of individuals at higher risk for neurologic sequelae.

Patients following cardiac surgery commonly experience post-operative delirium (POD) during their postoperative hospital stay. A multifaceted, specialty wide, quality improvement (QI) project was undertaken for patients experiencing POD. The goal was to develop a reduction in POD care bundle (rPOD-a structured patient care program) that encompasses efficient preoperative risk factor identification and a postoperative patient-care process to ensure early POD identification and treatment. The following steps were taken to implement the rPOD care bundle including: (a) Developing a quality driven, evidence-based guideline for the perioperative cardiac surgery health care team, (b) identifying and addressing local barriers to implementation, (c) selecting performance measures to assess intervention adherence and patient outcomes, and (d) ensuring that all patients receive the interventions through staff engagement and education, and regular project evaluation. Trends of process measures and quality improvement measures were examined. An increasing trend in the rate of postoperative delirium screening during implementation of rPOD intervention was demonstrated. This quality improvement study provides a bases for future postoperative delirium reduction interventions.

Acute kidney injury (AKI) is a potentially fatal complication of cardiac surgery. The inability to predict cardiac surgery-associated AKI is a major barrier to prevention and early treatment. Current clinical risk models for the prediction of cardiac surgery-associated AKI are insufficient, particularly in patients with preexisting kidney dysfunction. Methods: To identify intraoperative variables that might improve the performance of a validated clinical risk score (Cleveland Clinic Score, CCS) for the prediction of cardiac surgery-associated AKI, we conducted a prospective cohort study in 289 consecutive elective cardiac surgery patients at a tertiary care center. We compared the area under the receiver operator characteristic curve (AUC) of a base model including only the CCS with models containing additional selected intraoperative variables including mean arterial pressure, hematocrit, duration of procedure, blood transfusions, and fluid balance. AKI was defined by the Kidney Disease Improving Global Outcomes 2012 criteria. Results: The CCS alone gave an AUC of 0.72 (95% confidence interval, 0.62–0.82) for postoperative AKI. Nadir intraoperative hematocrit was the only variable that improved AUC for postoperative AKI when added to the CCS (AUC = 0.78; 95% confidence interval, 0.70–0.87; P = 0.002). In the subcohort of patients without preexisting chronic kidney disease (n = 214), where the CCS underperformed (AUC, 0.60 [0.43–0.76]), the improvement with the addition of nadir hematocrit was more marked (AUC, 0.74 [0.62–0.86]). Other variables did not improve discrimination. Discussion: Nadir intraoperative hematocrit is useful in improving discrimination of clinical risk scores for AKI, and may provide a target for intervention.

Background: Acute kidney injury (AKI) following cardiac surgery leads to increased morbidity and mortality. Characterization and validation of early biomarkers of AKI may ultimately facilitate early therapeutic intervention. We have previously identified that elevated urinary hepcidin-25 is inversely and independently associated with the development of AKI in adult cardiac surgery patients. Hepcidin-25 is an antimicrobial peptide that sequesters iron intracellularly, and its elevation following human ischemia reperfusion injury may represent a renoprotective response to minimize renal injury. Objective: Our goal was to validate urinary hepcidin-25 as a non-invasive biomarker in an independent cardiac surgery cohort, within the context of clinical AKI predictors. Design: Prospective observational cohort study. Setting: Adult cardiac surgery program at St. Boniface Hospital, Winnipeg, Manitoba, Canada. Patients: Adult cardiac surgery patients undergoing cardiopulmonary bypass (CPB), n = 306. Measurements: Urine hepcidin-25, measured on post-operative day (POD) 1. Methods: A prospective, observational cohort of adult CPB patients (n = 306) was collected with serial perioperative urine samples. Urine hepcidin-25 at POD 1 was measured by competitive ELISA. Its diagnostic performance was evaluated in conjunction with clinical parameters and the Thakar clinical prediction score, using multivariate logistic regression. Results: Urinary hepcidin-25 is elevated following cardiac surgery in AKI and non-AKI patients. Elevated urinary hepcidin-25 concentration was inversely associated with AKI on both univariate (odds ratio [OR]: 0.61, 95% confidence interval [CI]: 0.45-0.83, P = .002) and multivariate analysis (OR: 0.67, 95% CI: 0.50-0.95, P = .02). A combined model with clinical risk factors demonstrated that baseline estimated glomerular filtration rate (eGFR), diabetes mellitus, and urinary hepcidin-25 concentration had an overall area under the curve (AUC) of 0.82 (0.75-0.88) for predicting subsequent AKI development, which was superior to clinical prediction alone as determined by the Thakar score. Limitations: (1) A single-center observational study. (2) Polyclonal antibody–based competitive ELISA. Conclusion: Hepcidin-25 is inversely associated with AKI in a multivariate model when combined with eGFR and diabetes mellitus, with an overall AUC of 0.82. Notably, urinary hepcidin-25 improves on clinical AKI prediction compared to the Thakar score alone.

BackgroundProlonged intensive care unit length of stay (prICULOS) following cardiac surgery (CS) in older adults is increasingly common but rehospitalization characteristics and outcomes are understudied. We sought to describe the rehospitalization characteristics and subsequent non‐institutionalized survival of prICULOS (ICULOS ≥5 days) patients and identify modifiable risk factors to decrease 30‐day rehospitalization. Methods and ResultsConsecutive patients from January 1, 2000 to December 31, 2011 were analyzed utilizing linked clinical and administrative databases. Logistic regression was used to identify risk factors associated with 30‐day rehospitalization. Out of 9210 consecutive patients discharged from the hospital alive, 596 (6.5%) experienced prICULOS. Cumulative incidence of rehospitalization for the prICULOS cohort at 30 and 365 days was 17.5% and 45.6% versus 11.4% and 28.1% for non‐prICULOS (P

After seven-day exposure to 0.5-Tesla Static Magnetic Field (SMF), Adipose-derived Stem Cells (ASCs) and those labeled by superparamagnetic iron oxide (SPIO) nanoparticles were examined for viability by methyl thiazol tetrazolium (MTT) assay, proliferation by cell counting and bromodeoxyuridine (BrdU) incorporation, DNA integrity by single cell gel electrophoresis, surface antigen by flow cytometry analysis, and the expression of cytokines and genetic markers by reverse transcription-PCR and underwent adipogenic and osteogenic differentiation assessed by quantifying related specific genes expression. The SMF slightly reduced cell viability and proliferation and inhibited the expression of CD49d, CD54, and CD73 but did not damage DNA integrity. The SMF slightly downregulated the expression of cytokines including Vascular Endothelial Growth Factor (VEGF), Insulin-like Growth Factor-1 (IGF-1), Transforming Growth Factor Beta 1 (TGF-β1), genetic markers comprising Stem Cell Antigen-1 (Sca1), Octamer-4 (Oct-4), ATP-binding Cassette Subfamily B Member 1 (ABCB1), adipogenic marker genes containing Lipoprotein Lipase (LPL), Peroxisome Proliferator-Activated Receptor Gamma (PPAR-γ), and osteogenic marker genes including Secreted Phosphor-protein 1 (SPP1) and Osterix (OSX). Exposure to 0.5 T SMF for seven days inhibited viability, proliferation, surface antigen expression, cytokine secretion, stem cell genetic marker expression, and adipogenic and osteogenic differentiation but did not affect the DNA integrity in ASCs with or without SPIO labeling.

Adipose-derived stem cells (ASCs) from subcutaneous and visceral adipose tissues have been studied individually. No studies have compared their abilities in treatment of heart failure. This study was designed to evaluate whether ASCs from the two sources could provide a long-term improvement of cardiac function in infarcted hearts. Rat subcutaneous and visceral adipose tissues were excised for isolation of ASCs. Morphology, yield, proliferation, surface markers, differentiation, and cytokine secretion of the subcutaneous ASCs (S-ASCs) and visceral ASCs (V-ASCs) were analyzed. Then a rat model of myocardial infarction (MI) was established by a coronary occlusion. Seven days after occlusion, S-ASCs ( n = 22), V-ASCs ( n = 22), and Dulbecco's modified Eagle medium (DMEM, n = 20) were injected into the infarct rim, respectively. Cardiac function was then monitored with MRI for up to 6 months. The hearts were then removed for histological assessments. The yield of V-ASCs per gram of the visceral adipose depot was significantly greater than that of S-ASCs in 1 g of the subcutaneous adipose depot. On the other hand, the S-ASCs showed a greater proliferation rate and colony-forming unit relative to the V-ASCs. In addition, the infarcted hearts treated with either S-ASCs or V-ASCs showed a significantly greater left ventricular ejection fraction (LVEF) than those treated with DMEM at 4 weeks and 6 months following the cell/DMEM transplantation. Moreover, the infarct sizes of both S-ASC- and V-ASC-treated hearts were significantly smaller than that in the DMEM-treated hearts. MRI showed the implanted ASCs at the end of 6 months of recovery. Despite the differences in cell yield, proliferation, and colony formation capacity, both S-ASCs and V-ASCs provide a long-lasting improvement of cardiac contractile function in infarcted hearts. We conclude that the subcutaneous and visceral adipose tissues are equally effective cell sources for cell therapy of heart failure.