BackgroundThe relationship between rewarming rate during cardiopulmonary bypass (CPB) and postoperative delirium (POD) in cardiac surgery remains unclear. This retrospective study aimed to evaluate whether rapid rewarming is associated with an increased risk of POD.MethodsA total of 548 adult cardiac surgery patients (January 2021-December 2023) were enrolled. POD was identified through medical record review based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)criteria or documented delirium symptoms combined with olanzapine use (serving as a surrogate marker). Rewarming rate was defined as the average temperature increase per minute from the lowest nasopharyngeal temperature during CPB to 36.5°C, calculated as (36.5°C - lowest temperature)/rewarming time (min). Multivariable logistic regression and ROC analysis were performed.ResultsRewarming rate was significantly higher in the POD group (n = 300) than the non-POD group (n = 248) (0.095 ± 0.044 vs 0.072 ± 0.034°C/min, p < 0.001). Olanzapine dosage (18.5 ± 8.2 mg vs 0 mg) and duration (4.2 ± 2.1 days vs 0 days) in the POD group showed significant positive correlations with rewarming rate (r = 0.887 and r = 0.814, respectively, both p < 0.01). Rewarming rate (OR = 1.782), red blood cell transfusion (OR = 1.456), CPB duration (OR = 1.023), and mean CVP (OR = 1.156) were identified as independent risk factors for POD (all p < 0.05). The predictive model achieved an AUC of 0.775 (95% CI: 0.736-0.814).ConclusionsRapid rewarming during CPB is associated with increased POD risk and may be a modifiable perioperative factor. Prospective studies with standardized POD screening are warranted to validate these findings.
BackgroundFrailty is increasingly recognized as a key determinant of outcomes in critically ill patients, yet its utility among patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO) remains unclear. We evaluated the hospital frailty risk score (HFRS) as a risk factor of 90-day mortality in VA ECMO patients.MethodsWe conducted a retrospective analysis of VA ECMO patients at Johns Hopkins Hospital from 2016 to 2024. HFRS was derived from ICD-10 codes. An optimal frailty cut point was determined using maximally selected rank statistics, and patients were subsequently stratified into high (>10) and low (<=10) frailty groups. Cox proportional hazards models evaluated the association between frailty and mortality, adjusting for demographics, comorbidities, and clinical variables.Results180 patients receiving VA ECMO were included (median age:53 years, 46.2% female). Overall, 25 patients (13.9%) were classified as high frailty (HFRS >10) and 155 (86.1%) as low frailty (HFRS≤10). Of the 180 patients, 80 patients survived 90-days following initial ECMO cannulation. Median HFRS was higher among non-survivors (4.9 vs 3.4), with a greater proportion classified as high frailty (18.0% vs 8.8%). In multivariable Cox regression adjusting for demographics, comorbidities, and clinical covariates, low HFRS remained independently associated with reduced 90-day mortality (HR=0.47, 95% CI 0.26-0.87, p=0.017), while obesity (HR=10.44) and older age (HR 1.02) were independently associated with increased mortality.ConclusionHFRS is independently associated with 90-day mortality in patients undergoing VA ECMO. Incorporating frailty into pre-ECMO evaluation may enhance prognostication and inform patient selection and clinical decision-making.
IntroductionSevere congenital diaphragmatic hernia (CDH) is associated with significant morbidity and mortality. Pre/post-natal risk factors guide decisions on extracorporeal membrane oxygenation (ECMO) intervention. We aimed to describe variations in ECMO decision-making for neonatal CDH.MethodsWe distributed a practice-based survey (October 2023) to assess institutional ECMO guidelines for neonatal CDH. Respondents included neonatal/pediatric intensivists, surgeons, and ECMO coordinators. We used descriptive statistics for analysis.ResultsFormal CDH management guidelines were reported by 60 (77%) from 82 respondents across 12 countries. The most common exclusion criteria were prematurity (73%), low birthweight (72%), and aneuploidy (58%). Pre-existing neurological complications, single ventricle palliation heart disease, and genetics-related poor neurodevelopmental prognosis were the most cited exclusion criteria independent of CDH severity.ConclusionSignificant practice variation exists in the exclusion criteria for ECMO in neonatal CDH. There remains an opportunity for a more unified approach regarding ECMO use in infants with severe CDH.
IntroductionExtracorporeal Membrane Oxygenation (ECMO) is a highly complex support modality that requires specialized training for successful and optimal management and patient care. Literature regarding ECMO education provided to pediatric subspecialty physicians is limited. We conducted a survey study of pediatric critical care medicine (PCCM), neonatal-perinatal medicine (NPM), and pediatric surgery (PS) fellowship directors with the goal of understanding the extent of ECMO education offered in these training programs.MethodsSurveys were sent via email to 77 PCCM, 110 NPM, and 51 PS directors.ResultsThe overall response rate was 56%, with PCCM fellowship directors being the highest percentage of respondents. Most fellowships provided separate ECMO training in the form of a course, typically lasting ≤2 days and primarily conducted for first-year fellows. Other ECMO educational opportunities included lectures, simulation, and case-based discussions. A majority of the responding fellowship directors in PCCM and PS felt that ECMO management was a core competency of training (96% PCCM, 95% PS). However, a minority reported a formal assessment of ECMO management competency.ConclusionThis study highlights substantial variation in ECMO educational practices and limited competency evaluation across pediatric subspecialty training programs.
IntroductionDeep hypothermia (DH) has been widely adopted for cerebral and visceral protection during pediatric cardiac surgery, but concerns about perioperative complications remain. This meta-analysis aims to evaluate the impact of DH compared to moderate hypothermia (MH) on outcomes in pediatric cardiac surgery patients.MethodsFollowing a PRISMA-compliant systematic search in PubMed, Cochrane, and Embase, eligible studies comparing DH (<22°C) with MH (22-30°C) in pediatric cardiac surgery were assessed. Risk of bias was evaluated using the ROBINS-I tool.ResultsFive comparative studies with 448 patients (250 in the MH group and 198 in the DH group) were included. Baseline characteristics were similar between groups, with the majority of patients undergoing aortic arch repairs. Perioperative variables were also similar, except for cross-clamp time, which was significantly longer in the DH group (p = 0.02), and circulatory arrest was more frequently used in DH patients (p = 0.01). No significant differences were found in overall postoperative complication rates, acute kidney injury, 24-h chest drainage volume, or in-hospital mortality. However, the incidence of early postoperative neurological complications was significantly higher in the DH group (p < 0.001).ConclusionsModerate hypothermia may be associated with a significantly lower incidence of postoperative neurological complications compared to deep hypothermia, while overall in-hospital mortality and morbidity rates remained similar between the two groups. Taken together, these findings support moderate hypothermia with regional perfusion as a clinically feasible and well-tolerated alternative to deep hypothermia in pediatric cardiac surgery.
IntroductionGoal-directed perfusion during cardiopulmonary bypass (CPB) has traditionally focused on indexed oxygen delivery (DO2i), yet metabolic behavior during aortic cross-clamping likely reflects a more complex interaction among oxygen delivery, oxygen extraction (O2ER), and temperature-dependent oxygen demand. We aimed to identify temperature-adjusted perfusion-metabolic phenotypes during cross-clamping and to explore their association with early postoperative outcomes.MethodsIn this retrospective single-center study, perfusion data (restricted to the aortic cross-clamp period) were linked with clinical data at the case level. Variables' trajectories were normalized in time, resampled at 15 equidistant points, and represented using DO2i, O2ER, and temperature-adjusted indexed oxygen consumption and carbon dioxide production corrected to 37°C with a Q10-based approach (VO2i_37eq and VCO2i_37eq). Principal component analysis and k-means clustering were applied. Logistic regression was used to assess the association between cluster membership and postoperative acute kidney injury (AKI) according to KDIGO criteria.ResultsSeventy patients were included (mean age 64.3 years, 35.7% females). A 3-cluster solution identified a low-extraction/low-metabolic-demand phenotype, a high-delivery/compensated-metabolic-demand phenotype, and a high-extraction/high-metabolic-stress phenotype. The latter showed the highest incidence of AKI of any stage (53.1%, p = 0.034), the highest incidence of stage 2-3 AKI (18.8%), greater postoperative creatinine increase, and longer intensive care unit stay. In multivariable logistic regression, this phenotype remained associated with postoperative AKI after exploratory multivariable adjustment.ConclusionsTemperature-adjusted unsupervised analysis of perfusion trajectories identified three physiologically coherent phenotypes. The high-extraction/high-metabolic-stress phenotype was associated with the least favorable early postoperative renal profile, supporting a GDP framework beyond DO2i alone.
BackgroundVeno-venous extracorporeal membrane oxygenation (VV ECMO) is an advanced therapy for patients with respiratory failure refractory to conventional management. Volume overload and elevated lactate levels have been associated with poor outcomes in medical patients with respiratory failure managed with VV ECMO, but this has not been studied in trauma patients.MethodsThis was a single-center retrospective study of trauma patients treated with VV ECMO between 2014 and 2024. Associations between in-hospital survival and (1) lactate trends before and after cannulation, and (2) fluid balance before and after cannulation were analyzed. We determined lactate clearance using linear regression of serial values, and assessed fluid balance in 12-h intervals normalized to the time of cannulation.ResultsSeventy-eight patients were included, with an overall survival rate of 69%. Survivors exhibited lower pre-cannulation lactate levels (4.7 mmol/L vs. 12.4 mmol/L, p < 0.001) and lower cumulative pre-ECMO fluid balance (2.1 L vs. 5.6 L, p = 0.03). Pre-cannulation lactate clearance was significantly greater among survivors (-0.37 ± 0.16 mmol/L per hour vs. +0.09 ± 0.12 mmol/L per hour, p = 0.02). Post-cannulation trends in lactate and volume status were not associated with mortality. Mortality risk increased sharply beyond a cumulative +3.5 L fluid balance at cannulation. Combined modeling showed lowest survival when lactate exceeded 10 mmol/L and fluid balance surpassed +3 L.ConclusionsIn trauma patients undergoing VV ECMO, both impaired lactate clearance and positive fluid balance prior to cannulation were associated with increased mortality, while post-cannulation changes were not. A pre-ECMO fluid balance exceeding +3.5 L was an inflection point associated with increased mortality risk. These findings suggest that lactate clearance and volume overload may have prognostic value before ECMO initiation in trauma populations.
IntroductionMyocardial protection is crucial in heart surgery to minimize ischemia-reperfusion injury. Del Nido cardioplegia has demonstrated clinical advantages; however, cost-effectiveness data over Custodiol remain scarce. We aimed to assess whether Del Nido could achieve comparable clinical outcomes at lower costs.MethodsA retrospective single-center study was conducted on patients ≥18 years undergoing isolated surgical aortic valve replacement between 2009-2023. Patients received either Custodiol or Del Nido cardioplegia at the discretion of the surgical team. 30-day major adverse cardiac events (MACE) outcomes were extracted from medical records. Cost data was collected from hospital records. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics and mitigate indication bias. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic sensitivity analyses were performed using Monte Carlo simulations.Results179 patients were included (58 Custodiol, 121 Del Nido). While both alternatives had similar 30-day survival (98.3%) and MACE-free survival (88.4% vs. 89.7%), the cost for Del Nido was lower (41,761 USD vs. 47,599 USD). Using the IPTW-weighted sample, an ICER of 123,363 USD for Custodiol favored Del Nido, particularly under local willingness-to-pay thresholds of 6,947-20,841 USD. Probabilistic sensitivity analyses confirmed the robustness of these findings, with Del Nido being cost-effective in up to 75.5% simulations.ConclusionsDel Nido cardioplegia offers a cost-effective alternative to Custodiol, providing similar clinical outcomes at lower costs. These findings support the adoption of Del Nido in resource-limited settings, emphasizing value-based care in cardiac surgery.
ObjectiveDurable repair of penetrating cardiac injuries remains technically challenging, particularly when performed under load in the absence of cardiopulmonary bypass. Conventional sutures are prone to tear-out under dynamic wall stress, and current ex vivo models fail to replicate realistic ventricular mechanics. This study presents a physiologically relevant ex vivo platform, termed the Pseudo-Beating Heart (PBH) model, for evaluating myocardial injury mechanics and suture performance under controlled pulsatile ventricular loading.MethodsFresh porcine hearts were prepared and equipped with a dual-balloon system simulating ventricular preload, afterload, and cyclic ventricular deformation (80 bpm). Intraventricular pressures were recorded continuously, and wall tension was estimated using a thick-wall Laplace model. Standardized transmural injuries (1 cm) were introduced to assess cleft widening and pressure loss under cyclic loading. Hysteresis loop areas were calculated to characterize viscoelastic fatigue. Hearts were obtained from unrelated terminal animal studies in accordance with 3R principles; no animals were sacrificed specifically for this model.ResultsPhysiologically relevant ventricular pressure ranges (LV: 130/10 mmHg; RV: 40/8 mmHg) were stably maintained. Transmural injuries produced reproducible wound gaping (up to 6.1 cm) and pressure loss (10-17%). Wall tension and hysteresis behavior correlated with published biomechanical data. The model enabled consistent evaluation of repair techniques under defined mechanical load.ConclusionThe PBH model provides a reproducible, physiologically relevant ex vivo platform for testing myocardial repair strategies under pulsatile ventricular loading. It offers potential value as a low-resource, ethically compliant simulator to bridge the gap between bench-top testing and subsequent in vivo validation of trauma repair techniques and extracorporeal support strategies.
BackgroundSnakebite envenomation is a global health problem, though rarely encountered in Europe outside captive settings. The Western diamondback rattlesnake (Crotalus atrox) is one of the most medically important North American pit vipers, with venom capable of provoking profound coagulation disorders and systemic toxicity. Respiratory complications are exceedingly rare, and the role of extracorporeal membrane oxygenation (ECMO) in this context has not been previously described.Case presentationWe report the case of a 36-year-old man who sustained a facial bite from a captive Crotalus atrox. On arrival, he presented with rapidly progressive facial and pharyngeal edema requiring emergent intubation. Laboratory investigations revealed disseminated intravascular coagulation (DIC), characterized by thrombocytopenia, hypofibrinogenemia, prolonged INR and aPTT, markedly elevated D-dimers, and ROTEM evidence of impaired clot formation. High-dose antivenom and targeted factor replacement were administered. Within hours, the patient developed pulmonary hemorrhage and acute respiratory distress syndrome (ARDS), unresponsive to maximal conventional therapy. Veno-venous extracorporeal membrane oxygenation (V-V ECMO) was initiated as rescue support, resulting in rapid stabilization of gas exchange. The subsequent ICU course was complicated by acute kidney injury and seizures during sedation tapering, all managed successfully. ECMO was explanted on the 4th postcannulation day, tracheostomy was performed on the 6th postcannulation day, and the patient was decannulated on the 16th postcannulation day. He was discharged home on the 22nd postcannulation day in good general condition, without residual organ dysfunction.ConclusionThis case highlights the potential for Crotalus atrox envenomation to cause fulminant systemic complications including DIC and ARDS. It also demonstrates that V-V ECMO can be safely and effectively applied as salvage therapy in venom-induced ARDS, provided it is initiated promptly within specialized centers.
IntroductionSerum aquaporin-1 increases with inflammation and edema. However, its role as a cardiovascular biomarker remains unexplored. The goal of this study is to evaluate serum aquaporin-1 concentrations across two distinct clinical settings characterized by myocardial stress and congestion: acute heart failure and surgical aortic valve replacement with cardiopulmonary bypass.MethodsThis observational study included healthy volunteers (n = 8), acute heart failure patients (n = 11), and surgical aortic valve replacement patients (n = 11). Serum aquaporin-1 was measured using ELISA. Myocardial biopsies were obtained for aquaporin-1 and aquaporin-4 protein quantification before and after cardiopulmonary bypass in six patients.ResultsSerum aquaporin-1 levels were significantly higher in acute heart failure (3,921 ± 1,396 pg/mL; p = 0.0006) and surgical aortic valve replacement patients (3,318 ± 1,394 pg/mL; p = 0.0070) compared to healthy volunteers (1,755 ± 807 pg/mL). These differences remained significant after adjusting for sex and age. All patients with low cardiac output had serum aquaporin-1 concentrations in the upper half of their group distribution. Serum aquaporin-1 correlated moderately with B-type natriuretic peptide (r = 0.40; p = 0.0265), C-reactive protein (r = 0.42; p = 0.0203), and erythrocyte sedimentation rate (r = 0.45; p = 0.0117). Following cardiopulmonary bypass, myocardial aquaporin-1 increased (73%; p = 0.0310), while aquaporin-4 decreased (53%; p = 0.0440), with a strong but non-significant correlation between cardiac and serum aquaporin-1 changes.ConclusionSerum aquaporin-1 levels are elevated in acute heart failure and post-surgical aortic valve replacement patients, particularly in those with low cardiac output.
Introduction The blood pump is a central component of the extracorporeal life support (ECLS) circuit. Modern centrifugal and diagonal pumps are mainly used in preference to roller pumps. Compared to roller pumps, centrifugal and diagonal pumps offer lower priming volume, less hemolysis and enable miniaturization of circuits. Drawback is the open design promoting internal recirculation, which influences performance and, in few studies at low flow, may increase risk of coagulation activation and hemolysis. The aim of this work was to provide performance data on available pumps. Methods Manufacturers were asked to lend ECLS consoles and donate pump samples for the study. No financial support was accepted. Missing pumps were bought by the investigators. In a mock-loop, measurements of volume flow and pressures were performed. Pumps were assessed over the operating flow range stated by the manufacturer at different preloads and afterload levels. Results Eight different ECLS pumps were tested, two available for pediatric use and six for adult use. Six pumps were centrifugal and two were of diagonal design. All were magnetically driven and three were magnetically levitated. Five had impellers with shrouded (covered) design. Water or water-glucose were used as a test fluid and choice of medium is herewith also discussed. Flow-pressure maps for each pump were generated over its operating range. As agreed with manufacturers, no direct comparisons between pumps were made. Conclusions Performance curves for blood pumps designed for ECLS use in children and adults were reported and important aspects of design features discussed to support clinicians.
Length of hospitalization post coronary artery bypass grafting is a critical marker for the post-operative recovery and quality of life of the individual along with healthcare resource utilization but it varies significantly across individuals and depends on numerous factors. The existing predictive models that are developed have a variety of factors that predict the length of hospitalization but no universally accepted fixed set of variables exist currently. The study aimed to establish a consensus among the variables that should be included in the development of a predictive model for length of hospitalization post coronary artery bypass grafting surgery where the expert panel comprised of cardiothoracic surgeons, cardiologists, physiotherapists and nursing professionals answered multiple questions related to factors that can affect the recovery of an individual. Consensus was predefined as more than 75% agreement among the experts. Strong consensus was achieved after one round for inclusion of preoperative co-morbidities, pre operative cardiac functions and experts concluded that patient reported outcomes also act as predictors for recovery of an individual and should be included in the predictive model. This consensus study provides a strong foundation for developing a clinically relevant, patient-centred predictive model to assist in predicting the hospitalization duration, improve the recovery of the individual along with optimum hospital resource allocation.
Asthma is a common chronic respiratory disease where exacerbations can be associated with significant morbidity, mortality, and economic burden. Severe asthma exacerbations (SAEs) represent life-threatening episodes of symptom burden that require intensive care treatment. While outpatient asthma management is well-established by major organizational guidelines, there are limited evidence-based recommendations for treatment of SAEs requiring intensive care. This narrative review synthesizes current literature regarding conventional inpatient asthma therapies, ventilation strategies, and emerging rescue modalities for management of SAEs, including inhaled anesthetics and veno-venous extracorporeal membrane oxygenation and discusses future areas of interest for research. Until more robust clinical data is available, intensivists should weigh the potential risks and benefits of more advanced rescue therapies and consider a multidisciplinary approach to determining those most likely to benefit from these interventions.
Goal directed perfusion (GDP) aims to maintain an O 2 delivery above 270-300 ml/min/m 2 , during cardiopulmonary bypass. This strategy decreases the incidence of postoperative acute kidney injury. We first developed a simple physiological hypothesis that explained why maintaining an indexed DO 2 above 280-300 ml/min/m 2 could optimize organ protection during bypass, then we propose to tailor the O 2 supply to patient real time VO 2 as an individualized strategy, to optimize supply to metabolism need.
Background Infective endocarditis is a life-threatening condition requiring surgical intervention in certain cases. Despite advances in surgical techniques and medical management, postoperative mortality remains high. Preoperative optimisation, including the assessment of preoperative albumin levels, may play a crucial role in improving surgical outcomes. This systematic review and meta-analysis examine the relationship between preoperative albumin levels and in hospital mortality of patients undergoing cardiac surgery for IE. Materials & Methods Following the PRISMA guidelines, a comprehensive search of PubMed, MEDLINE via Ovid, Embase, Scopus, ClinicalGov, and Cochrane CENTRAL was performed. Studies including patients with IE who underwent cardiac surgery with documented preoperative albumin levels were selected. Data extraction and quality assessment were performed using the Newcastle-Ottawa Scale (NOS). Statistical analyses were conducted to evaluate the impact of albumin levels on postoperative mortality. Result A total of nine studies involving 1863 patients met the inclusion criteria. Meta-analysis demonstrated significantly lower preoperative albumin levels in patients who did not survive following surgery. A random-effects meta-analysis showed a significant large effect (SMD = 1.14, 95% CI: 0.63 to 1.64). However, heterogeneity was substantial (I 2 = 91%), indicating considerable variability in effect sizes across studies. There was no publication bias with visual inspection of funnel plots and Egger’s test ( p = 0.388). Conclusion Preoperative hypoalbuminemia is strongly associated with increased mortality in patients undergoing surgery for IE. Given that most IE surgeries are non-emergent, addressing low albumin levels preoperatively may offer a significant therapeutic opportunity to improve surgical outcomes.
This study aims to assess current quality indicators and determine the added value of total area under the threshold (TAUT) and largest area under the threshold (LAUT) for risk factors associated with post-cardiosurgical acute kidney injury (AKI) in a large patient population. This approach may offer insights to further reduce the incidence of AKI. Methods: This is a retrospective single center study of procedures from January 1st 2019 to August 31st 2023. The final cohort included 3086 patients who underwent on-pump cardiothoracic surgery procedures at a temperature ≥ 34°C. This study particularly focused of three risk factors for AKI, namely, the oxygen delivery (DO 2 i), venous saturation (SvO 2 ) and mean arterial pressure (MAP). Results: The TAUT-DO 2 i 300 (threshold value 300 mL/min/m 2 ), as well as the TAUT-SvO 2 70 (threshold value 70%) were significantly larger in the group of patients who developed AKI (P < 0.001). The TAUT-MAP 60 (threshold value 60 mmHg) was significantly different between AKI and non-AKI groups during CPB, but they were significantly larger for the AKI group during the first 6 h at the ICU (P < 0.001). Conclusion: The findings indicate that increased cumulative AUT-DO 2 i 300 exposure may be linked to a higher risk of AKI, supporting the potential role of AUT-based monitoring in guiding intraoperative management during on-pump cardiac surgery.
A 68-year-old woman presented with palpitations, though ECG monitoring showed sinus rhythm. Multimodal imaging (cardiac magnetic resonance and echocardiography) showed asymmetric septal hypertrophy with left ventricular outflow tract obstruction (resting gradient of up to 87 mmHg). Echocardiography showed severe mitral regurgitation with multiple regurgitant jets and systolic anterior motion of the mitral valve. Mitral valve anatomy was abnormal, with anterior leaflet restriction and a clefted posterior leaflet. Symptoms persisted despite medical therapy (beta-blockers), and following multidisciplinary discussion, she proceeded to surgery on symptomatic and prognostic grounds. The patient underwent successful septal myectomy and bioprosthetic mitral valve replacement with excellent valve function. Following a generally uneventful postoperative recovery, she was discharged on postoperative day ten with stable cardiac function. This case highlights a rare trileaflet configuration of the mitral valve contributing to severe mitral regurgitation in hypertrophic obstructive cardiomyopathy and underscores the importance of detailed anatomical assessment in guiding surgical decision-making.
The journal retracts the article titled “Therapeutic Potential of Mesenchymal Stem Cells versus Omega n − 3 Polyunsaturated Fatty Acids on Gentamicin-Induced Cardiac Degeneration” [...]
