BACKGROUND:Intramuscular adrenaline (epinephrine) is the first-line treatment for anaphylaxis. This recommendation is based purely on consensus, not randomised controlled trials. In humans, hypotension and shock strongly correlate with plasma histamine concentrations. The efficacy of intramuscular adrenaline in reversing histamine-induced hypotension remains unproven. This trial evaluated whether intramuscular adrenaline reverses histamine-induced shock. METHODS:We conducted an exploratory open-label trial and a confirmatory randomised, double-blind, placebo-controlled, crossover trial. Healthy volunteers received a 15-min continuous intravenous histamine infusion to induce hypotension. At 5 min, participants received either intramuscular adrenaline (300-500 μg) or placebo. A second adrenaline dose was administered if the mean arterial pressure (MAP) remained below 60 mmHg at 10 min. The primary endpoint was area under the effect curve for change in MAP. RESULTS:During histamine-induced hypotension, intramuscular adrenaline failed to produce a pressor response and was indistinguishable from placebo in the majority of participants. Excluding two subjects who needed a simultaneous dose reduction of histamine, only 5 of 20 participants (25%; 95% CI 8.7%-49.1%) demonstrated a transient MAP recovery after a single dose. A second adrenaline dose administered to participants who did not reach a MAP > 60 mmHg also failed to reverse hypotension. The primary outcome in the confirmatory cohort, excluding two subjects with histamine dose adjustments, was not different between treatments (adrenaline-placebo: 7 mmHg·min, 95% CI -2 to 25; p = 0.06). CONCLUSION:In this study of a limited number of healthy human subjects, intramuscular adrenaline injections did not provide a sustained response in severe histamine-mediated hypotension in a majority of recipients. TRIAL REGISTRATION:CTIS (2022-003591-16) and ISRCTN (Nr. 11335622; https://doi.org/10.1186/ISRCTN11335622).

BACKGROUND:Postoperative atrial fibrillation (POAF) is considered a convergence of preexisting vulnerability and periprocedural stressors. Although clinical risk scores such as the CHA2DS2-VA score capture clinical risk factors, they do not account for biological processes. Neutrophil activation and the release of extracellular DNA, counterbalanced by endogenous deoxyribonuclease (DNase) activity, may represent a mechanistically relevant pathway in POAF development. OBJECTIVE:We investigated neutrophil markers and DNase activity as indicators of POAF. METHODS:503 patients undergoing major cardiovascular surgery were investigated. Double-stranded DNA (dsDNA), citrullinated histone H3, neutrophil elastase, myeloperoxidase, and DNase activity were measured before surgery. Associations with POAF were assessed using logistic regression adjusted for the CHA2DS2-VA score. Cardiovascular and all-cause mortality was evaluated using Cox regression. Incremental prognostic information was assessed by comparing nested regression models. RESULTS:POAF occurred in 42.1% of patients. Although baseline dsDNA levels did not differ between groups, multivariable analysis identified dsDNA as independently associated with POAF. DNase activity was independently associated with lower risk of POAF. The DNase factor, calculated as dsDNA divided by DNase activity, conferred an increased risk of POAF. Inclusion of the DNase factor significantly improved model fit beyond the CHA2DS2-VA score. During a median follow-up of 72 months, 109 patients (21.7%) died. dsDNA independently predicted mortality. Higher DNase activity was independently associated with lower mortality. CONCLUSION:Preoperative extracellular DNA burden and DNase activity associate with POAF and long-term mortality after major cardiovascular surgery. Impaired regulation of extracellular DNA reflects a vulnerability phenotype not captured by established clinical risk scores and provides incremental prognostic information.

Background: In the era of personalized medicine, tools for risk stratification after cardiovascular interventions are crucial to reduce mortality and morbidity, especially in the aging population. Biomarker-based approaches, in particular, have gained significant importance. Mid-regional pro-adrenomedullin (MR-proADM) represents an easily assessable biomarker that mirrors cardiac function and fibrosis. Therefore, we aimed to investigate the prognostic potential of MR-proADM in patients undergoing elective cardiac surgery. Methods: Patients undergoing elective cardiac bypass and/or valve surgery were prospectively enrolled between May 2013 and August 2018. The primary endpoint was the composite of hospitalization for heart failure (HHF) or cardiovascular (CV) mortality. Results: In total, 500 patients (146 female [29.2%]; median age 69.8 years (IQR 60.6–75.5 years) were included. Individuals were stratified into risk categories based on their MR-proADM values (Low Risk ≤ 0.63 nmol/L, Intermediate Risk > 0.63 and ≤0.84, High Risk > 0.84). A significant increase in 5-year event rates for HHF/CV mortality in patients in the high-risk category (Low Risk 8.6% vs. High Risk 37.7%, p < 0.001) was observed. MR-pro ADM showed an independent association with HHF/ CV mortality (adjusted HR of 3.43, 95% CI 1.83–6.42; p < 0.001 comparing the High-Risk group to the Low-Risk group). Conclusions: MR-pro ADM was found to be a strong and independent predictor for HHF/CV mortality in patients undergoing elective cardiac surgery. Considering a personalized diagnostic and prognostic work-up, a standardized preoperative evaluation of MR-proADM levels might help to identify patients at risk for major adverse events and early re-hospitalization.

BACKGROUND:The anticoagulant argatroban, a direct thrombin inhibitor, serves as an alternative to heparin in patients with heparin-induced thrombocytopenia (HIT). However, its dose titration using activated partial thromboplastin time (aPTT) has limitations. We aimed to investigate whether ecarin clotting time (ECA-CT) correlates better with plasma argatroban concentrations than aPTT. METHODS:In this single-centre, observational study, 22 patients with HIT undergoing cardiac surgery and receiving argatroban anticoagulation were monitored over 5 days. The outcomes assessed were aPTT and ecarin clotting time (ECA-CT ClotPro®) values, plasma argatroban concentrations measured by a functional assay, and their correlations with each other. RESULTS:Ecarin clotting time demonstrated a strong correlation with plasma argatroban concentrations (r=0.881, 95% confidence interval [CI] 0.790-0.934, P<0.0001), but aPTT was not correlated (r=0.12, 95% CI -0.182 to 0.412, P=0.843). The association between plasma argatroban concentration and aPTT was near-random above aPTT values >55 s, and was best described by a nonlinear approximation. Factor XII was the main independent driver of aPTT variability apart from argatroban concentration. Conversely, ecarin clotting time was independently affected by Factor II, X, and XI apart from argatroban. CONCLUSIONS:This study presents ECA-CT as a reliable point-of-care test for monitoring argatroban concentration in patients with HIT. aPTT demonstrated a pronounced inability to track argatroban concentrations, especially when aPTT was >55 s. These findings highlight the need to reconsider optimal anticoagulation targets when using argatroban.

ObjectivesThe diagnosis of invasive Candida infection remains challenging due to tests with slow turnaround times or mediocre performance. T2MR is a new diagnostic tool. We investigated the diagnostic accuracy of the T2Candida® panel (T2) in comparison to blood culture (BC) and the SeptiFast® (SF) for the detection of five different Candida species among high-risk ICU patients with suspected candidemia.MethodsWe analysed blood samples collected from patients with suspected candidemia (177 samples from 138 patients) from August 2018 to April 2020. Blood samples were collected and analysed concurrently by BC, SF and T2Candida®. Subsequently – based on clinical and microbiological findings – patient samples were assigned to specific risk categories (proven, probable, no candidemia).ResultsTwenty-two samples from 17 patients were classified as proven candidemia, and 15 samples from 14 patients were classified as probable candidemia. A sensitivity of 68.2% (95% CI 45∼86%) was observed for the BC and the SF, and a sensitivity of 63.6% (95% CI 41∼83%) was observed for the T2 when only cases with proven candidemia were evaluated. For proven & probable candidemia, the sensitivity was 40.5% (95% CI 23∼58) for BC, 81.1% (95% CI 65∼92%) for SF and 73.0% (95% CI 56∼86%) for T2.ConclusionsThe diagnostic performance of SF and T2 was similar. For samples with proven/probable candidemia, SF and T2 had a higher sensitivity compared to BC. Used in conjunction with other diagnostic methods, T2 can replace the no longer available SF for the diagnosis of candidemia, enabling the timely initiation of a targeted antifungal therapy.

Background: Postoperative atrial fibrillation (POAF) represents the most common complication following cardiac surgery. Approximately one-third of patients experiencing POAF transition to atrial fibrillation within a year, challenging the notion of POAF as merely a transient event. Soluble ST2 (sST2) is an established biomarker regarding fibrosis and myocardial stretch, however, its role in predicting the onset of POAF remains unclear. Methods: Preoperative sST2 levels have been assessed in 496 individuals with no prior history of AF who underwent elective cardiac surgery, including valve, coronary artery bypass graft surgery, or a combined procedure. Results: The average age was 70 years, and 29.4 % were female. Overall, 42.3 % developed POAF. sST2 levels were found to be significantly higher in patients with POAF. Interestingly, sST2 was only predictive of POAF in females with an adjusted OR of 1.894 (95 %CI:1.103-3.253; p = 0.021) and not males (OR:1.091; 95 % CI:0.849-1.402; p = 0.495). Furthermore, within a linear regression model it was observed that for every 1 ng/ mL increase in sST2 levels, the average POAF duration extended by 39.5 min (95 %CI:15.8-63.4 min; p = 0.001). Conclusion: sST2 predicts the onset of POAF in women but not men undergoing cardiac surgery. Furthermore, sST2 levels were associated with the subsequent burden of POAF. Thus, assessment of sST2 in addition to clinical risk factors could improve risk stratification for development of POAF following elective cardiac surgery.

Background Fibroblast growth factor 23 (FGF‐23) is crucial in regulating phosphate and vitamin D metabolism and is moreover associated with an increased cardiovascular risk. The specific objective of this study was to investigate the influence of FGF‐23 on cardiovascular outcomes, including hospitalization for heart failure (HHF), postoperative atrial fibrillation, and cardiovascular death, in an unselected patient population after cardiac surgery. Methods and Results Patients undergoing elective coronary artery bypass graft and/or cardiac valve surgery were prospectively enrolled. FGF‐23 blood plasma concentrations were assessed before surgery. A composite of cardiovascular death/HHF was chosen as primary end point. A total of 451 patients (median age 70 years; 28.8% female) were included in the present analysis and followed over a median of 3.9 years. Individuals with higher FGF‐23 quartiles showed elevated incidence rates of the composite of cardiovascular death/HHF (quartile 1, 7.1%; quartile 2, 8.6%; quartile 3, 15.1%; and quartile 4, 34.3%). After multivariable adjustment, FGF‐23 modeled as a continuous variable (adjusted hazard ratio for a 1‐unit increase in standardized log‐transformed biomarker, 1.82 [95% CI, 1.34–2.46]) as well as using predefined risk groups and quartiles remained independently associated with the risk of cardiovascular death/HHF and the secondary outcomes, including postoperative atrial fibrillation. Reclassification analysis indicated that the addition of FGF‐23 to N‐terminal pro‐B‐type natriuretic peptide provides a significant improvement in risk discrimination (net reclassification improvement at the event rate, 0.58 [95% CI, 0.34–0.81]; P <0.001; integrated discrimination increment, 0.03 [95% CI, 0.01–0.05]; P <0.001). Conclusions FGF‐23 is an independent predictor of cardiovascular death/HHF and postoperative atrial fibrillation in individuals undergoing cardiac surgery. Considering an individualized risk assessment, routine preoperative FGF‐23 evaluation may improve detection of high‐risk patients.

BACKGROUND:The study investigated the prognostic value of soluble urokinase plasminogen activator receptor (suPAR) in patients undergoing cardiac surgery and calculated a simplified biomarker score comprising suPAR, N-terminal pro B-type natriuretic peptide (NT-proBNP) and age.METHODS AND RESULTS:Biomarkers were assessed in a cohort of 478 patients undergoing elective cardiac surgery. After a median follow-up of 4.2 years, a total of 72 (15.1%) patients died. SuPAR, NT-proBNP and age were independent prognosticators of mortality in a multivariable Cox regression model after adjustment for EuroScoreII. We then calculated a simplified biomarker score comprising age, suPAR and NT-proBNP, which had a superior prognostic value compared to EuroScoreII (Harrel's C of 0.76 vs. 0.72; P for difference = 0.02). Besides long-term mortality, the biomarker score had an excellent performance predicting one-year mortality and hospitalization due to heart failure.CONCLUSION:The biomarker suPAR and NT-proBNP were strongly and independently associated with mortality in patients undergoing cardiac surgery. A simplified biomarker score comprising only three variables (age, suPAR and NT-proBNP) performed better than the established EuroScoreII with respect to intermediate and long-term outcome as well as hospitalization due to heart failure. As such, integration of established and upcoming biomarkers in clinical practice may provide improved decision support in cardiac surgery.

Abstract Background Postoperative atrial fibrillation (POAF) constitutes a common complication after cardiac surgery, that is associated with major adverse cardiac events and prolonged hospital stay. Causes for developing POAF are multifactorial. While there are non-modifiable predisposing characteristics such as higher age or comorbidities, several factors of postoperative patient management could be modulated in order to lower the individual risk of POAF. In this regard, inotropic agents (i.e. norepinephrine, dobutamine) in postoperative care are known to possess arrhythmogenic potential. It is unknown, however, to what extent this postoperative catecholamine therapy influences the emergence of POAF. Methods Within this prospective observational study 514 patients were included who underwent elective coronary artery bypass graft (CABG), heart valve, or combined valve/CABG surgery. In total, 438 patients received vasoactive drugs during the postoperative course. These participants were subsequently followed for the occurrence of POAF. Results Overall, 43.4% (n=190) of all catecholamine-receiving patients developed POAF. Interestingly, participants who developed POAF had received significantly higher median doses of norepinephrine as compared to non-POAF individuals (POAF: 0.083μg/kg/min vs. non-POAF: 0.062μg/kg/min; p=0.001), while the median dobutamine dose did not significantly differ between groups (POAF: 3.332 μg/kg/min vs. non-POAF 3.289μg/kg/min; p=0.254). Moreover, regression analysis identified norepinephrine with an adjusted hazard ratio (HR) per standard deviation (1-SD) of 1.388 (95% CI:1.114-1.728; p=0.003) as an independent risk factor for the occurrence of POAF. In addition, a norepinephrine dose of 0.18μg/kg/min was determined as the cut-off value, from which the POAF risk increased significantly. Notably, no association between dobutamine and POAF was found (adjusted HR 1.140 [95% CI:0.773-1.683; p=0.508]). Conclusion Within this prospective observational study, we were able to demonstrate that the postoperative use of norepinephrine, in contrast to dobutamine, represents an independent risk factor for the development of POAF. Furthermore, a dose dependency was found for norepinephrine from which the risk for POAF substantially increased. To prevent POAF episodes and thus prolonged intensive care unit stay it may be suggested to further promote rapid norepinephrine weaning if feasible.

Background: The highly β1-selective beta-blocker Landiolol is known to facilitate efficient and safe rate control in non-compensatory tachycardia or dysrhythmia when administered continuously. However, efficacy and safety data of the also-available bolus formulation in critically ill patients are scarce. Methods: We conducted a retrospective cross-sectional study on a real-life cohort of critical care patients, who had been treated with push-dose Landiolol due to sudden-onset non-compensatory supraventricular tachycardia. Continuous hemodynamic data had been acquired via invasive blood pressure monitoring. Results: Thirty patients and 49 bolus applications were analyzed. Successful heart rate control was accomplished in 20 (41%) cases, rhythm control was achieved in 13 (27%) episodes, and 16 (33%) applications showed no effect. Overall, the heart rate was significantly lower (145 (130–150) vs. 105 (100–125) bpm, p < 0.001) in a 90 min post-application observational period in all subgroups. The median changes in blood pressure after the bolus application did not reach clinical significance. Compared with the ventilation settings before the bolus application, the respiratory settings including the required FiO2 after the bolus application did not differ significantly. No serious adverse events were seen. Conclusions: Push-dose Landiolol was safe and effective in critically ill ICU patients. No clinically relevant impact on blood pressure was noted.

Abstract Aims The study investigated the prognostic value of soluble urokinase plasminogen activator receptor (suPAR) patients undergoing cardiac surgery and calculated a simplified biomarker score comprising suPAR, N-terminal pro B-type natriuretic peptide (NT-proBNP) and age. Methods and results Biomarkers were assessed in a cohort of 478 patients undergoing elective cardiac surgery. After a median follow-up of 4.2 years a total of 72 (15.1%) patients died. SuPAR, NT-proBNP and age were independent prognosticators of mortality in a multivariable Cox regression model after adjustment for EuroScoreII. We then calculated a simplified biomarker score comprising age, suPAR and NT-proBNP, which had a superior prognostic value compared to EuroScoreII (Harrel's C of 0.76 vs 0.72; P for difference = 0.02). Besides long-term mortality, the biomarker score had an excellent performance predicting one-year mortality and hospitalization due to heart failure. Conclusion The biomarker suPAR and NT-proBNP were strongly and independently associated with mortality in patients undergoing cardiac surgery. A simplified biomarker score comprising only 3 variables (age, suPAR and NT-proBNP) performed better than the established EuroScoreII with respect to intermediate and long-term outcome as well as hospitalization due to heart failure. As such, integration of established and upcoming biomarkers in clinical practice may provide improved decision support in cardiac surgery. Funding Acknowledgement Type of funding sources: None.

Background GDF-15 (growth/differentiation factor 15) is induced by myocardial stretch, volume overload, inflammation, and oxidative stress. Its expression is tightly linked with cardiovascular events as well as the risk for major bleeding and all-cause mortality. The present study aimed to elucidate the prognostic potential of GDF-15 in patients after cardiac surgery. Methods A total of 504 patients undergoing elective cardiac valve and/or coronary artery bypass graft surgery were prospectively enrolled. GDF-15 levels were measured prior to surgery to evaluate the impact on bleeding events, thromboembolic events, and mortality. Results Preoperative GDF-15 was associated with the primary endpoint of intra- and postoperative red blood cell transfusion (for bleeding risk factors adjusted [adj] OR [odds ratio] per 1-SD [standard deviation] of 1.62 [95% confidence interval [CI]: 1.31-2.00]; p < 0.001). Higher concentrations of GDF-15 were observed in patients reaching the secondary endpoint of major or clinically relevant minor bleeding (for bleeding risk factors adj. OR per 1-SD of 1.70 [95% CI: 1.05-2.75]; p = 0.030) during the first postoperative year, but not for thromboembolic events. GDF-15 was a predictor for cardiovascular mortality (for comorbidities adj. HR [hazard ratio] per 1-SD of 1.67 [95% CI: 1.23-2.27]; p = 0.001) and all-cause mortality (for comorbidities adj. HR per 1-SD of 1.55 [95% CI: 1.19-2.01]; p = 0.001). A combined risk model of GDF-15 and EuroSCORE II outperformed the EuroSCORE II alone for long-term survival (C-index: 0.75 [95% CI: 0.70-0.80], p = 0.046; net reclassification improvement: 33.6%, p < 0.001). Conclusion Preoperative GDF-15 concentration is an independent predictor for intra- and postoperative major bleeding, major bleeding during the first year, and for long-term cardiovascular or all-cause mortality after cardiac surgery.

BACKGROUND Postoperative atrial fibrillation (POAF) is a frequent complication after heart surgery and is associated with thromboem-bolic events, prolonged hospital stay, and adverse outcomes. Inflammation and fibrosis are involved in the pathogenesis of atrial fibrillation.OBJECTIVE The purpose of this study was to assess whether galectin-3, which reflects preexisting atrial fibrosis, has the poten-tial to predict POAF and mortality after cardiac surgery.METHODS Four hundred seventy-five consecutive patients (mean age 67.4 +/- 11.8 years; 336 (70.7%) male) undergoing elective heart surgery at the Medical University of Vienna were included in this prospective single-center cohort study. Galectin-3 plasma levels were assessed on the day before surgery.RESULTS The 200 patients (42.1%) who developed POAF had significantly higher galectin-3 levels (9.60 +/- 6.83 ng/mL vs 7.10 +/- 3.54 ng/mL; P < .001). Galectin-3 significantly predicted POAF in multivariable logistic regression analysis (adjusted odds ratio per 1-SD increase 1.44; 95% confidence interval 1.15-1.81; P = .002). During a median follow-up of 4.3 years (interquartile range 3.4-5.4 years), 72 patients (15.2%) died. Galectin-3 predicted all-cause mortality in multivariable Cox regression analysis (adjusted hazard ratio per 1-SD increase 1.56; 95% confidence in-terval 1.16-2.09; P = .003). Patients with the highest-risk galec-tin-3 levels according to classification and regression tree analysis (>11.70 ng/mL) had a 3.3-fold higher risk of developing POAF and a 4.4-fold higher risk of dying than did patients with the lowest-risk levels (<5.82 ng/mL).CONCLUSION The profibrotic biomarker galectin-3 is an indepen-dent predictor of POAF and mortality after cardiac surgery. This finding highlights the role of the underlying arrhythmogenic sub-strate in the genesis of POAF. Galectin-3 may help to identify patients at risk of POAF and adverse outcome after cardiac surgery.

OBJECTIVES: Postoperative atrial fibrillation (POAF) represents a common complication after cardiac surgery that is associated with unfavourable clinical outcome. Identifying patients at risk for POAF is crucial but challenging. This study aimed to investigate the prognostic potential of speckle-tracking echocardiography on POAF and fatal adverse events from a long-term perspective. METHODS: A total of 124 patients undergoing elective cardiac surgery were prospectively enrolled and underwent preoperative speckle-tracking echocardiography. Patients were followed prospectively for the occurrence of POAF within the entire hospitalization and reaching the secondary end points cardiovascular and all-cause mortality. RESULTS: Within the study population 43.5% (n = 53) of enrolled individuals developed POAF. After a median follow-up of 3.9 years, 25 (20.2%) patients died. We observed that patients presenting with POAF had lower global peak atrial longitudinal strain (PALS) values compared to the non-POAF arm {POAF: 14.8% [95% confidence interval (CI): 10.9-17.8] vs non-POAF: 19.4% [95% CI: 14.8-23.5], P < 0.001}. Moreover, global PALS was a strong and independent predictor for POAF [adjusted odds ratio per 1 standard deviation: 0.37 (95% CI: 0.22-0.65), P < 0.001] and independently associated with mortality [adjusted hazard ratio per 1 standard deviation: 0.63 (95% CI: 0.40-0.99), P= 0.048]. Classification and Regression Tree analysis revealed a cut-off value of <17% global PALS as high risk for both POAF and mortality. CONCLUSIONS: Global PALS is associated with the development of POAF following surgery in an unselected patient population undergoing CABG and/or valve surgery. Since patients with global PALS <17% face a poor long-term prognosis, routine assessment of global PALS needs to be considered in terms of proper secondary prevention in the era of personalized medicine.

BackgroundHeart failure patients are frequently on coagulation-active medications before LVAD implantation and perioperative bleeding is a frequent complication after left ventricular assist device (LVAD) implantation. The role of point-of-care coagulation tests in assessing bleeding risk for LVAD implantation and the early postoperative time course of these tests is not well established.MethodsWe prospectively enrolled 25 patients with terminal heart failure undergoing LVAD implantation. Study related TRAP-, ASPI- and ADP- tests of Multiplate® platelet aggregometry, ROTEM® rotational thromboelastometry (INTEM, EXTEM, FIBTEM), thrombin generation assay and conventional laboratory studies were measured at 11 predefined time-points during the first 21 postoperative days. We examined if preoperative TRAP-, ASPI-, ADP- and ROTEM values are correlated with estimated total blood loss (primary outcome parameter) during the first 21 days after LVAD implantation and compared the baseline values of these measurements between patients with a bleeding event to those without. We performed Spearman's correlation and non-parametric tests for paired and non-paired comparisons.Results7 out of 25 (28%) patients experienced a bleeding event of which 4 required surgical revision. Of the preoperatively performed measurements the TRAP test [Spearman's Rho (ρ) = −0.5, p = 0.01], INTEM CFT (ρ = 0.72, p < 0.001), INTEM alpha (−0.7, p < 0.001), EXTEM MCF (ρ = −0.63; p < 0.001), EXTEM alpha (ρ = −0.67; p < 0.001), FIBTEM MCF (ρ = −0.41; p = 0.042), Fibrinogen (Clauss) (ρ = −0.5; p = 0.011), Anti-thrombin activity (ρ = −0.49; p = 0.013) and platelet count (ρ = −0.42; p = 0.034) were significantly correlated to total blood loss. Patients undergoing a surgical bleeding revision had significantly reduced values in TRAP—[31.5 IQR (17.25–43.5U) vs. 69 IQR (52.5–87U); p = 0.004], ASPI—[16.5 IQR (5.5–35.7U) vs. 39 IQR (24.5–62.5U); p = 0.038], ADP—[30 IQR (22–69U) vs. 12.5 IQR (8.7–21.5U); p = 0.01], EXTEM MCF—[63 IQR (57.7–63.7) vs. 67 IQR (65–75.5); p = 0.019] and EXTEM alpha [74 IQR (68.75–74) vs. 79 IQR (78–80.5); p = 0.002] values before LVAD implantation.ConclusionMultiplate® and ROTEM® measurements before LVAD implantation may identify LVAD candidates with platelet dysfunction and alterations of the primary hemostasis and could guide anesthetists and intensive care practitioners in bleeding risk stratification and in the perioperative clinical management.

OBJECTIVE The aim of this study was to identify perioperative risk factors associated with intensive care unit readmission and in-hospital death after cardiac surgery. DESIGN Retrospective analysis using a multivariate regression model to identify independent risk factors for intensive care unit [ICU] readmission and in-hospital mortality. SETTING The study was carried out in a single tertiary-care hospital. PARTICIPANTS This was an analysis of 2,789 adult patients. INTERVENTIONS All patients underwent cardiac surgery and were admitted to the intensive care unit perioperatively at the General Hospital Vienna. MEASUREMENTS AND MAIN RESULTS Among the 2,789 patients included in the analysis, 167 (6%) were readmitted to the intensive care unit during the same hospital stay. Preoperative risk factors associated with ICU readmission included end-stage renal failure (odds ratio [OR] 2.80, 95% CI: 1.126-6.964), arrhythmia (OR 1.59, 95% CI: 1.019-2.480), chronic obstructive pulmonary disease (OR 1.51, 95% CI: 1.018-2.237), age >80 (OR 2.55, 95% CI: 1.189-5.466), and European System for Cardiac Operative Risk Evaluation II >8 (OR 1.40, 95% CI: 1.013-1.940). Readmitted patients were more likely to die than nonreadmitted patients (OR 5.3, 95% CI: 3.284-8.558). In-hospital mortality in readmitted patients was 19.2%, whereas that in the nonreadmitted study population was 5.1%. CONCLUSION Preoperative risk assessment is crucial for identifying cardiac surgery patients at risk of ICU readmission and in-hospital death. The potentially modifiable risk factors pinpointed by this study call for the optimization of care before surgery and after ICU discharge.

OBJECTIVE:To evaluate the association of postoperative hemoglobin values and mortality in patients undergoing double- lung transplantation with intraoperative transfusion.DESIGN:Retrospective cohort study.SETTING:University hospital.PARTICIPANTS:Adult patients who underwent double-lung transplantation at the authors' institution, with intraoperative transfusion of packed red blood cells between 2009 and 2015.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULTS:Intraoperative transfusion requirements and general characteristics of 554 patients were collected. A generalized additive model, controlling for postoperative hemoglobin levels, number of transfused units of packed red blood cells, perioperative change in hemoglobin levels, disease leading to lung transplantation, and postoperative extracorporeal membrane oxygenation, was created to predict one-year mortality. A postoperative hemoglobin level of 11.3 g/dL was calculated as an optimal cutoff point. The patients were stratified according to this level. The end -point was all-cause one-year mortality after double-lung transplantation, assessed using the Kaplan-Meier analysis with log-rank test. All-cause mortality of the 554 patients was 17%. Postoperatively, 171 patients (31%) were categorized as being below the cutoff point. Improved survival was observed in the group with higher postoperative hemoglobin values (p = 0.002).CONCLUSION:Lower postoperative hemoglobin levels in double-lung transplantation recipients were associated with increased mortality during the first year after surgery. Confirmation of these findings in additional investigations could alter patient blood management for double-lung transplantation.

Optimal antithrombotic therapy in patients who underwent surgical biological aortic valve replacement (AVR) represents an issue of ongoing discussion. Additionally, the prognostic impact of anti-thrombotic treatment strategies after biological AVR and real-life data on anticoagulation strategies (AC) of patients presenting with short-term postoperative atrial fibrillation (POAF) has not clearly been investigated so far. Therefore, this study aimed to investigate the impact of therapeutic AC after biological AVR on patient outcome and whether the presence of POAF affects decision making on anti-thrombotic management. Within this prospective observational study, 200 individuals that underwent biological AVR surgery were enrolled. Participants were followed prospectively until the primary study endpoint was reached. Multivariate logistic regression analysis was performed to elucidate the effect of therapeutic AC on outcome. Overall, 106 individuals received therapeutic AC at the time of discharge. The fraction of patients presenting with POAF was balanced between individuals receiving AC and the non-AC subgroup (p = 0.617). After a median follow-up time of 1418 days, 31 (15.5

Study objective: Postoperative atrial fibrillation (POAF) is a frequent complication after cardiac valve- or coronary artery bypass (CABG) surgery and is associated with increased mortality. While it is known that prolonged postoperative invasive ventilation triggers POAF, the impact of ventilatory settings on POAF development has not been studied yet. Design: Prospective observational study. Setting: Postoperative Intensive Care Unit. Patients: Patients having undergone elective CABG and/or cardiac valve surgery. Measurements: Screening for the development of POAF. Patients' clinical data and postoperative ventilatory settings (driving pressure, controlled pressure above positive endexpiratory pressure (PEEP), respiration rate, and FiO2) were investigated to elucidate their impact on POAF. Main results: Out of 441 enrolled individuals, a total of 192 participants developed POAF (43.5%). We observed that POAF patients received a higher peak driving pressure, and a higher peak respiration rate than non-POAF individuals. Within the multivariate regression model, plateau pressure (adjusted OR 1.199 [1.038-1.661], p = 0.019), driving pressure (adjusted OR 1.244 [1.103-1.713], p = 0.021), and peak respiration rate (adjusted OR 1.206 [1.005-1.601], p = 0.040) proved to be independently associated with the development of POAF. CART analysis revealed a cut-off of >17.5 cmH2O of plateau pressure, >11.5 cmH2O of driving pressure and > 17 respirations per minute as high-risk for POAF development. Conclusions: The ventilatory settings of plateau pressure, driving pressure, and respiration rate after cardiac surgery influence POAF occurrence probability. Optimized postoperative care such as lung-protective ventilation and increased awareness towards postoperative ventilatory efforts should be considered to prevent POAF development and poor patient outcome.