Achieving early and timely diagnosis and treatment for disease is a major challenge. Recent applications of machine learning (ML) algorithms trained on patient data have shown promise in many different settings for predicting the patient health state. A challenge often faced when applying these ML algorithms is that at any given time, not all clinical variables (features) needed as input to perform prediction tasks are available. We define the concept of full-feature-capacity (FFC) to refer to prediction performance when such algorithms make use of all features on which they were trained. We then introduce Feature Sufficiency Analysis (FSA) - an analysis for determining whether a subset of all clinical features needed by an AI model is sufficient to achieve FFC. FSA estimates the underlying distributions of missing variables conditioned on features that are available. FSA provides a patient-specific assessment of whether the existing set of measured features achieves FFC. If yes, then there is no need to acquire further inputs and a ML-based prediction. We provide two case studies: prediction of need for postoperative prolonged ventilation in patients recovering from heart surgery; 10-year mortality prediction in an outpatient cohort. We also demonstrate that FSA also provides a clinically interpretable feature-ranking methodology based on prediction sufficiency, identifies intrinsically hard-to-predict patient populations, and has the potential to perform cost-aware optimization for clinical data acquisition. FSA provides a generic computational approach for determining whether incomplete clinical information is sufficient to support trustworthy AI-assisted clinical decision-making, thereby facilitating the prospective deployment of healthcare AI systems across diverse clinical settings.

Importance:Early recognition of adverse events after cardiac surgery is vital for treatment. However, the widely used Society of Thoracic Surgery (STS) risk model has modest performance in predicting adverse events and only applies <80% of cardiac surgeries. Objective:To develop and validate machine learning (ML) models for predicting outcomes after cardiac surgery. Design setting and participants:ML models, referred as Roux-MMC model, were developed and validated using a retrospective cohort extracted from the STS Adult Cardiac Surgery Database (ACSD) at Maine Medical Center (MMC) between January 2012 to December 2021. It was further validated on a prospective cohort of MMC between January 2022 to February 2024. The performance of Roux-MMC model is compared with the STS model.Exposure cardiac surgery. Main outcomes and measures:Postoperative outcomes: mortality, stroke, renal failure, reoperation, prolonged ventilation, major morbidity or mortality, prolonged length of stay (PLOS) and short length of stay (SLOS). Primary measure: area under the receiver-operating curve (AUROC). Results:A retrospective cohort of 9,841 patients (median [IQR] age, 67 [59-74] years; 7,127 [72%] males) and a prospective cohort of 2,305 patients (median [IQR] age, 67 [59-73] years; 1,707 [74%] males) were included. In the prospective cohort, the Roux-MMC model achieves performance for prolonged ventilation (AUROC 0.911 [95% CI, 0.887-0.935]), PLOS (AUROC 0.875 [95% CI, 0.848-0.898]), renal failure (AUROC 0.878 [95% CI, 0.829-0.921]), mortality (AUROC 0.882 [95% CI, 0.837-0.920]), reoperation (AUROC 0.824 [95% CI, 0.787-0.860]), SLOS (AUROC 0.818 [95% CI, 0.801-0.835]) and major morbidity or mortality (AUROC 0.859 [95% CI, 0.832-0.884]). The Roux-MMC model outperforms the STS model for all 8 outcomes, achieving 0.020-0.167 greater AUROC. The Roux-MMC model covers all cardiac surgery patients, while the STS model applies to only 65% in the retrospective and 77% in the prospective cohorts. Conclusion and relevance:We developed ML models to predict 8 postoperative outcomes on all cardiac surgery patients using preoperative and intraoperative variables. The Roux-MMC model outperforms the STS model in the prospective cohort. The Roux-MMC model is built on STS ACSD, a data system used in ~1000 US hospitals, thus, it has the potential to easily applied in other hospitals.

BackgroundTricuspid valve annuloplasty (TA) during mitral valve repair (MVr) is associated with increased risk of permanent pacemaker (PPM) implantation, but the magnitude of risk and long-term clinical consequences have not been firmly established.ObjectivesThis study assesses the incidence rates of PPM implantation after isolated MVr and following MVr with TA as well as the associated long-term clinical consequences of PPM implantation.MethodsState-mandated hospital discharge databases of New York and California were queried for patients undergoing MVr (isolated or with concomitant TA) between 2004 and 2019. Patients were stratified by whether or not they received a PPM within 90 days of index surgery. After weighting by propensity score, survival, heart failure hospitalizations (HFHs), endocarditis, stroke, and reoperation were compared between patients with or without PPM.ResultsA total of 32,736 patients underwent isolated MVr (n = 28,003) or MVr + TA (n = 4,733). Annual MVr + TA volumes increased throughout the study period (P < 0.001, trend), and PPM rates decreased (P < 0.001, trend). The incidence of PPM implantation <90 days after surgery was 7.7% for MVr and 14.0% for MVr + TA. In 90-day conditional landmark-weighted analyses, PPMs were associated with reduced long-term survival among MVr (HR: 1.96; 95% CI: 1.75-2.19; P < 0.001) and MVr + TA recipients (HR: 1.65; 95% CI: 1.28-2.14; P < 0.001). In both surgical groups, PPMs were also associated with an increased risk of HFH (HR: 1.56; 95% CI: 1.27-1.90; P < 0.001) and endocarditis (HR: 1.95; 95% CI: 1.52-2.51; P < 0.001), but not with stroke or reoperation.ConclusionsCompared to isolated MVr, adding TA to MVr was associated with a higher risk of 90-day PPM implantation. In both surgical groups, PPM implantation was associated with an increase in mortality, HFH, and endocarditis.

Objectives: In a recent trial, tricuspid annuloplasty (TA) during mitral valve surgery (MVS) for degenerative mitral regurgitation and moderate or less tricuspid regurgitation (TR) reduced the composite rate of death, reoperation for TR, or TR progression at 2 years. However, this benefit was counterbalanced by an increase in implantation of permanent pacemakers (PPMs). In this study, we analyzed the timing, indications, and risk factors for these implantations. Methods: We randomized 401 patients (MVS alone = 203; MVS + TA = 198). Potential risk factors for PPMs were assessed using multivariable time-to-event models with death and PPM implantation for heart failure indications as competing risks. Results: A PPM was implanted in 36 patients (9.6; 95% CI, 6.8-13.0) within 2 years of randomization, with 30/187 (16.0%) in the MVS + TA and 6/188 (3.2%) in the MVS groups (rate ratio, 5.08; 95% CI, 2.16-11.94; P <.001). Most (29/36; 80.6%) implantations occurred within 30 days postoperatively. Independent risk factors for PPM implantation within 2 years were TA (hazard ratio [HR], 5.94; 95% CI, 2.27-15.53; P <.001), increasing age (5 years, HR, 1.23; 95% CI, 1.01-1.52; P = .04), and left ventricular ejection fraction (LVEF; HR, 0.96; 95% CI, 0.92-0.99; P = .02). In the subset of TA recipients (n = 197), age (5 years, HR, 1.05; 95% CI, 1.00-1.10; P = .04) and LVEF (HR, 0.95; 95% CI, 0.91-0.99; P = .01) were associated with PPM within 2 years. Conclusions: Concomitant TA, age, and baseline LVEF were risk factors for PPM implantation in patients who underwent MVS for degenerative mitral regurgitation. Although TA was effective in preventing progression of TR, innovation is needed to identify ways to decrease PPM implantation rates. (J Thorac Cardiovasc Surg 2024;167:2104-16)

Background: The clinical consequences of coexistent tricuspid regurgitation (TR) in patients with severe ischemic mitral regurgitation (IMR) remain unclear. We examined the association of baseline TR severity with outcomes after mitral valve (MV) surgery for IMR. Methods: We conducted a secondary analysis of a randomized trial evaluating the effectiveness and safety of MV replacement versus repair for severe IMR. Patients were stratified by baseline TR (none/trace/mild vs moderate/severe). The primary endpoint was all-cause mortality. Secondary endpoints included major adverse cardiac and cerebrovascular events (MACCE) and quality of life (QoL) using the Minnesota Living with Heart Failure Questionnaire (MLHFQ). Cox proportional hazards and logistic models were used in the analysis. Results: Of 251 randomized patients with severe IMR, 246 undergoing MV repair or replacement (123 each) were included in this secondary analysis. Sixty-one patients (25%) had ≥ severe TR, of whom 43% underwent MV repair and 57% underwent MV replacement. The 2-year all-cause mortality was significantly higher for those with moderate/severe TR compared to those with none/trace/mild TR (38% vs 16%; adjusted hazard ratio [aHR], 2.93; 95% confidence interval [CI], 1.59-5.38). MACCE rates were higher in patients with moderate/severe TR (53%) compared to those with none/trace/mild TR (39%) (aHR, 1.91; 95% CI, 1.21-3.03). No significant difference in 1-year QoL, measured as being alive with a 5-point improvement in the MLHFQ, was observed (odds ratio, 0.61; 95% CI, 0.28-1.33). Conclusions: In patients undergoing surgery for severe IMR, preoperative moderate/severe TR was significantly associated with increased all-cause mortality and MACCE. Whether concomitant TV surgery would improve postoperative outcomes in patients with severe IMR and different degrees of TR should be evaluated in a randomized trial.

Removal of plasma water and its soluble components across a microporous membrane is one of the basic tools of the cardiopulmonary perfusionist. In this issue of The Annals of Thoracic Surgery, Alfirevic and colleagues1 show worse outcomes with conventional ultrafiltration (CUF) when compared with no ultrafiltration at all, thus concluding that CUF has no benefit in adult cardiac surgery.

Background. The Perceval S is a sutureless, bovine pericardial aortic prosthesis on a nitinol stent, which has limited data on outcomes, as well as cost, from the United States. Methods. We performed a retrospective review of Perceval S implantation at a single center between 2015 and 2018. After exclusion criteria, we compared 234 patients who underwent sutureless aortic valve (SLV) implantation with 370 patients who underwent standard sutured aortic valves (SAVR). Hospital cost data were reviewed, and risk adjustment, done by propensity score and inverse probability weighting, was used to compare outcomes. Results. Compared to those undergoing SAVR, the SLV group was older and had a higher proportion of multicomponent operations, higher preoperative white blood cell count, higher rate of previous percutaneous coronary interventions, more comorbid conditions (diabetes, renal insufficiency, and dialysis), and more three-vessel coronary disease. For isolated AVR, partial upper hemisternotomy was more frequent in SLV. The mean cardiopulmonary bypass and cross-clamp times for isolated SLV were significantly lower than SAVR. After adjustment, the cohort was balanced. Operative differences for SLV were lower cross-clamp and pump time, larger valve size, more minimally invasive approaches, and shorter operating room times. There were no differences in other postoperative complications (postoperative atrial fibrillation, stroke, renal failure, prolonged ventilation, and in-hospital mortality; p > 0.05 for all). Mean and median hospital costs were higher in the SLV group, largely due to the cost of the implant. Conclusion. Sutureless tissue aortic valves can be used safely with lower cardiopulmonary bypass and clamp times than sutured prostheses and facilitate use of minimally invasive approaches. This valve may be advantageous in older, higher risk patients requiring more complex operations.

The 2020 American Health Association/American College of Cardiology valve guidelines recommend surgical aortic valve replacement (SAVR) for symptomatic patients with aortic stenosis (AS) age <65 years and transcatheter aortic valve implantation (TAVI) for patients with AS age >80 years. We analyzed TAVI versus SAVR practice patterns using age-based recommendations. We compared 2016-to-2019 TAVI and isolated SAVR in northern New England at 5 centers according to guideline-recommended age groups. Multivariable logistic regression was performed to identify independent predictors of TAVI for the intermediate age group. The study was approved by each site's institutional review board in accordance with ongoing participation and quality improvement efforts in the Northern New England Cardiovascular Study Group. Among 4,161 patients with isolated severe AS, TAVI increased from 2016 to 2019: 55.8% versus 76.1%, p <0.01 for trend. SAVR for patients with AS age >80 years was uncommon and decreased over time: 13.1% versus 1.6%, p <0.01. TAVI utilization nearly doubled over time in young patients with AS age <65 years (14.3% vs 26.2%, p <0.01). Preference for SAVR decreased by 50% over time (p <0.01) in the intermediate age group (65 to 80 years). Independent predictors of TAVI among patients aged 65 to 80 years included older age, chronic obstructive pulmonary disease, previous stroke, and coronary artery bypass grafting, whereas vascular disease and clinical urgency favored SAVR. In conclusion, consistent with current American Health Association/American College of Cardiology guidelines, TAVI was the treatment of choice in >97% of severe patients with AS age >80 years by 2019. TAVI utilization in patients <65 years has doubled over time and thus may not reflect current guideline recommendations. TAVI is the preferred choice in those aged 65 to 80 years, especially among patients with previous stroke or coronary artery bypass grafting.

Introduction: The optimal transfusion strategy for patients with ACS is unclear. Current data are inconclusive and there is a paucity of long term data; therefore, we performed a subgroup analysis of patients with AMI in the Transfusion Thresholds in Cardiac Surgery (TRICS-III) randomized controlled trial (RCT) to add evidence addressing this important clinical question, and interpret the results in the context of a systematic review and meta-analysis. Methods: The TRICS-III trial randomized patients undergoing cardiac surgery on cardiopulmonary bypass with a moderate-to-high risk of death to restrictive transfusion (transfuse at hemoglobin <7.5g/dL) or a liberal strategy (operating room and ICU: transfuse at hemoglobin <9.5g/dL; ward: <8.5g/dL). AMI patients were those undergoing coronary artery bypass graft surgery with a recent MI and ≥1 of the following enrichment criteria: unstable angina, critical preoperative state, preoperative intra aortic balloon pump, and/or emergency surgery. The primary outcome for this analysis was MACE (all-cause death, MI, and revascularization) at 6 months. The MEDLINE and EMBASE databases were searched through April 2022 to identify RCTs evaluating restrictive versus liberal transfusion in patients with ACS. The primary outcome was MACE at the longest available timepoint. Results: In the TRICS AMI population (N=194), a restrictive transfusion strategy did not increase the risk of MACE (OR: 1.36; 95% CI: 0.57-3.27). Three additional RCTs met eligibility criteria for the systematic review yielding a total of 1015 patients. The transfusion strategies were similar across all studies. After synthesizing the data, restrictive transfusion was associated with a trend toward an increased absolute risk of MACE (4%; 95% CI, -1 to 9%) and MI (3%; 95% CI, 0 to 6%) at the longest available timepoint (Figure). Conclusion: In the setting of ACS, liberal transfusion strategies may reduce the risk of long term adverse cardiovascular events.

The primary focus in goaldirected perfusion should be maximizing flow and minimizing hemodilution, with transfusion of red blood cells being the last resort.

Spending time to “dry up” at the end of an operation in cardiac surgery pays off with a lower rate of return to the operating room for bleeding and a lower transfusion rate. Somehow, the maxim of “dry going in…dry going out” is not always followed and can then be compounded by delaying a necessary return to the operating room with attempts to avoid re-exploration by giving blood products. The authors of the article “Five-Minute Test to Prevent Post-Cardiotomy Re-Exploration”1 did a retrospective analysis comparing 2 standards of care in 2 different time periods.

Variability persists in intraoperative red blood cell (RBC) transfusion rates, despite evidence supporting associated adverse sequelae. We evaluated whether beliefs concerning transfusion risk and safety are independently associated with the inclination to transfuse. We surveyed intraoperative transfusion decision-makers from 33 cardiac surgery programs in Michigan. The primary outcome was a provider’s reported inclination to transfuse (via a six-point Likert Scale) averaged across 10 clinical vignettes based on Class IIA or IIB blood management guideline recommendations. Survey questions assessed hematocrit threshold for transfusion (“hematocrit trigger”), demographic and practice characteristics, years and case-volume of practice, knowledge of transfusion guidelines, and provider attitude regarding perceived risk and safety of blood transfusions. Linear regression models were used to estimate the effect of these variables on transfusion inclination. Mixed effect models were used to quantify the variation attributed to provider specialties and hematocrit triggers. The mean inclination to transfuse was 3.2 (might NOT transfuse) on the survey Likert scale (SD: .86) across vignettes among 202/413 (48.9%) returned surveys. Hematocrit triggers ranged from 15% to 30% (average: 20.4%; SE: .18%). The inclination to transfuse in situations with weak-to-moderate evidence for supporting transfusion was associated with a provider’s hematocrit trigger ( p < .01) and specialty. Providers believing in the safety of transfusions were significantly more likely to transfuse. Provider specialty and belief in transfusion safety were significantly associated with a provider’s hematocrit trigger and likelihood for transfusion. Our findings suggest that blood management interventions should target these previously unaccounted for blood transfusion determinants.

Central MessageManaging preoperative anemia during the blood shortage associated with the COVID-19 pandemic decreases the demand on the blood bank while improving results.See Article page 85. Managing preoperative anemia during the blood shortage associated with the COVID-19 pandemic decreases the demand on the blood bank while improving results. See Article page 85. The COVID-19 pandemic has exposed vulnerabilities of our society, such as weaknesses in our public health infrastructure, economic disparities, and structural racism. In their article in this issue of the Journal, Perelman and colleagues1Perelman S.I. Shander A. Mabry C. Preoperative anemia management in the coronavirus disease 2019 (COVID-19) era.J Thorac Cardiovasc Surg Open. 2021; 5: 85-94Google Scholar focus on the vulnerability of cardiac surgical patients with preoperative anemia, a modifiable risk factor in preoperative management. Cardiac surgeons often do not take advantage of the opportunity to address preoperative anemia despite the preponderance of data demonstrating that anemia drives perioperative morbidity and mortality, which is exacerbated by transfusions. Nevertheless, many cardiac surgeons persist in exercising the default treatment of transfusing donated red blood cells, literally harming their patients while draining a limited blood supply. COVID-19 has been associated with a significant deficit of thousands of units of blood owing to cancelled blood drives and fewer donors. Perelman and colleagues point out how in the face of a profound blood shortage, adult cardiac surgery centers need to reset priorities to align with principles addressed by the American College of Surgeons, the Society of Thoracic Surgeons COVID-19 Taskforce, and the STS Workforce for Adult Cardiac and Vascular Surgery. Preoperative anemia occurs in up to 40% of adult cardiac surgery patients and is associated with a nearly 5-fold increase in the odds of postoperative mortality, an order of magnitude that should get the attention of any cardiac surgeon. Nevertheless, Perelman and colleagues relate the astounding fact that most preoperative coronary artery bypass grafting patients are not treated for their anemia. Although the possibility of a blood shortage threatening the ability to administer necessary transfusions, the authors provide step-by-step instructions on how to safely manage these patients. It has taken a tragic pandemic to leverage behaviors that we should have been practicing all along. Shotgun strategies that manage anemia and decrease transfusions such as described by Spahn and colleagues2Spahn D.R. Schoenrath F. Spahn G.H. Seifert B. Stein P. Theusinger O.M. et al.Effect of ultra-short-term treatment of patients with iron deficiency or anemia undergoing cardiac surgery: a prospective randomized trial.Lancet. 2019; 393: 2201-2212Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar (discussed by the authors) or more targeted strategies as discussed by Ranucci and colleagues3Ranucci M. Pavesi M. Pistuddi V. Baryshnikova E. Preoperative anemia correction cardiac surgery: a propensity-matched study.J Cardiothorac Vasc Anesth. 2021; 35: 874-881Abstract Full Text Full Text PDF PubMed Scopus (1) Google Scholar show promise, recognizing that the most common anemias are often a consequence of an inflammatory state generated by multiple comorbidities that often respond to the administration of parenteral iron. We need to address the barriers to practicing sound patient blood management; develop an evidence-based, multidisciplinary approach to caring for patients who might need a blood transfusion; be unwilling to accept a 5-fold increase in complications and death, which is further exacerbated by blood transfusions in our anemic patients. Otherwise, despite good surgery, the results might not be so good. Preoperative anemia management in the coronavirus disease (COVID-19) eraJTCVS OpenVol. 5PreviewThe novel coronavirus, severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), causes the disease COVID-19 and is responsible for a global pandemic with more than 30,000,000 affected patients worldwide with a significant mortality exceeding 1,000,000.1 Certain underserved segments of the population are particularly hard hit, conferring severe risk of exposure and adverse outcomes.2 The tragic human toll is unprecedented and resembles the flu epidemic that occurred more than 100 years ago. The current outbreak impacted the global economy and placed a tremendous strain on all health care systems. Full-Text PDF Open Access

The novel HbA1c/Hb (HH) ratio has the potential to become a new prognostic metric by identifying modifiable risk factors and contributing to decision-making in patient selection. A Newly Proposed HbA1C-Hemoglobin Ratio - A Better Predictor of Outcomes in Cardiac Surgery When Compared to HbA1C and Anemia AloneSeminars in Thoracic and Cardiovascular SurgeryVol. 33Issue 3PreviewHbA1C's predictive value for postoperative complications in cardiac surgery has been mixed. Studies did not account for HbA1C being over-read in anemic patients. This study proposes a novel way of using a ratio of HbA1C over hemoglobin (HH ratio). Retrospective recruitment of patients undergoing cardiac surgery was done with ethics approval. The primary objective of our study is to look for the correlation of HH ratio with 90-day (short-term) and 1-year (long-term) mortality. The secondary objective is to investigate its association with other adverse events. Full-Text PDF

An immunologically oriented concept of the genesis of acquired immunodeficiency syndrome is presented in which the central event is the lack of cytotoxic T8 cells. An interlocking system wherein the T4 (helper) cells do not synthesize interleukin-2 to generate the cytotoxic cells due to the lack of functional thymosin as well as the lack of interleukin-1 from the macrophages is postulated. The transmissible agent which sets the cascade of immunologic imbalance into play replicates only in the thymic epithelium and subverts thymosin synthesis. The T8 cells in the syndrome are exclusively H2 positive and functionally suppressor. The macrophage which phagocytizes the effete thymic epithelium hematogenously spreads the transmissible agent to others. Kaposi's sarcoma is considered to be an integral component of the immunologic disarray in that angiogenesis is proposed to require two essential events — endothelial cell proliferation and movement of those cells. Under normal circumstances although the activated macrophage elaborates a monokine that has endothelial cell proliferative inducing capacity the cells are held in situ by a lymphokine that prevents movement. The lymphokine is considered to be IL-2. Eight predictions of the model which are experimentally testable are presented.

Background: The endothelial glycocalyx (EG) is involved in critical regulatory mechanisms that maintain endothelial vascular integrity. We hypothesized that prolonged cardiopulmonary bypass (CPB) may be associated with EG degradation. We performed an analysis of soluble syndecan-1 levels in relation to duration of CPB, as well as factors associated with cell stress and damage, such as mitochondrial DNA (mtDNA) and inflammation. Methods: Blood samples from subjects undergoing cardiac surgery with CPB (n = 54) were obtained before and during surgery, 4-8 h and 24 h after completion of CPB, and on postoperative day 4. Flow cytometry was used to determine subpopulations of white blood cells. Plasma levels of mtDNA were determined using quantitative polymerase chain reaction and plasma content of shed syndecan-1 was measured. To determine whether syndecan-1 was signaling white blood cells, the effect of recombinant syndecan-1 on mobilization of neutrophils from bone marrow was tested in mice. Results: CPB is associated with increasedmtDNA during surgery, increased syndecan-1 blood levelsat 4-8h, andincreasedwhite blood cellcountat4-8hand24h. Correlationanalysis revealed significant positive associations between time on CPB and syndecan-1 (r(s) = 0.488, P < 0.001) and level of syndecan-1 and neutrophil count (r(s) = 0.351, P = 0.038) at 4-8 h. Intravenous administration of recombinant syndecan-1 in mice resulted in a 2.5-fold increase in the number of circulating neutrophils, concurrent with decreased bonemarrow neutrophil number. Conclusions: Longer duration of CPB is associated with increased plasma levels of soluble syndecan-1, a signal for EG degradation, which can induce neutrophil egress from the bone marrow. Development of therapy targeting EG shedding may be beneficial in patients with prolonged CPB. (C) 2020 Elsevier Inc. All rights reserved.

Central MessageMost of the patients undergoing cardiac surgery should be safe with a DOAC hold time 4 days before the procedure, providing a thorough history is taken.See Article page 1864. Most of the patients undergoing cardiac surgery should be safe with a DOAC hold time 4 days before the procedure, providing a thorough history is taken. See Article page 1864. The manuscript entitled “Protocol for Safe Management of Patients Under Direct Oral Anticoagulant Therapy Before Cardiothoracic Surgery Compared With Patients Undergoing Vitamin K Antagonist or No Anticoagulation Therapy”1Fox V. Kleikamp A. Dittrich M. Zittermann A. Flieder T. Knabbe C. et al.Direct oral anticoagulants and cardiac surgery: a descriptive study of preoperative management and postoperative outcomes.J Thorac Cardiovasc Surg. 2021; 161: 1864-1874.e2Abstract Full Text Full Text PDF Scopus (2) Google Scholar outlines how an applied protocol allowed anticoagulated patients on direct oral anticoagulants (DOACs) to undergo major cardiac surgery as safely as those on vitamin K antagonists (VKAs). The timing of discontinuing direct thrombin inhibitors and factor Xa inhibitors before cardiac surgery is currently variable in and between centers. This analysis adds to the evidence supporting readiness for surgery guidelines in an era in which preoperative patients requiring oral anticoagulant therapy are taking DOACs more often than the traditional VKAs. The authors have concluded that discontinuing the DOAC 4 days before admission for cardiac surgery appears to be a safe way to avoid hemorrhagic complications of cardiac surgery, providing that there is an accurate history. Discontinuing the anticoagulant (without bridging) 4 days before surgery (surgery being day zero) combined with a measurement of the DOAC on the day before surgery regardless of the DOAC with a defined no-go threshold (<30 ng/mL for both direct thrombin inhibitors and anti-Xa drugs) offers a high degree of safety with regard to hemorrhagic complications in the perioperative setting of cardiac surgery, as the authors were unable to detect any difference in outcome measures between the VKA antagonist and DOAC groups. In 75 of 487 patients (15%), the drug levels were >30 ng/mL on the day before scheduled surgery. In total, 59% of those patients had taken their DOAC despite their physicians advising them otherwise. This strategy fits most patients, but not all, as 85% of the patients in this study were able to have cardiac surgery safely after discontinuing DOACs 4 days before their operation. The other 15% were postponed until their drug levels became lower than the 30 ng/mL threshold. The question remains as how to generalize this study for centers in which the laboratories do not provide the testing done in this study to safely manage the other 15%. A careful history may find most of the patients who continued to take their DOAC longer than advised. In the absence of testing, there may remain a few patients who will be at risk for being above the 30 ng/mL drug level used in this study. There remains a paucity of data regarding DOAC drug levels and a correlation with clinically significant bleeding; therefore, the use of a specific “go or no-go” threshold for surgery is difficult to determine. In the recently published Perioperative Anticoagulation Use for Surgery Evaluation (PAUSE) cohort study,2Douketis J.D. Spyropoulos A.C. Duncan J. Carrier M. Le Gal G. Tafur A.J. et al.Perioperative management of patients with atrial fibrillation receiving a direct oral anticoagulant.JAMA Intern Med. 2019; 179: 1469-1478Crossref PubMed Scopus (113) Google Scholar 1119 of 3007 (37.2%) of patients underwent cardiothoracic surgery just 2 days after discontinuing DOACS, with a major bleeding rate of <3%. Furthermore, drug levels obtained before the procedure (but not known at the time of the procedure) showed that >90% of patients had levels <50 ng/mL and >85% had levels <30 ng/mL, illustrating that most of the patients undergoing these high-bleed risk procedures should be safe with a DOAC hold time between 2 and 4 days before the procedure. Direct oral anticoagulants and cardiac surgery: A descriptive study of preoperative management and postoperative outcomesThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5PreviewRecommendations for perioperative management of direct oral anticoagulant (DOAC) treatment in cardiac surgery are lacking. To establish a standardized approach for these patients, we compared hemorrhagic complications and clinical outcomes in patients on DOAC medication, patients on vitamin K antagonists (VKA), and patients without preoperative anticoagulation. Full-Text PDF