Cardiac surgery in the afternoon is not associated with increased operative morbidity and mortality

Implications of an off-hours setting in patients undergoing transcatheter edge-to-edge repair for mitral regurgitation

BACKGROUND

Little is known about transcatheter edge-to-edge repair (TEER) for mitral regurgitation (MR) that is performed outside of usual working hours. We aimed to explore the prevalence, correlates, and outcomes of mitral TEER initiated off-hours, ie, before 7:30 am, after 5:30 pm, or on weekends/holidays.

METHODS

A single-center registry of isolated, first-time interventions was retrospectively analyzed in its entirety and after propensity-score matching. Outcomes included all-cause mortality, heart failure (HF) hospitalizations, and the persistence of MR and functional incapacitation along the first postprocedural year.

RESULTS

A total of 1,177 procedures were studied. Of them, 117 (9.9%) took place off-hours. These were more often urgent interventions (30.8% vs. 14.3%, P < .001) performed in the midst of acute HF / hemodynamic compromise and on individuals with greater comorbidity, more advanced HF, and higher interventional risk. Overall procedural features were unaffected by interventional timing, and a high (>97%) technical success rate was achieved unanimously. MR severity and functional class similarly improved from baseline in the 2 study groups. Deaths and the composite of deaths or HF hospitalizations occurred earlier and more frequently following off-hours procedures (18.8% vs. 11.5%, P = .022 and 33.3% vs. 24.6%, P = .040, respectively). None of the explored endpoints' risks were independently associated with procedural timing. Within a 234-patient, 1-to-1 matched sub-cohort, no inter-group differences were observed in pre-, intra-, and postprocedural findings and outcomes.

CONCLUSIONS

A noninfrequent procedure, off-hours mitral TEER is performed in high-risk cases but, in the hands of experienced interventionalists, should prove safe, feasible, and efficacious.

Impact of perioperative dexmedetomidine on long-term outcomes in older patients following cardiac surgery: follow-up of a randomized trial

BACKGROUND

Perioperative dexmedetomidine is reported to reduce complications and even in-hospital mortality after cardiac surgery. We therefore tested the hypothesis that perioperative dexmedetomidine may improve long-term outcomes after cardiac surgery.

METHODS

This was long-term follow-up of a randomized trial. We enrolled 285 patients aged 60 years or older who were scheduled for elective cardiac surgery. Patients were randomized to receive either dexmedetomidine or placebo (normal saline) during and early after surgery. Follow-up was conducted for up to 6 years post-surgery. The primary endpoint was overall survival. Secondary outcomes included major adverse cardiovascular events (MACE)-free and hospital-free survivals, as well as cognitive function and quality of life in 6-year survivors.

RESULTS

All 285 patients were included in final analysis. Median follow-up duration was 80 months (interquartile range 30 to 80). Overall survival did not differ between the two groups: there were 18 deaths (12.6%) with placebo versus 22 deaths (15.5%) with dexmedetomidine; hazard ratio (HR) 1.22, 95% CI 0.65 to 2.27, p = 0.418. MACE-free survival was 23 (16.1%) with placebo versus 24 (16.9%) with dexmedetomidine; HR 1.03, 95% CI 0.58 to 1.83, P = 0.911. Hospital-free survival was 39 (27.3%) with placebo versus 42 (29.6%) with dexmedetomidine; HR 1.04, 95% CI 0.67 to 1.61, P = 0.853. Among 6-year survivors, the scores of cognitive function and quality of life were similar between groups.

CONCLUSIONS

We found that, for older patients undergoing elective cardiac surgery, dexmedetomidine administered during and early after surgery did not alter overall and MACE-free survivals, as well as long-term cognitive function and quality of life. However, considering the underpowered sample size and non-negligible loss to follow-up rate, our results need further confirmation.

TRIAL REGISTRATION

ClinicalTrials.gov: NCT03289325 (September 20, 2017).

Does performing cardiac surgery after hours impact postoperative outcomes? A systematic review and meta-analysis

INTRODUCTION

There has been concern regarding the safety of cardiac surgical intervention during off-hours. Sleep deprivation, resource limitations, and an increased case urgency have been postulated to increase off-hours surgical risk, although outcomes are inconsistent in the existing literature. In this systematic review and meta-analysis, we review the literature comparing patients undergoing cardiac surgery during on and off-hours.

EVIDENCE ACQUISITION

PubMed and Embase were systematically searched for literature published from January 2000-September 2023, comparing outcomes of patients undergoing cardiac surgery during on and off-hours. Overall, 3540 manuscript titles and abstracts were screened and 11 articles were included.

EVIDENCE SYNTHESIS

Overall aggregate analysis indicated no significant differences in rates of in-hospital mortality(OR 1.04; 95% CI, 0.41-2.63; P=0.93) and perioperative morbidity, including stroke (P=0.52), reoperation (P=0.92), major bleeding (P=0.10), and renal complications (P=0.55). Composite rates of sternal wound infection favored on-hours surgery (P=0.01).

CONCLUSIONS

Although inferior outcomes in patients undergoing cardiac surgery during off-hours have been noted, aggregate analysis largely revealed equivalent perioperative morbidity and mortality during on and off-hours surgery, although with the exclusion of one outlier study in-hospital mortality and reoperation favored on-hours surgery. Heterogeneity in outcomes is likely multifactorial, with surgical staff fatigue, patient preoperative risk, clinical setting, and resource limitations all contributing. Further investigation is required directly comparing emergent cardiac surgical intervention during on-hours and off-hours controlling for baseline surgical risk to elucidate the true impact of timing of surgery on postoperative outcomes.

Hypotension prediction index for the prevention of hypotension during surgery and critical care: A narrative review

Surgeons and anesthesia clinicians commonly face a hemodynamic disturbance known as intraoperative hypotension (IOH), which has been linked to more severe postoperative outcomes and increases mortality rates. Increased occurrence of IOH has been positively associated with mortality and incidence of myocardial infarction, stroke, and organ dysfunction hypertension. Hence, early detection and recognition of IOH is meaningful for perioperative management. Currently, when hypotension occurs, clinicians use vasopressor or fluid therapy to intervene as IOH develops but interventions should be taken before hypotension occurs; therefore, the Hypotension Prediction Index (HPI) method can be used to help clinicians further react to the IOH process. This literature review evaluates the HPI method, which can reliably predict hypotension several minutes before a hypotensive event and is beneficial for patients' outcomes.