Patient and caregiver preferences and prioritized outcomes for cardiac surgery: A scoping review and consultation workshop

OBJECTIVE(S)

In light of the absence of patient and caregiver input in Enhanced Recovery After Surgery Cardiac Surgery guideline development, we conducted a scoping review to identify patient and caregiver preferences and prioritized outcomes related to perioperative care in cardiac surgery and its lifelong impact.

METHODS

Five electronic databases were searched to retrieve studies investigating patient or caregiver preferences and prioritized outcomes. Information was charted in duplicate and analyzed using descriptive statistics or thematic analysis. A patient and caregiver consultation workshop validated scoping review findings and solicited novel preferences and outcomes.

RESULTS

Of the 5292 articles retrieved, 43 met inclusion criteria. Most were from Europe (n = 19, 44%) or North America (n = 15, 35%) and qualitative and quantitative designs were represented in equal proportions. Fifty-two methods were used to obtain stakeholder preferences and prioritized outcomes, the majority being qualitative in nature (n = 32, 61%). Based on the collective preferences of 3772 patients and caregivers from the review and 17 from the consultation workshop, a total of 108 patient preferences, 32 caregiver preferences, and 19 prioritized outcomes were identified. The most commonly identified theme was "information and education." Improved quality of life was the most common patient-prioritized outcome, and all caregiver-prioritized outcomes were derived from the consultation workshop.

CONCLUSIONS

Patient and caregiver preferences overlap with Enhanced Recovery After Surgery Cardiac Surgery recommendations targeting preoperative risk reduction strategies, prehabilitation, patient engagement technology, and intra- and postoperative strategies to reduce discomfort. To support clinical practice, future research should investigate associations with key surgical outcomes.

Minimally invasive mitral valve surgery

There is considerable interest and demand in the application of minimally invasive techniques in cardiac surgery driven by multiple factors including patient cosmesis and satisfaction, reduction of surgical trauma and the development of specialized instrumentation that allows these procedures to be performed safely. Minimally invasive mitral valve surgery (MIMVS) has been conducted for more than 25 years and has been shown to offer multiple benefits including better cosmetic results, enhanced post-operative recovery, improved patient satisfaction and most importantly, equivalent clinical outcomes with regards to quality and safety when compared to the standard sternotomy approach. MIMVS may be particularly beneficial in certain subgroups of patients, for example patients undergoing redo mitral valve surgery. In this article, we discuss patient selection criteria for MIMVS, the merits and drawbacks of MIMVS relative to conventional sternotomy approaches, and detail procedural aspects including anaesthetic management, intraoperative technique, and important considerations in myocardial protection and cardiopulmonary bypass (CPB). When considering developing a MIMVS programme, as for any new technique, a team approach to the introduction of the programme is essential. Although it is clear that patient selection is important, particularly early in a surgical programme, with experience complex repairs can be performed through a minimally invasive approach with excellent outcomes.

Clinical and Operative Determinants of Acute Kidney Injury after Cardiac Surgery

INTRODUCTION

Cardiac surgery-associated acute kidney injury (CSA-AKI) is associated with increased morbidity and mortality.

OBJECTIVES

We aimed to identify potentially modifiable risk factors for CSA-AKI.

METHODS

This was asingle-center retrospective cohort study of 495 adult patients undergoing cardiac surgery. AKI was diagnosed and staged using full KDIGO criteria incorporating baseline serum creatinine (SC) levels and correction of postoperative SC levels for fluid balance. We examined the association of routinely available clinical and laboratory data with AKI using multivariate logistic regression modeling.

RESULTS

A total of 103 (20.8%) patients developed AKI: 16 (15.5%) patients were diagnosed with AKI upon hospital admission, and 87 (84.5%) patients were diagnosed with CSA-AKI. Correction of SC levels for fluid balance increased the number of AKI cases to 104 (21.0%), with 6 patients categorized to different AKI stages. Univariate logistic regression analysis identified five preoperative (age, sex, diabetes mellitus, preoperative systolic pulmonary arterial pressure [PSPAP], acute decompensated heart failure) and five intraoperative predictors of AKI (age, sex, red blood cell [RBC] volume transfused, use of minimally invasive surgery, duration of cardiopulmonary bypass). When all preoperative and intraoperative variables were incorporated into one model, six predictors remained significant (age, sex, use of minimally invasive surgery, RBC volume transfused, PSPAP, duration of cardiopulmonary bypass). Model discrimination performance showed an area under the curve of 0.69 for the model including only preoperative variables, 0.76 for the model including only intraoperative variables, and 0.77 for the model including all preoperative and intraoperative variables.

CONCLUSIONS

Use of minimally invasive surgery and therapies mitigating PSPAP and intraoperative blood loss may offer protection against CSA-AKI.

Beating heart minimally invasive mitral valve surgery in patients with previous sternotomy: the operative technique and early outcomes

Objective

Reoperative mitral valve surgery is increasingly required and can be associated with significant morbidity and mortality. The beating heart minimally invasive mitral valve surgery has a proposed benefit in avoiding the risks of repeat sternotomy, with reducing the need for adhesiolysis and cardioplegia reperfusion injury. We describe our experience with such a technique in patients with previous sternotomy.

Methods

A retrospective study was performed and all patients undergoing surgery of mitral valve through a right limited thoracotomy without application of an aortic cross-clamp (beating heart) as a redo cardiac surgery between January 2006 and January 2015 were included (n=25). Perioperative data as well as the operative technique are presented.

Results

Six patients (24%) had two previous sternotomies and one (4%) had three previous sternotomies. Mitral valve repair was performed in 11 patients (44%). No patient required conversion to median sternotomy. Inotropic support beyond 4 hours after operation was required in seven patients (28%). Ventilation time was less than 12 hours in 14 patients (56%) with another six patients (24%) extubated within 24 hours after surgery. Postoperative course was complicated with cerebrovascular accident in two patients (8%). In-hospital mortality was 4% (n=1). There was no 30-day mortality after discharge.

Conclusions

Reoperative mitral valve surgery can be safely performed through a limited right thoracotomy approach on a beating heart while on full cardiopulmonary bypass. The technique can be associated with potentially shorter operation, shorter cardiopulmonary bypass and a less complicated recovery.

Early feasibility evaluation of thoracoscopically assisted transcatheter ventricular reconstruction in an experimental model of ischaemic heart failure with left anteroapical aneurysm

AIMS

To test the feasibility of a thoracoscopically assisted, off-pump, transcatheter ventricular reconstruction (TCVR) approach in an ovine model of left ventricular (LV) anteroapical aneurysm.

METHODS AND RESULTS

Myocardial infarction (MI) was induced by coil occlusion of the middle left anterior descending artery and diagonals. Two months after MI creation, TCVR was performed via a minimal thoracotomy in eight sheep. Under endoscopic and fluoroscopic guidance, trans-interventricular septal puncture was performed from the LV epicardial scar. A guidewire was externalised via a snare placed in the right ventricle from the external jugular vein. An internal anchor was inserted over the wire and positioned on the right ventricular septum and an external anchor was deployed on the LV anterior epicardium. Serial pairs of anchors were placed and plicated together to exclude the scar completely. Immediately after TCVR, echocardiography showed LV end-systolic volume decreased from pre-procedure 58.8±16.6 ml to 25.1±7.6 ml (p<0.01) and the ejection fraction increased from 32.0±7.3% to 52.0±7.5% (p<0.01). LV twist significantly improved (3.83±2.21 vs. pre-procedure -0.41±0.94, p=0.01) and the global peak-systolic longitudinal strain increased from -5.64% to -10.77% (p<0.05).

CONCLUSIONS

TCVR using minimally invasive access techniques on the off-pump beating heart is feasible and resulted in significant improvement in LV performance.

Mitral valve surgery using video-assisted right minithoracotomy and deep hypothermic perfusion in patients with previous cardiac operations

Background

Redo-sternotomy for mitral valve (MV) surgery may be complex and attendant complications can be avoided using anterolateral right thoracotomy, deep hypothermia (20°C, nasopharyngeal) with low flow cardiopulmonary perfusion. Video-assisted minithoracotomy technique is a further improvement.

Methods

We performed 20 consecutive MV operations in patients with previous cardiac surgery using video-assisted right minithoracotomy, femoro-femoral bypass, deep hypothermia, low flow cardiopulmonary bypass without aortic cross-clamping. The mean follow-up was 30 ± 17.8 mo. Data is presented as the mean ± standard deviation of the mean.

Results

There were 11 males and 9 females (age, 62.3 ± 12.1; ejection fraction 50.1 ± 11.2). Operations included MV replacement (n = 11), MV repair (n = 5), and MV re-replacement (n = 4). There were no hospital deaths, and the mean hospital stay was 8 ± 2.9 days. There were no postoperative strokes or need for mechanical circulatory support. The mean cardiopulmonary bypass time was 152 ± 28 minutes. Two patients (10%) required inotropic support beyond 24 hrs. All patients were free from inotropic support at 48 hours. The mean number of transfused red cell units was 2.8 ± 0.8 (range, 2 to 4). One patient died in another institution six months postoperatively following surgery for acute type III aortic dissection. At 30 ± 17.8 months follow-up all patients were found to be in NYHA Class I or II.

Conclusions

Minimally invasive video-assisted MV surgery using deep hypothermia, low-flow cardiopulmonary bypass without aortic clamping can result in excellent clinical outcomes in patients with previous cardiac surgery via a median sternotomy. This technique offers reproducible results, good myocardial protection (as evidenced by the low rate of inotropic support that patients needed postoperatively), and low rates of complications.

Acute kidney injury after aortic valve replacement: incidence, risk factors and outcomes

The occurrence of acute kidney injury (AKI) following aortic valve replacement (AVR) has very serious clinical implications and has therefore been the focus of several studies. The authors report the results of previous studies evaluating both transcatheter AVR (TAVR) and indirectly surgical AVR (SAVR) through looking at cardiopulmonary bypass (CPB) cardiac surgeries, and identify the incidence, predictors and outcomes of AKI following AVR. In most studies, AKI was defined using the Risk, Injury, Failure, Loss and End Stage, Valve Academic Research Consortium (modified Risk, Injury, Failure, Loss and End Stage) or Valve Academic Research Consortium-2 (Acute Kidney Injury Network) AKI classification criteria. Twelve studies including more than 90,000 patients undergoing cardiac surgery on CPB were considered as well as 26 studies with more than 6000 patients undergoing TAVR. Depending on the definition used, AKI occurred in 3.4-43% of SAVR cases with up to 2.5% requiring dialysis, and in 3.4-57% of TAVR cases. Factors identified as independent predictors of AKI were: baseline kidney failure, EUROSCORE, diabetes mellitus, hypertension, chronic obstructive pulmonary disease, anemia, peripheral vascular disease, heart failure, surgical priority, CPB time, reoperation, use of intra-aortic balloon pump, need for re-exploration, contrast agent volume, transapical access, blood transfusion, postoperative thrombocytopenia, postoperative leukocytosis as well as demographic variables such as age and female gender. The 30-day mortality rate for patients with AKI following SAVR ranged from 5.5 to 46% and was 3- to 16-times higher than in those without AKI. Similarly, patients who developed AKI after TAVR had a mortality rate of 7.8-29%, which was two- to eight-times higher than those who did not suffer from AKI. AKI confers up to a fourfold increase in 1-year mortality. Finally, hospital length of stay was significantly increased in patients with AKI in both SAVR and TAVR groups, with increases up to 3- and 2.5-times, respectively.

Minimally invasive approach for redo mitral valve surgery

Redo cardiac surgery represents a clinical challenge due to a higher rate of peri-operative morbidity and mortality. Mitral valve re-operations can be particularly demanding in patients with patent coronary artery bypass grafts, previous aortic valve replacement, calcified aorta or complications following a previous operation (abscesses, perivalvular leaks, or thrombosis). Risk of graft injuries, hemorrhage, the presence of dense adhesions and complex valve exposure can make redo valve operations challenging through a median sternotomy. In this review article we provide an overview of minimally invasive approaches for redo mitral valve surgery discussing indications, techniques, outcomes, concerns and controversies. Scientific literature about minimally invasive approach for redo mitral surgery was reviewed with a MEDLINE search strategy combining "mitral valve" with the following terms: 'minimally invasive', 'reoperation', and 'alternative approach'. The search was limited to the last ten years. A total of 168 papers were found using the reported search. From these, ten papers were identified to provide the best evidence on the subject. Mitral valve reoperations can be safely and effectively performed through a smaller right thoracotomy in the fourth intercostal space termed "mini" thoracotomy or "port access". The greatest potential benefit of a right mini-thoracotomy is the avoidance of sternal re-entry and limited dissection of adhesions, avoiding the risk of injury to cardiac structures or patent grafts. Good percentages of valve repair can be achieved. Mortality is low as well as major complications. Minimally invasive procedures with an unclamped aorta have the potential to combine the benefits of minimally invasive access and continuous myocardial perfusion. Less invasive trans-catheter techniques could be considered as the natural future evolution for management of structural heart disease and mitral reoperations. The safety and efficacy of these procedures has never been compared to open reoperations in a randomized trial, although published case series and comparisons to historical cohorts suggest that they are an effective and feasible alternative. Ongoing follow-up on current series will further define these procedures and provide valuable clinical outcome data.

Cross-sectional survey on minimally invasive mitral valve surgery

BACKGROUND

Minimally invasive mitral valve surgery (MIMVS) has become a standard technique to perform mitral valve surgery in many cardiac centers. However, there remains a question regarding when MIMVS should not be performed due to an increased surgical risk. Consequently, expert surgeons were surveyed regarding their opinions on patient factors, mitral valve pathology and surgical skills in MIMVS.

METHODS

Surgeons experienced in MIMVS were identified through an electronic search of the literature. A link to an online survey platform was sent to all surgeons, as well as two follow-up reminders. Survey responses were then submitted to a central database and analyzed.

RESULTS

The survey was completed by 20 surgeons. Overall results were not uniform with regard to contraindications to performing MIMVS. Some respondents do not consider left atrial enlargement (95% of surgeons), complexity of surgery (75%), age (70%), aortic calcification (70%), EuroSCORE (60%), left ventricular ejection fraction (55%), or obesity (50%) to be contraindication to surgery. Ninety percent of respondents believe more than 20 cases are required to gain familiarity with the procedure, while 85% believe at least one MIMVS case needs to be performed per week to maintain proficiency. Eighty percent recommend establishment of multi-institutional databases and standardized surgical mentoring courses, while 75% believe MIMVS should be incorporated into current training programs for trainees.

CONCLUSIONS

These results suggest that MIMVS has been accepted as a treatment option for patients with mitral valve pathologies according the expert panel. Initial training and continuing practice is recommended to maintain proficiency, as well as further research and formalization of training programs.

Cardiac surgery-associated acute kidney injury

Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery requiring cardiopulmonary bypass (CPB), and it is the second most common cause of AKI in the intensive care unit. Although the complication has been associated with the use of CPB, the etiology is likely multifactorial and related to intraoperative and early postoperative management including pharmacologic therapy. To date, very little evidence from randomized trials supporting specific interventions to protect from or prevent AKI in broad cardiac surgery populations has been found. The definition of AKI employed by investigators influences not only the incidence of CSA-AKI, but also the identification of risk variables. The advent of novel biomarkers of kidney injury has the potential to facilitate the subclinical diagnosis of CSA-AKI, the assessment of its severity and prognosis, and the early institution of interventions to prevent or reduce kidney damage. Further studies are needed to determine how to optimize cardiac surgical procedures, CPB parameters, and intraoperative and early postoperative blood pressure and renal blood flow to reduce the risk of CSA-AKI. No pharmacologic strategy has demonstrated clear efficacy in the prevention of CSA-AKI; however, some agents, such as the natriuretic peptide nesiritide and the dopamine agonist fenoldopam, have shown promising results in renoprotection. It remains unclear whether CSA-AKI patients can benefit from the early institution of such pharmacologic agents or the early initiation of renal replacement therapy.

Redo mitral valve operation via right minithoracotomy--"no touch" technique

Five patients who had had previous cardiac operations underwent minimally invasive beating heart mitral valve operations via a right minithoracotomy between November 2006 and February 2009. The mean age was 64 ± 10 years and 4 were female. Under general anesthesia with single-lumen ventilation, cardiopulmonary bypass was established using the right femoral artery and vein. Through right minithoracotomy, the left atrium was opened without dissection of pericardial adhesion. The aorta was not cannulated or clamped, using a so-called "No Touch" technique. Four patients had mitral valve replacement and one had mitral ring annuloplasty with the heart beating. Mean cardiopulmonary bypass time was 118 ± 38 minutes. There was no early mortality or confirmed stroke. One patient who underwent mitral ring annuloplasty for ischemic mitral regurgitation died 3 months after surgery due to renal failure. At follow-up, New York Heart Association functional class had improved in 3 patients. In conclusion, in our initial series, minimally invasive beating heart redo mitral valve surgery through right minithoracotomy was safely performed with no early mortality.

[Vidéo-assisted mitral valve surgery: state of the art]

Video-assisted mitral valve surgery by right mini-thoracotomy is adopted systematically in many centers in the world. It is a safe procedure that offers good results with low morbidity. His major interest can be appreciated in surgical management of mitral valve regurgitation after coronary artery bypass.