The Use of Frailty Scoring to Predict Early Physical Activity Levels After Cardiac Surgery

BACKGROUND

Assessing patient fitness prior to high-risk operations is becoming increasingly vital in cardiothoracic surgery. Physical activity (PA) and frailty measures are powerful perioperative tools, albeit underused in clinical practice. This study aimed to assess the influence of patient frailty on PA postsurgery and other short-term outcomes.

METHODS

Eighty patients undergoing a variety of cardiac surgical procedures (coronary revascularisation, valve repair/replacement, or combination) were recruited to participate. The Reported Edmonton Frailty Scale was used to measure preoperative frailty. As objective measures of PA, participants wore a wrist accelerometer device for 14 days prior to their operation and early in the postoperative period for 30 days.

RESULTS

A global reduction in PA was observed in the early postoperative period. Frailty was a significant predictor of reduced light (coefficient -2.23, 95% CI -4.21 to -0.25, P = .028) and moderate activity (coefficient -1.85, 95% CI -2.99 to -0.70, P = .002) postoperatively. Neither frailty nor preoperative PA were predictors of postoperative composite complications. Both frailty (coefficient 0.134, 95% CI 0.106-0.162, P < .001) and PA scores (P < .05) were strong predictors of length of hospital stay (coefficient 1.76, 95% CI 0.003-3.524, P = .05). Furthermore, patients who stayed in hospital longer were more likely to suffer early postoperative complications (stroke, renal failure, reoperation, pacemaker) if they were frail (P < .0001) compared to non-frail patients (P = .607).

CONCLUSIONS

This study highlights the predictive ability of objective frailty scoring and PA measurement for outcomes after cardiac surgery. This has important implications for surgical risk stratification and personalized postoperative planning.

Systematic review on the predictive ability of frailty assessment measures in cardiac surgery

Objectives

Patient frailty is increasingly recognised as contributing to adverse postoperative outcomes in cardiothoracic surgery. The goal of this review is to evaluate the predictive ability of frailty scoring systems and their limitations in risk assessment of patients undergoing cardiac surgery.

Methods

Frailty studies were identified by searching electronic databases. Studies in which the measuring instrument was defined as a multidimensional tool focusing on a population undergoing cardiac operations were included. The focus was on the predictive ability of frailty in this population and a comparison with conventional risk scoring systems. Unfortunately, the lack of a significant number of studies with the same postoperative outcome precluded a formal meta-analysis.

Results

Of 783 studies identified in our initial search, 6 fulfilled our inclusion criteria. Frailty was identified as a predictor of mortality, morbidity and/or prolonged hospital stay in patients undergoing cardiac surgery. Our systematic review revealed the increased application of frailty scores compared to standardized risk stratification scores in cardiothoracic patients. In approximately 50% of these studies, frailty scores continued to be predictive even after adjusting for the conventional risk scoring systems.

Conclusions

The assessment of frailty may enhance the preoperative workup and offer an optimized risk stratification measure in patients undergoing cardiothoracic procedures even though the reporting standards of calibration and classification measures have been relatively poor.

Bailouts to LIMA Damage for Avoiding Conversion in Minimal Access Coronary Procedures

Minimally invasive and robotic coronary revascularization strategies offer less pain, fewer adverse events, better cosmesis, and speedier recovery. These procedures are vulnerable to left internal mammary artery (LIMA) injury that may require a full sternotomy, which eliminates the benefits of minimally invasive procedures. We present a management protocol to avoid conversion to sternotomy in minimally invasive cases based on the location of the LIMA injury at proximal, mid, and distal locations. By applying axillary bypass, LIMA extension, and repair over a shunt approaches, our protocol can be used as a successful bailout to LIMA damage in minimally invasive coronary cases.

Late surgical repair of a traumatic ventricular septal defect

Ventricular Septal Defect (VSD) complicates approximately 1-5% of patients presenting with penetrating chest trauma, however not all VSDs are evident at the time of initial presentation to the emergency department. Acute closure of traumatic VSDs is indicated in patients with a large defect and haemodynamic compromise, however closure may be delayed in smaller defects in order to minimise operative time, reduce operative mortality and allow for recovery from the initial trauma. We describe the case of a previously healthy 23 year-old Caucasian man who presented in extremis following stab wounds to the precordium. After emergency cardiopulmonary bypass and closure of lacerations to both the left and right ventricles, postoperative trans-thoracic echocardiography (TTE) noted a restrictive intramuscular VSD with a high velocity left to right shunt, initially managed conservatively. Elective surgical closure was performed 10 months after the initial injury through a right ventriculotomy using 4–0 Proline sutures reinforced with Teflon pledgets. Despite excellent clinical recovery, 3-month follow-up TTE noted a residual VSD in the mid apical septum. However, given the presence of minimal left to right shunt and the small size of the defect, the patient was managed conservatively with annual review and repeat transthoracic echo. This case highlights the potential pitfalls in both the diagnosis and management of traumatic VSDs particularly where the patient presents in extremis with other life-threatening injuries. Furthermore, it exemplifies the importance of a multidisciplinary approach when planning any elective intervention. Regardless of the management strategy, repeated re-assessment and re-evaluation is vital following penetrating cardiac trauma, and vigilant long-term follow-up is of paramount importance in these cases.

Contrasting effect of different cardiothoracic operations on echocardiographic right ventricular long axis velocities, and implications for interpretation of post-operative values

Background

Patients undergoing coronary artery bypass grafting (CABG) experience a reduction in right ventricular long axis velocities post surgery.

Objectives

We tested whether the phenomenon of right ventricular (RV) long axis velocity decline depends on the chest being opened fully by mid-line sternotomy, pericardial incision, or on the type of operation performed.

Method

By intraoperative transoesophageal echocardiography (TEE) we recorded serial right ventricular (RV) systolic pulse-wave tissue Doppler velocities during 6 types of elective procedure: 53 CABG surgery, 15 robotic-assisted minimally-invasive CABG (RCABG), 28 aortic valve replacement (AVR), 8 minimally-invasive aortic valve replacement (mini-AVR), 5 mediastinal mass excision, and 1 left atrial myxoma excision. Pre and post operative transthoracic echocardiography (TTE) were also conducted.

Results

Surgery without substantial opening of the pericardium did not significantly reduce RV systolic velocities (RCABG 13 ± 1.8 versus 12.4 ± 2.7 cm/s post; mini-AVR 11.9 ± 2.3 versus 11.1 ± 2.3 cm/s; mediastinal mass excision 13.9 ± 3.1 versus 13.8 ± 4 cm/s). In contrast, within 5 min of pericardial incision those whose surgery involved full opening of the pericardium had large reductions in RV velocities: 54 ± 11% decline with CABG (11.3 ± 1.9 to 5.1 ± 1.6 cm/s, p < 0.0001), 54 ± 5% with AVR (12.6 ± 1.4 to 5.7 ± 0.6 cm/s, p < 0.001) and 49% with left atrial myxoma excision (11.3 to 15.8 cm/s). This persisted immediately after pericardial opening to the end of surgery (61 ± 11%, p < 0.0001; 58 ± 7%, p < 0.0001; 59% respectively).

Conclusions

It is full opening of the pericardium, and not cardiac surgery in general, which causes RV long axis decline following cardiac surgery. The impact is immediate (within 5 min) and persistent.

The right ventricular annular velocity reduction caused by coronary artery bypass graft surgery occurs at the moment of pericardial incision

Background

Right ventricular (RV) long-axis function is known to be depressed after cardiac surgery, but the mechanism is not known. We hypothesized that intraoperative transesophageal echocardiography could pinpoint the time at which this happens to help narrow the range of plausible mechanisms.

Method

Transthoracic echocardiography was conducted in 33 patients before and after elective coronary artery bypass graft. In an intensively monitored cohort of 9 patients, we also monitored RV function intraoperatively using serial pulsed wave tissue Doppler (PW TD) transesophageal echocardiography.

Results

There was no significant difference in myocardial velocities from the onset of the operation up to the beginning of pericardial incision, change in RV PW TD S′ velocities 3% ± 2% (P = not significant).

Within the first 3 minutes of opening the pericardium, RV PW TD S′ velocities had reduced by 43% ± 17% (P < .001). At 5 minutes postpericardial incision, 2 minutes later, the velocities had more than halved, by 54% ± 11% (P < .0001). Velocities thereafter remained depressed throughout the operation, with final intraoperative S′ reduction being 61% ± 11% (P < .0001).

One month after surgery, in the full 33-patient cohort, transthoracic echocardiogram data showed a 55% ± 12% (P < .0001) reduction in RV S′ velocities compared with preoperative values.

Conclusions

Minute-by-minute monitoring during cardiac surgery reveals that, virtually, all the losses in RV systolic velocity occurs within the first 3 minutes after pericardial incision. Right ventricular long-axis reduction during coronary bypass surgery results not from cardiopulmonary bypass but rather from pericardial incision.

Evolving techniques for endoscopic radial artery harvesting

The role of radial artery as an arterial conduit for myocardial revascularisation is well established. Minimally invasive approaches for the harvesting of conduits are desirable for clinical and cosmetic reasons. We report our experience with two techniques of endoscopic radial artery harvesting. The techniques are illustrated and their relative advantages discussed.

Is early hospital discharge feasible following normothermic coronary artery surgery on the fibrillating heart?

AIM

Protocols for the earlier discharge of cardiac surgical patients are gaining popularity. We present our experience with an early hospital discharge policy following coronary artery bypass grafting (CABG) on the fibrillating heart.

METHODS

Three-hundred and ninety-two consecutive patients who underwent elective CABG by a single surgeon were retrospectively reviewed. CABG was performed initially (1998-1999) in 191 patients with cardiopulmonary bypass (CPB) normothermia, intermittent aortic cross-clamping (AXC) and ventricular fibrillation and later (2001-2003) in 201 patients without CPB. Emphasis was given on short AXC and CPB times, early extubation, early mobilization and atrial fibrillation prophylaxis. Discharge criteria were as follows: walking on stairs unassisted, sinus rhythm for 24 hours, normal bowel function, apyrexia, family support at home. A 6-week follow-up clinic visit was arranged. Hospital re-admissions were carefully monitored.

RESULTS

The mean (+/-SD) age of the patients was 62+/-9.6 years and the mean Parsonnet score was 6.7. The mean hospital stay was 6.1+/-2.5 days. Sixty-three (16%) and 171 (44%) patients were discharged by postoperative day 4 and 5, respectively. The following factors were independently associated with longer hospital stay: number of grafts performed (>3), requirement for postoperative inotropic support and social circumstances inadequate for early discharge. Twenty-three patients (5.8%) were re-admitted in the 6-week postoperative period. Shorter hospital stay was not associated with increased risk of re-admission.

CONCLUSION

Early discharge after CABG with ventricular fibrillation is achievable, comparable to "fast-track techniques" without the use of CPB and is not associated with higher re-admission rates. We recommend the routine use of this protocol in all patients undergoing primary elective CABG.

Is the female gender an independent predictor of adverse outcome after off-pump coronary artery bypass grafting?

BACKGROUND

The female gender is an independent predictor of adverse outcome after conventional coronary artery bypass grafting using cardiopulmonary bypass. The aim of this study is to assess the effect of the female gender on the outcome after off-pump coronary artery bypass (OPCAB) surgery.

METHODS

This study is a retrospective review of 413 consecutive patients (181 women and 232 men) who underwent OPCAB between January 1999 and May 2001. Adverse outcomes were divided into minor adverse outcomes (MINAO), major adverse outcomes (MAJAO), and prolonged length of stay (PLOS) more than 7 days. MINAO included atrial fibrillation, respiratory complications except adult respiratory distress syndrome, and any wound infection except mediastinitis. MAJAO included stroke, myocardial infarction, renal failure, adult respiratory distress syndrome, mediastinitis, low cardiac output, mechanical ventilation more than 24 hours, intensive therapy unit stay more than 24 hours, gastrointestinal complications, cardiorespiratory arrest, and mortality within 30 days. Preoperative and intraoperative variables were evaluated as predictors of MINAO, MAJAO, and PLOS by univariate and multivariate analyses.

RESULTS

The groups were matched for age and Parsonnet score-predicted mortality. However, the women had a higher incidence of chronic obstructive airway disease (p = 0.04), diabetes (p = 0.01), obesity (p = 0.000), peripheral vascular disease (p = 0.000), hypertension (p = 0.000), unstable angina (p = 0.005), history of previous failed nonsurgical intervention (p = 0.02), and nonelective operation (p = 0.000). There were a fewer number of grafts performed in the female group (2.8 vs 3.4, p = 0.000), with the circumflex territory being revascularised less frequently (p = 0.001). Univariate analysis identified the female gender to be a predictor of only MINAO (p = 0.001) and PLOS (p = 0.000). However, with multivariate analysis, female gender was not found to be an independent predictor of MINAO, MAJAO, or PLOS.

CONCLUSIONS

In OPCAB, the female gender is not an independent predictor of MINAO, MAJAO, or PLOS.

Pulmonary vein augmentation for single lung transplantation

We describe a simple method of augmenting pulmonary veins using the donor pericardium in lung grafts which have been procured without an adequate donor left atrial cuff. The method allows making use of lungs procured with suboptimal surgical technique, such as those with short atrial cuffs or completely separated superior and inferior pulmonary veins. We also have applied it equally successfully on the right lung.