BackgroundThe relationship between rewarming rate during cardiopulmonary bypass (CPB) and postoperative delirium (POD) in cardiac surgery remains unclear. This retrospective study aimed to evaluate whether rapid rewarming is associated with an increased risk of POD.MethodsA total of 548 adult cardiac surgery patients (January 2021-December 2023) were enrolled. POD was identified through medical record review based on Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)criteria or documented delirium symptoms combined with olanzapine use (serving as a surrogate marker). Rewarming rate was defined as the average temperature increase per minute from the lowest nasopharyngeal temperature during CPB to 36.5°C, calculated as (36.5°C - lowest temperature)/rewarming time (min). Multivariable logistic regression and ROC analysis were performed.ResultsRewarming rate was significantly higher in the POD group (n = 300) than the non-POD group (n = 248) (0.095 ± 0.044 vs 0.072 ± 0.034°C/min, p < 0.001). Olanzapine dosage (18.5 ± 8.2 mg vs 0 mg) and duration (4.2 ± 2.1 days vs 0 days) in the POD group showed significant positive correlations with rewarming rate (r = 0.887 and r = 0.814, respectively, both p < 0.01). Rewarming rate (OR = 1.782), red blood cell transfusion (OR = 1.456), CPB duration (OR = 1.023), and mean CVP (OR = 1.156) were identified as independent risk factors for POD (all p < 0.05). The predictive model achieved an AUC of 0.775 (95% CI: 0.736-0.814).ConclusionsRapid rewarming during CPB is associated with increased POD risk and may be a modifiable perioperative factor. Prospective studies with standardized POD screening are warranted to validate these findings.

BackgroundFrailty is increasingly recognized as a key determinant of outcomes in critically ill patients, yet its utility among patients receiving venoarterial extracorporeal membrane oxygenation (VA ECMO) remains unclear. We evaluated the hospital frailty risk score (HFRS) as a risk factor of 90-day mortality in VA ECMO patients.MethodsWe conducted a retrospective analysis of VA ECMO patients at Johns Hopkins Hospital from 2016 to 2024. HFRS was derived from ICD-10 codes. An optimal frailty cut point was determined using maximally selected rank statistics, and patients were subsequently stratified into high (>10) and low (<=10) frailty groups. Cox proportional hazards models evaluated the association between frailty and mortality, adjusting for demographics, comorbidities, and clinical variables.Results180 patients receiving VA ECMO were included (median age:53 years, 46.2% female). Overall, 25 patients (13.9%) were classified as high frailty (HFRS >10) and 155 (86.1%) as low frailty (HFRS≤10). Of the 180 patients, 80 patients survived 90-days following initial ECMO cannulation. Median HFRS was higher among non-survivors (4.9 vs 3.4), with a greater proportion classified as high frailty (18.0% vs 8.8%). In multivariable Cox regression adjusting for demographics, comorbidities, and clinical covariates, low HFRS remained independently associated with reduced 90-day mortality (HR=0.47, 95% CI 0.26-0.87, p=0.017), while obesity (HR=10.44) and older age (HR 1.02) were independently associated with increased mortality.ConclusionHFRS is independently associated with 90-day mortality in patients undergoing VA ECMO. Incorporating frailty into pre-ECMO evaluation may enhance prognostication and inform patient selection and clinical decision-making.

IntroductionSevere congenital diaphragmatic hernia (CDH) is associated with significant morbidity and mortality. Pre/post-natal risk factors guide decisions on extracorporeal membrane oxygenation (ECMO) intervention. We aimed to describe variations in ECMO decision-making for neonatal CDH.MethodsWe distributed a practice-based survey (October 2023) to assess institutional ECMO guidelines for neonatal CDH. Respondents included neonatal/pediatric intensivists, surgeons, and ECMO coordinators. We used descriptive statistics for analysis.ResultsFormal CDH management guidelines were reported by 60 (77%) from 82 respondents across 12 countries. The most common exclusion criteria were prematurity (73%), low birthweight (72%), and aneuploidy (58%). Pre-existing neurological complications, single ventricle palliation heart disease, and genetics-related poor neurodevelopmental prognosis were the most cited exclusion criteria independent of CDH severity.ConclusionSignificant practice variation exists in the exclusion criteria for ECMO in neonatal CDH. There remains an opportunity for a more unified approach regarding ECMO use in infants with severe CDH.

IntroductionExtracorporeal Membrane Oxygenation (ECMO) is a highly complex support modality that requires specialized training for successful and optimal management and patient care. Literature regarding ECMO education provided to pediatric subspecialty physicians is limited. We conducted a survey study of pediatric critical care medicine (PCCM), neonatal-perinatal medicine (NPM), and pediatric surgery (PS) fellowship directors with the goal of understanding the extent of ECMO education offered in these training programs.MethodsSurveys were sent via email to 77 PCCM, 110 NPM, and 51 PS directors.ResultsThe overall response rate was 56%, with PCCM fellowship directors being the highest percentage of respondents. Most fellowships provided separate ECMO training in the form of a course, typically lasting ≤2 days and primarily conducted for first-year fellows. Other ECMO educational opportunities included lectures, simulation, and case-based discussions. A majority of the responding fellowship directors in PCCM and PS felt that ECMO management was a core competency of training (96% PCCM, 95% PS). However, a minority reported a formal assessment of ECMO management competency.ConclusionThis study highlights substantial variation in ECMO educational practices and limited competency evaluation across pediatric subspecialty training programs.

IntroductionMyocardial protection during neonatal aortic arch repair may influence postoperative cardiac function and subsequent systemic organ perfusion. We investigated whether the addition of myocardial perfusion during arch repair is associated with improved postoperative renal function in neonates.MethodsWe retrospectively analyzed neonates, including premature infants who underwent surgery beyond the neonatal period after reaching an appropriate corrected gestational age, who underwent aortic arch repair with associated simple defects under cardiopulmonary bypass (CPB) between 2008 and 2019. All patients received selective cerebral perfusion, and additional myocardial perfusion was selectively applied. Acute kidney injury (AKI) was defined using the pediatric modified RIFLE criteria. Multivariable analysis and propensity score matching were performed to evaluate the association between perfusion strategy and renal function.ResultsA total of 202 patients (median age 9 days, weight 3.1 kg) were included. Additional myocardial perfusion was used in 96 patients (47.5%). Postoperative AKI occurred in 49 patients (24.3%). In multivariable analysis, prematurity was associated with increased risk of AKI (odds ratio [OR] 2.669; 95% confidence interval [CI] 1.107-6.433; p = 0.029), whereas additional myocardial perfusion was associated with reduced risk (OR 0.397; 95% CI 0.196-0.806; p = 0.011). Longer CPB time showed a marginal association (p = 0.054). In propensity-matched cohorts, recovery of estimated creatinine clearance was significantly faster in patients receiving additional myocardial perfusion (p < 0.001).ConclusionsAKI is not uncommon after aortic arch repair under CPB in neonates. The use of additional myocardial perfusion was associated with a reduced risk of postoperative AKI and improved recovery of renal function. Prematurity remained an independent risk factor for postoperative AKI.

BackgroundSevere glucose-6-phosphate dehydrogenase (G6PD) deficiency presents unique challenges during cardiopulmonary bypass (CPB) because of increased susceptibility to oxidative injury and haemolysis. Published guidance regarding optimal perfusion management remains limited, particularly in patients with a history of severe haemolytic complications and renal dysfunction.TechniqueA 63-year-old male with severe G6PD deficiency, a previous dialysis-requiring haemolytic crisis, chronic renal impairment and residual hemiparesis following a cerebrovascular accident underwent urgent three-vessel coronary artery bypass grafting. A modified CPB strategy was developed to minimise oxidative stress and mechanical haemolysis. Key components included controlled oxygenation (PaO2 approximately 10 kPa), alpha-stat management, tepid blood cardioplegia, minimisation of cardiotomy suction and blood-air interface exposure, albumin-enriched priming, continuous haemofiltration, and avoidance of oxidant medications, including methylene blue. Oxygen delivery and haematocrit were maintained to support end-organ perfusion and reduce renal hypoxic stress.ResultsCPB duration was 112 min, with an aortic cross-clamp time of 76 min. No clinically significant intravascular haemolysis or haemoglobinuria occurred. Plasma free haemoglobin, bilirubin and lactate dehydrogenase elevations were modest and transient. A single postoperative haemodialysis session was required, after which renal function improved without the need for ongoing renal replacement therapy. The patient was discharged on postoperative day seven without evidence of delayed haemolysis.ConclusionA carefully modified CPB strategy focused on reducing oxidative stress, preventing haemolysis and protecting renal function may facilitate successful cardiac surgery in selected patients with severe G6PD deficiency. This report provides a practical perfusion approach for managing patients at exceptionally high risk of peri-operative haemolytic complications.

ObjectivesTo compare early postoperative outcomes between mitral valve repair (MVr) and replacement (MVR) in patients with degenerative mitral valve disease (DMVD) and poor preoperative left ventricular ejection fraction (LVEF).MethodsA retrospective propensity-score matched analysis of 1,138 patients (612 MVr, 526 MVR) undergoing mitral valve surgery for DMVD with LVEF <30% between 2000-2019 was undertaken using the UK National Adult Cardiac Surgery Audit. The primary outcome was in-hospital mortality; secondary outcomes included stroke, postoperative dialysis, re-exploration for bleeding and length of stay >10 days. Binary logistic regression was conducted to further examine the relationship between procedure and outcomes.ResultsIn unadjusted analyses, MVr demonstrated lower in-hospital mortality (7.2% vs 17.1%, p < 0.001), postoperative dialysis (7.2% vs 14.1%, p < 0.001), and prolonged hospital stay (54.5% vs 67.1%, p < 0.001). After propensity matching, unadjusted outcomes continued to favour MVr for mortality (8.5% vs 13.0%, p = 0.040) and dialysis (8.3% vs 12.8%, p = 0.038). However, multivariable adjustment demonstrated no significant difference in mortality (OR = 0.64, 95% CI 0.39-1.05, p = 0.080) or major morbidity between techniques. Independent predictors of mortality included emergency surgery, concomitant aortic valve surgery, peripheral vascular disease, and redo sternotomy.ConclusionsIn patients with DMVD and severely reduced LVEF, MVr demonstrated comparable early mortality and morbidity to MVR after adjustment. These findings suggest that mitral valve repair is safe and feasible in this higher-risk population when appropriate surgical expertise and careful patient selection are applied. Further investigation with larger cohorts and long-term follow-up is needed to assess durability and functional outcomes.

IntroductionThe anticoagulation strategy and the cardiopulmonary bypass management represent two core elements of the intraoperative care of the cardiac surgery patient. The ideal approach remains an issue of debate, though data encourage the development of a coagulation friendly environment. Our aim was to investigate the effect of intraoperative management on postoperative thrombocytopenia in cardiac surgery patients.MethodsThis is a retrospective study set at a tertiary university hospital. Patients who underwent valve and complex cardiac surgery from January 2019 to December 2021 were included. All patients were managed with Minimally Invasive Extracorporeal Circulation. Platelet count, the anticoagulation technique, hemoglobin, transfusion and bleeding data were recorded perioperatively.ResultsA total of 65 patients met the inclusion criteria and were analysed. Postoperatively platelet count decreased from 208 (84) to 169 (63) (p < 0.001), while at 48 hours 7 patients had a platelet count <80 × 10[9].l[-1]. According to regression analysis, CPB duration and total heparin dose were independent predictors of platelet count whereas no significant correlation was found for protamine dose. After selecting for the anticoagulation technique, patients who received heparin concentration monitoring had significantly lower relative decline in platelet count at 48 hours (p = 0.04), received a higher total heparin dose (p = 0.03) but were given less protamine (p < 0.001). Overall, the frequency of transfusion was low and a trend toward less RBC transfusion was recorded when heparin-level concentration was used (p = 0.051).ConclusionsStrict heparin-level concentration monitoring combined with Minimally Invasive Extracorporeal circulation may have contributed to a coagulation-friendly cardiac surgery translating into a low incidence of thrombocytopenia and transfusions.

IntroductionGuidelines recommend concomitant surgical ablation for atrial fibrillation (AF) in selected patients with pre-existing AF undergoing coronary artery bypass grafting (CABG). We assessed temporal trends, early clinical outcomes, and factors associated with surgical AF ablation in patients undergoing isolated CABG in the United Kingdom.MethodsRetrospective observational cohort study including all patients with pre-existing AF undergoing first-time, elective or urgent isolated CABG from 2011 to April 2019 using the United Kingdom National Cardiac Surgical Audit database. Temporal trends, in-hospital outcomes, and factors associated with concomitant surgical AF ablation were evaluated.ResultsA total of 5337 patients were included; 747 (14.0%) underwent concomitant surgical AF ablation. The annual ablation rate ranged from 11.2% to 16.3% during the study period. After inverse probability treatment weighting, surgical AF ablation was associated with longer cardiopulmonary bypass time (103 [79, 129] vs 82 [63, 104] minutes, p < 0.0001), aortic cross-clamp time (58 [41, 77] vs 48 [35, 64] minutes, p < 0.0001), and deep sternal wound infection (2.04% vs 0.95%, p = 0.021). There were no differences in the incidence of in-hospital mortality, return to theatre bleeding/tamponade, postoperative stroke, or postoperative dialysis.ConclusionIn UK patients with pre-existing AF undergoing isolated CABG, concomitant surgical AF ablation was used in approximately one in seven cases. It was associated with longer operative times and a higher weighted incidence of deep sternal wound infection, but no statistically significant differences were observed in mortality, stroke, dialysis or return to theatre. Longer-term data are needed to define freedom from atrial tachyarrthymia and stroke, anticoagulation use, and survival.

IntroductionDeep hypothermia (DH) has been widely adopted for cerebral and visceral protection during pediatric cardiac surgery, but concerns about perioperative complications remain. This meta-analysis aims to evaluate the impact of DH compared to moderate hypothermia (MH) on outcomes in pediatric cardiac surgery patients.MethodsFollowing a PRISMA-compliant systematic search in PubMed, Cochrane, and Embase, eligible studies comparing DH (<22°C) with MH (22-30°C) in pediatric cardiac surgery were assessed. Risk of bias was evaluated using the ROBINS-I tool.ResultsFive comparative studies with 448 patients (250 in the MH group and 198 in the DH group) were included. Baseline characteristics were similar between groups, with the majority of patients undergoing aortic arch repairs. Perioperative variables were also similar, except for cross-clamp time, which was significantly longer in the DH group (p = 0.02), and circulatory arrest was more frequently used in DH patients (p = 0.01). No significant differences were found in overall postoperative complication rates, acute kidney injury, 24-h chest drainage volume, or in-hospital mortality. However, the incidence of early postoperative neurological complications was significantly higher in the DH group (p < 0.001).ConclusionsModerate hypothermia may be associated with a significantly lower incidence of postoperative neurological complications compared to deep hypothermia, while overall in-hospital mortality and morbidity rates remained similar between the two groups. Taken together, these findings support moderate hypothermia with regional perfusion as a clinically feasible and well-tolerated alternative to deep hypothermia in pediatric cardiac surgery.

IntroductionGoal-directed perfusion during cardiopulmonary bypass (CPB) has traditionally focused on indexed oxygen delivery (DO2i), yet metabolic behavior during aortic cross-clamping likely reflects a more complex interaction among oxygen delivery, oxygen extraction (O2ER), and temperature-dependent oxygen demand. We aimed to identify temperature-adjusted perfusion-metabolic phenotypes during cross-clamping and to explore their association with early postoperative outcomes.MethodsIn this retrospective single-center study, perfusion data (restricted to the aortic cross-clamp period) were linked with clinical data at the case level. Variables' trajectories were normalized in time, resampled at 15 equidistant points, and represented using DO2i, O2ER, and temperature-adjusted indexed oxygen consumption and carbon dioxide production corrected to 37°C with a Q10-based approach (VO2i_37eq and VCO2i_37eq). Principal component analysis and k-means clustering were applied. Logistic regression was used to assess the association between cluster membership and postoperative acute kidney injury (AKI) according to KDIGO criteria.ResultsSeventy patients were included (mean age 64.3 years, 35.7% females). A 3-cluster solution identified a low-extraction/low-metabolic-demand phenotype, a high-delivery/compensated-metabolic-demand phenotype, and a high-extraction/high-metabolic-stress phenotype. The latter showed the highest incidence of AKI of any stage (53.1%, p = 0.034), the highest incidence of stage 2-3 AKI (18.8%), greater postoperative creatinine increase, and longer intensive care unit stay. In multivariable logistic regression, this phenotype remained associated with postoperative AKI after exploratory multivariable adjustment.ConclusionsTemperature-adjusted unsupervised analysis of perfusion trajectories identified three physiologically coherent phenotypes. The high-extraction/high-metabolic-stress phenotype was associated with the least favorable early postoperative renal profile, supporting a GDP framework beyond DO2i alone.

BackgroundVeno-venous extracorporeal membrane oxygenation (VV ECMO) is an advanced therapy for patients with respiratory failure refractory to conventional management. Volume overload and elevated lactate levels have been associated with poor outcomes in medical patients with respiratory failure managed with VV ECMO, but this has not been studied in trauma patients.MethodsThis was a single-center retrospective study of trauma patients treated with VV ECMO between 2014 and 2024. Associations between in-hospital survival and (1) lactate trends before and after cannulation, and (2) fluid balance before and after cannulation were analyzed. We determined lactate clearance using linear regression of serial values, and assessed fluid balance in 12-h intervals normalized to the time of cannulation.ResultsSeventy-eight patients were included, with an overall survival rate of 69%. Survivors exhibited lower pre-cannulation lactate levels (4.7 mmol/L vs. 12.4 mmol/L, p < 0.001) and lower cumulative pre-ECMO fluid balance (2.1 L vs. 5.6 L, p = 0.03). Pre-cannulation lactate clearance was significantly greater among survivors (-0.37 ± 0.16 mmol/L per hour vs. +0.09 ± 0.12 mmol/L per hour, p = 0.02). Post-cannulation trends in lactate and volume status were not associated with mortality. Mortality risk increased sharply beyond a cumulative +3.5 L fluid balance at cannulation. Combined modeling showed lowest survival when lactate exceeded 10 mmol/L and fluid balance surpassed +3 L.ConclusionsIn trauma patients undergoing VV ECMO, both impaired lactate clearance and positive fluid balance prior to cannulation were associated with increased mortality, while post-cannulation changes were not. A pre-ECMO fluid balance exceeding +3.5 L was an inflection point associated with increased mortality risk. These findings suggest that lactate clearance and volume overload may have prognostic value before ECMO initiation in trauma populations.

IntroductionMyocardial protection is crucial in heart surgery to minimize ischemia-reperfusion injury. Del Nido cardioplegia has demonstrated clinical advantages; however, cost-effectiveness data over Custodiol remain scarce. We aimed to assess whether Del Nido could achieve comparable clinical outcomes at lower costs.MethodsA retrospective single-center study was conducted on patients ≥18 years undergoing isolated surgical aortic valve replacement between 2009-2023. Patients received either Custodiol or Del Nido cardioplegia at the discretion of the surgical team. 30-day major adverse cardiac events (MACE) outcomes were extracted from medical records. Cost data was collected from hospital records. Inverse probability of treatment weighting (IPTW) was applied to balance baseline characteristics and mitigate indication bias. Incremental cost-effectiveness ratios (ICERs) were calculated, and probabilistic sensitivity analyses were performed using Monte Carlo simulations.Results179 patients were included (58 Custodiol, 121 Del Nido). While both alternatives had similar 30-day survival (98.3%) and MACE-free survival (88.4% vs. 89.7%), the cost for Del Nido was lower (41,761 USD vs. 47,599 USD). Using the IPTW-weighted sample, an ICER of 123,363 USD for Custodiol favored Del Nido, particularly under local willingness-to-pay thresholds of 6,947-20,841 USD. Probabilistic sensitivity analyses confirmed the robustness of these findings, with Del Nido being cost-effective in up to 75.5% simulations.ConclusionsDel Nido cardioplegia offers a cost-effective alternative to Custodiol, providing similar clinical outcomes at lower costs. These findings support the adoption of Del Nido in resource-limited settings, emphasizing value-based care in cardiac surgery.