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Neutrophil-to-lymphocyte ratio (NLR) as a predictor in determining low cardiac output syndrome (LCOS) has not been widely reported. The aim of this study was to explore the role of pre-surgery, 0-, 4-, and 8-hour post-surgery NLR as predictors of LCOS incidence after open heart surgery in children with congenital heart disease (CHD). This study used a prognostic test with a prospective cohort design and was conducted from December 2020 until June 2021 at the cardiac intensive care unit (CICU) of Dr. Cipto Mangunkusumo Hospital, Jakarta, Indonesia. The subject consisted of children aged one month to 18 years who underwent open heart surgery using a cardiopulmonary bypass (CPB) machine. A receiver operating characteristic curve was applied to identify the predictive performance of NLR for poor outcomes (LCOS incidence). Out of 90 patients included in the study, 25 (27.8%) of them developed LCOS between 3 to 53 hours post-surgery. All NLR values (pre-surgery and 0-, 4-, and 8-hours post-surgery) were associated with the incidence of LCOS. Pre-surgery NLR (cut-off value ≥0.88) had a fair predictive value (area under curve (AUC) 70; 95%CI: 57-83) for predicting LCOS incidence with sensitivity and specificity of 64% and 64.62%, respectively. NLR 0-hour post-surgery (cut-off value ≥4.73) had a good predictive value (AUC 81; 95%CI: 69-94) for predicting LCOS incidence, with 80% sensitivity and 80% specificity. NLR 4- and 8-hours post-surgery had very good predictive values (AUC 97%; 95%CI: 92-100 and 98; 95%CI: 94-100, respectively), with cut-off values ≥6.19 and ≥6.78, had the same 92% sensitivity and the same 96% sensitivity. The presence of LCOS was associated with mortality (odds ratio of 5.11 with 95%CI: 3.09-8.46). This study highlights that pre-surgery, 0-, 4-, and 8-hours post-surgery NLR can be predictors of LCOS after open heart surgery in children with CHD.

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Cardiac relaxation is a complex process that involves various interconnected characteristics and, along with contractile properties, determines stroke volume. Perioperative ischemia-reperfusion injury and left ventricular diastolic dysfunction (DD) are characterized by the left ventricle's inability to receive a sufficient blood volume under adequate preload. Baseline DD and perioperative DD have an impact on postoperative complications, length of hospital stay, and major clinical outcomes in a variety of cardiac pathologies. Several baseline and perioperative factors, such as age, female sex, hypertension, left ventricle hypertrophy, diabetes, and perioperative ischemia-reperfusion injury, contribute to the risk of DD. The recommended diagnostic criteria available in guidelines have not been validated in the perioperative settings and still need clarification. Timely diagnosis of DD might be crucial for effectively treating postoperative low cardiac output syndrome. This implies the need for an individualized approach to fluid infusion strategy, cardiac rate and rhythm control, identification of extrinsic causes, and administration of drugs with lusitropic effects. The purpose of this review is to consolidate scattered information on various aspects of diastolic dysfunction in cardiac surgery and provide readers with well-organized and clinically applicable information.

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Background: Various inotropes and inodilators have been utilized to treat low cardiac output syndrome after the arterial switch operation. The use of levosimendan, a calcium sensitizer has been limited in this setting. This study compares the effects of levosimendan with milrinone in managing low cardiac output after the arterial switch operation. Methods: A retrospective, comparative study was conducted in a tertiary care hospital on patients weighing up to 3 kg undergoing the arterial switch operation between January 2017 and January 2022. Patients received a loading dose followed by continuous infusion of either levosimendan or milrinone. Echocardiographic, hemodynamic and biochemical parameters were compared. Results: Forty-three patients received levosimendan and 42 patients received milrinone as the primary test drug. Cardiac index of less than 2.2 L/min/m2 on postoperative day 1 and 2 was found in 9.3% and 2.3% of patients receiving levosimendan versus 26.2% and 11.9% in those receiving milrinone, respectively (P = .04 and .08, respectively). Early lactate-clearance and better central venous oxygen saturations were noted in the levosimendan group. Prevalence of acute kidney injury was higher in the milrinone group (50% vs 28%; P = .03). Use of peritoneal dialysis in the milrinone group versus levosimendan was 31% and 16.3%, respectively (P = .11). There was no difference in hospital mortality between the groups (milrinone, 3; levosimendan, 2, P = .62). Conclusions: Levosimendan is safe and as effective as milrinone to treat low cardiac output syndrome occurring in neonates after the arterial switch operation. In addition we found that levosimendan was renal protective when compared with milrinone.

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PURPOSE: Mitral valve surgery in children involves correcting congenital and acquired pathologies, with a reported mortality rate of 0.9%. Low cardiac output syndrome (LCOS) is a serious complication with the incidence of 20-25%. The aim of the study was to estimate possible prognostic factors of LCOS in children undergoing mitral valve procedure. MATERIAL AND METHOD: This single-center retrospective analysis enrolled children aged <18 years who underwent mitral valve surgery during 24 year period. Preoperative clinical and laboratory parameters, and operative factors were analyzed. RESULTS: Thirty consecutive pediatric patients (11 (37%) males and 19 (63%) females) in median (Q1 - Q3) age of 57 (25-115) months, who underwent mitral valve replacement, were included. The 30-day mortality was 7% (2 patients) and was related to postoperative multiorgan failure. LCOS occurred in 8 (27%) children. The receiver operator curve (ROC) analysis established parameters that have predictive value for LCOS occurrence: cardiopulmonary bypass (CPB) time, with 89 â€‹min as optimal cut-off point (AUC â€‹= â€‹0.744, p â€‹= â€‹0.011) yielding sensitivity of 100% and specificity of 42.9%; left ventricular ejection fraction (LVEF) â€‹< â€‹60 % (AUC â€‹= â€‹0.824, okp â€‹= â€‹0.001) with sensitivity of 62.5% and specificity of 93.75%; and red blood cell distribution width (RDW) above 14.5 % (AUC â€‹= â€‹0.840, p â€‹< â€‹0.001; sensitivity of 87.5% and specificity of 75%). CONCLUSIONS: In mitral valve replacement in pediatric patients, CPBtime above 89 â€‹min, preoperative LVEF below 60% and preoperative RDW above 14.5% can be regarded as the potential predictors of LCOS.

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OBJECTIVE: To verify the impact of preoperative levosimendan on patients with severe left ventricular dysfunction (ejection fraction <35%) undergoing isolated coronary artery bypass grafting. DESIGN: A meta-analysis. SETTING: Hospitals. PARTICIPANTS: The authors included 1,225 patients from 6 randomized controlled trials. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors performed a meta-analysis of trials that compared preoperative levosimendan with placebo or no therapy, reporting efficacy and safety endpoints. Statistical analyses used mean differences and risk ratios (RR), with a random effects model. Six studies were included, comprising 1,225 patients, of whom 615 (50.2%) received preoperative levosimendan, and 610 (49.8%) received placebo/no therapy. Preoperative levosimendan showed a lower risk of all-cause mortality (RR 0.31; 95% CI 0.16-0.60; p < 0.01; I2 = 0%), postoperative acute kidney injury (RR 0.44; 95% CI 0.25-0.77; p < 0.01; I2 = 0%), low-cardiac-output syndrome (RR 0.45; 95% CI 0.30-0.66; p < 0.001; I2 = 0%), and postoperative atrial fibrillation (RR 0.49; 95% CI 0.25-0.98; p = 0.04; I2 = 85%) compared to control. Moreover, levosimendan significantly reduced the need for postoperative inotropes and increased the cardiac index at 24 hours postoperatively. There were no differences between groups for perioperative myocardial infarction, hypotension, or any adverse events. CONCLUSION: Preoperative levosimendan in patients with severe left ventricular dysfunction undergoing isolated coronary artery bypass grafting was associated with reduced all-cause mortality, low-cardiac-output syndrome, acute kidney injury, postoperative atrial fibrillation, and the need for circulatory support without compromising safety.

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BACKGROUND: Studies have reported seasonal variations in heart failure (HF) hospitalizations and mortality that are observed to peak in the winter, although many of these studies are from Europe or the USA. However, some studies on non-US patients have reported contrasting results. We aimed to determine whether seasonal variation exists in hospitalizations due to HF, investigate the risk of death during hospitalization, and examine possible contributors to such variability in Japan. METHODS: This study was an exploratory analysis of our previous report, which included 269,636 hospitalizations due to HF between 2008 and 2018. The monthly hospitalization rate for HF was evaluated using a linear regression model with April as the reference month. The risk factors for in-hospital and monthly mortality were evaluated using the Cox proportional hazards model. RESULTS: The hospitalizations due to HF were significantly higher in the winter than in the summer. The peak admission rate occurred in January, and the lowest rate occurred in July. Based on April, changes in the number of hospitalizations per month were estimated using linear multiple regression analysis (adjusted R2 = 0.911). The risk of death during hospitalization was lowest in April and gradually increased from August to October (hazard ratio, 1.18-1.21). CONCLUSIONS: There was a significant seasonal variation in HF hospitalizations in Japan. Peak admission rates occurred in January. However, the risk of death during hospitalization was higher in August, September, and October than that in January.

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INTRODUCTION: Perioperative cardiogenic shock (CS) in cardiac surgery is still burdened by a high mortality risk. The introduction of Impella pumps in the therapeutic armory of temporary mechanical circulatory support (tMCS) has potential implications to improve the management of complex cases, although it has never been systematically addressed. We performed a systematic review of the reported use of tMCS with Impella in cardiac surgery. METHODS: We searched PubMed for all original studies on the Impella use in adult patients in cardiac surgery. RESULTS: Nineteen studies (out of 151 identified by search string) were included. All studies were observational and all but one (95%) were retrospective. Seven studies focused on the implantation of Impella in the pre-operative setting (coronary or valvular surgery), either as a prophylactic device in high-risk cases (3 studies) or in patients with CS as stabilization tool prior to cardiac surgery procedure (4 studies). Three studies reported the use of Impella as periprocedural support for percutaneous valvular procedure, three as bridge to heart replacement, and six for postcardiotomy CS. Impella support had a low complication rate and was successful in supporting hemodynamics pre-, intra- and postoperatively. Most consistently reported data were left-ventricular ejection fraction at implant, short-term survival and weaning rate. CONCLUSIONS: tMCS with Impella in cardiac surgery patients is feasible and successful. It can be applied in selected cardiac surgery patients and presents advantages over other types of support. Systematic prospective studies are needed to standardize indications for implant and management of surgical issues, and to identify which patients may benefit.

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SUMMARY OBJECTIVE: The objective of this study was to assess the effectiveness and safety of levosimendan as an alternative treatment for pediatric patients with decompensated heart failure unresponsive to conventional inotropes and to emphasize its role in enhancing cardiovascular stability. METHODS: A total of 15 pediatric patients with decompensated heart failure, stemming from acute fulminant myocarditis (53.3%) and post-congenital heart disease surgery complications (46.7%), received levosimendan. The evaluation focused on adverse effects, respiratory support requirements, and concurrent inotropic medication use during levosimendan treatment. Key cardiovascular parameters were assessed at 0, 6, 12, and 24 h post-levosimendan infusion. RESULTS: Levosimendan administration significantly improved key cardiovascular metrics. Left ventricular ejection fraction increased notably from 45±14.8% to 58±15.6% at 24 h (p<0.001). Systolic and diastolic blood pressures rose significantly, with systolic increasing from 79 (68-90) to 98 (89-109) mmHg and diastolic from 47 (40-57) to 66 (54-76) mmHg by 24 h (p<0.001). Heart rate decreased from 162 (111-175) to 132 (99-148) bpm (p=0.02), and lactate levels significantly decreased from 4.15 (2.3-6.5) to 1.85 (0.8-2.6) mmol/L within 6 h (p<0.001). CONCLUSION: Levosimendan demonstrates its significance in managing pediatric heart failure, indicating its safety and potential to enhance cardiac outcomes by reducing reliance on traditional inotropes.

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OBJECTIVE: Low cardiac output syndrome (LCOS) is a severe complication after valve surgery, with no uniform standard for early identification. We developed interpretative machine learning (ML) models for predicting LCOS risk preoperatively and 0.5 h postoperatively for intervention in advance. METHODS: A total of 2218 patients undergoing valve surgery from June 2019 to Dec 2021 were finally enrolled to construct preoperative and postoperative models. Logistic regression, support vector machine (SVM), random forest classifier, extreme gradient boosting, and deep neural network were executed for model construction, and the performance of models was evaluated by area under the curve (AUC) of the receiver operating characteristic and calibration curves. Our models were interpreted through SHapley Additive exPlanations, and presented as an online tool to improve clinical operability. RESULTS: The SVM algorithm was chosen for modeling due to better AUC and calibration capability. The AUCs of the preoperative and postoperative models were 0.786 (95% CI 0.729-0.843) and 0.863 (95% CI 0.824-0.902), and the Brier scores were 0.123 and 0.107. Our models have higher timeliness and interpretability, and wider coverage than the vasoactive-inotropic score, and the AUC of the postoperative model was significantly higher. Our preoperative and postoperative models are available online at http://njfh-yxb.com.cn:2022/lcos. CONCLUSIONS: The first interpretable ML tool with two prediction periods for online early prediction of LCOS risk after valve surgery was successfully built in this study, in which the SVM model has the best performance, reserving enough time for early precise intervention in critical care.

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BACKGROUND: The most favorable anesthesia protocol during on-pump coronary artery bypass grafting (CABG) in patients with coronary heart disease remains unclear, despite previous publications regarding the interaction between anesthesia protocol and postoperative complications. The aim of the study was to compare the effect of a multimodal low-opioid anesthesia protocol (MLOP) on early postoperative complications during on-pump CABG. METHODS: A single-center prospective cohort study including 120 patients undergoing on-pump CABG aged 18 to 65 years, divided into two groups according to undergoing MLOP or routine-opioid anesthesia protocol (ROP). The analyzed parameters were plasma IL-6 levels, complications, duration of mechanical ventilation, length of intensive care unit stay, and hospitalization. RESULTS: In the MLOP group, the levels of IL-6 at the end of the surgery were 25.6% significantly lower compared to the ROP group (33.4 ± 9.4 vs. 44.9 ± 15.9, p < 0.0001), the duration of mechanical ventilation was significantly shorter (2.0 (2.0; 3.0) h vs. 4.0 (3.0; 5.0) h, p < 0.001), the incidence of low cardiac output syndrome was almost two and half times lower (7 (11.7%) vs. 16 (26.7%), p = 0.037), and also the incidence of postoperative atrial fibrillation was significantly lower (9 (15.0%) vs. 19 (31.7%), p = 0.031). CONCLUSION: Our study confirms that using MLOP was characterized by significantly lower levels of IL-6 at the end of surgery and a lower incidence of low cardiac output syndrome and postoperative atrial fibrillation than ROP. TRIAL REGISTRATION: The study is registered in clinicaltrials.gov №NCT05514652.

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This detailed article presents a comprehensive overview of the initial two-year experience in establishing a new cardiothoracic vascular surgery (CTVS) facility in a tier-2 city in India. The article discusses various aspects of setting up and operating a specialized healthcare facility. The first two years of developing the CTVS facility were included in the study period. The manpower included one cardiothoracic vascular surgeon, one cardiac anesthesiologist, two perfusionists, and two physician assistants, along with four other ancillary staff to assist in the smooth functioning of the operation theater. The CTVS recovery staff included 15 nursing officers. There was only one modular operation theater reserved for cardiothoracic vascular surgeries, along with a five-bed recovery room (CTVS intensive care unit). One-hundred-seventy-two procedures were done, including 122 open heart surgeries, 36 vascular procedures, and 14 thoracic procedures. The majority of patients were discharged by the seventh day postoperatively. Overall complication and mortality rates were 8% and 4.6%, respectively. This article also discusses relevant hospital policy, challenges faced, and future recommendations for similar endeavors. The findings highlight the successful implementation of the facility and its impact on providing specialized cardiac care to the local population.

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BACKGROUND: In congenital heart surgery, low cardiac output syndrome (LCOS) is a major cause of morbidity in the immediate post-operative period. A decrease in cardiac output leads to an increase in tissue oxygen consumption. Several biomarkers such as venous oxygen saturation (SvO2), arteriovenous oxygen difference (DavO2), and lactate can assess tissue perfusion in the presence of LCOS. Recently, central venous to arterial CO2 difference (ΔCO2) has been proposed as a biomarker of tissue ischemia that could be used as a predictor of death in neonatal patients. This study aimed to analyze the relationship between ΔCO2 and immediate post-operative outcomes in pediatric patients undergoing congenital heart surgery and its correlation with DavO2, SvO2, and lactate. METHODS: We conducted a longitudinal study of patients aged 0-18 years who underwent congenital heart surgery with or without cardiopulmonary bypass at the Instituto Nacional de Pediatría, from March 2019 to March 2021. RESULTS: Eighty-two patients were included; the median age was 17 months. About 59% had a ΔCO2 ≥ 6 mmHg. Patients with ΔCO2 ≥ 6 mmHg had a vasoactive-inotropic score > 5 (p < 0.001), DavO2 > 5 mL/dL (p = 0.048), and lactate > 2 mmol/L (p = 0.027), as well as a longer hospital stay (p = 0.043). Patients with ΔCO2 > 6 mmHg and vasoactive-inotropic score ≥ 10 were 12.6 times more likely to die. CONCLUSION: ΔCO2 is a good marker of tissue hypoperfusion and outcome in the post-operative period of congenital heart surgery.

INTRODUCCIÓN: En la cirugía cardiaca de malformaciones congénitas, el síndrome de bajo gasto cardiaco (SBGC) es una de las principales causas de morbilidad en el postoperatorio inmediato. La caída del gasto cardiaco aumenta el consumo de oxígeno en los tejidos. Varios biomarcadores, como la saturación venosa de oxígeno (SvO2), la diferencia arteriovenosa de oxígeno (DavO2) y el lactato han sido utilizados como indicadores hipoperfusión tisular en presencia de SBGC. Recientemente, la diferencia arteriovenosa de CO2 (ΔCO2) se ha propuesto como otro biomarcador de isquemia tisular que podría utilizarse como predictor de muerte en pacientes en edad neonatal. El objetivo de este estudio fue analizar la relación entre la ΔCO2 y la evolución postoperatoria de pacientes pediátricos operados de cardiopatías congénitas y correlacionarlo con la DavO2, SvO2 y lactato. MÉTODOS: Se realizó un estudio longitudinal en pacientes de 0 a 18 años operados de corazón con empleo de bomba de circulación extracorpórea en el Instituto Nacional de Pediatría. RESULTADOS: Se incluyeron 82 pacientes; la mediana de edad fue de 17 meses. El 59% presentó un ΔCO2 > 6 mmHg. Los pacientes con un ΔCO2 > 6 mmHg mostraron un puntaje de inotrópicos > 5 (p < 0.001), DavO2 > 5 mL/dL (p = 0.048) y lactato > 2 mmol/L (p = 0.027), así como mayor estancia hospitalaria (p = 0.043). Los pacientes con ΔCO2 > 6 mmHg y un puntaje de inotrópicos ≥ 10 presentaron una probabilidad de muerte 12.6 veces mayor. CONCLUSIONES: El ΔCO2 en el periodo postoperatorio de una cirugía cardiaca congénita es un buen marcador de hipoperfusión tisular y de desenlace.

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Purpose: Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. Methods: All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. Results: After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Conclusions: Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.

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Abstract Background: In congenital heart surgery, low cardiac output syndrome (LCOS) is a major cause of morbidity in the immediate post-operative period. A decrease in cardiac output leads to an increase in tissue oxygen consumption. Several biomarkers such as venous oxygen saturation (SvO2), arteriovenous oxygen difference (DavO2), and lactate can assess tissue perfusion in the presence of LCOS. Recently, central venous to arterial CO2 difference (ΔCO2) has been proposed as a biomarker of tissue ischemia that could be used as a predictor of death in neonatal patients. This study aimed to analyze the relationship between ΔCO2 and immediate post-operative outcomes in pediatric patients undergoing congenital heart surgery and its correlation with DavO2, SvO2, and lactate. Methods: We conducted a longitudinal study of patients aged 0-18 years who underwent congenital heart surgery with or without cardiopulmonary bypass at the Instituto Nacional de Pediatría, from March 2019 to March 2021. Results: Eighty-two patients were included; the median age was 17 months. About 59% had a ΔCO2 ≥ 6 mmHg. Patients with ΔCO2 ≥ 6 mmHg had a vasoactive-inotropic score > 5 (p < 0.001), DavO2 > 5 mL/dL (p = 0.048), and lactate > 2 mmol/L (p = 0.027), as well as a longer hospital stay (p = 0.043). Patients with ΔCO2 > 6 mmHg and vasoactive-inotropic score ≥ 10 were 12.6 times more likely to die. Conclusion: ΔCO2 is a good marker of tissue hypoperfusion and outcome in the post-operative period of congenital heart surgery.

Resumen Introducción: En la cirugía cardiaca de malformaciones congénitas, el síndrome de bajo gasto cardiaco (SBGC) es una de las principales causas de morbilidad en el postoperatorio inmediato. La caída del gasto cardiaco aumenta el consumo de oxígeno en los tejidos. Varios biomarcadores, como la saturación venosa de oxígeno (SvO2), la diferencia arteriovenosa de oxígeno (DavO2) y el lactato han sido utilizados como indicadores hipoperfusión tisular en presencia de SBGC. Recientemente, la diferencia arteriovenosa de CO2 (ΔCO2) se ha propuesto como otro biomarcador de isquemia tisular que podría utilizarse como predictor de muerte en pacientes en edad neonatal. El objetivo de este estudio fue analizar la relación entre la ΔCO2 y la evolución postoperatoria de pacientes pediátricos operados de cardiopatías congénitas y correlacionarlo con la DavO2, SvO2 y lactato. Métodos: Se realizó un estudio longitudinal en pacientes de 0 a 18 años operados de corazón con empleo de bomba de circulación extracorpórea en el Instituto Nacional de Pediatría. Resultados: Se incluyeron 82 pacientes; la mediana de edad fue de 17 meses. El 59% presentó un ΔCO2 > 6 mmHg. Los pacientes con un ΔCO2 > 6 mmHg mostraron un puntaje de inotrópicos > 5 (p < 0.001), DavO2 > 5 mL/dL (p = 0.048) y lactato > 2 mmol/L (p = 0.027), así como mayor estancia hospitalaria (p = 0.043). Los pacientes con ΔCO2 > 6 mmHg y un puntaje de inotrópicos ≥ 10 presentaron una probabilidad de muerte 12.6 veces mayor. Conclusiones: El ΔCO2 en el periodo postoperatorio de una cirugía cardiaca congénita es un buen marcador de hipoperfusión tisular y de desenlace.

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OBJECTIVES: The authors aimed to develop a simple prediction score to help identify patients at high risk of low-cardiac-output syndrome after adult cardiac surgery. DESIGN: A single-center, retrospective, observational study. SETTING: At a tertiary hospital. PARTICIPANTS: Adult patients who underwent on-pump cardiac surgery between April 2016 and March 2021. INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: Among the 2,806 patients retained for final analyses, 355 (12.7%) developed low-cardiac-output syndrome. Using a stepwise backward variable selection procedure applied to a multivariate logistic regression, a prediction model, including 8 risk factors, could be identified-preoperative left ventricular ejection fraction, glomerular filtration rate <60 mL/min according to the Cockcroft formula or preoperative dialysis, combined surgery, nonelective surgery, mitral valve surgery for mitral valve regurgitation, history of extracardiac arteriopathy, preoperative hemoglobin <13 g/dL, and New York Heart Association functional class III or IV. A clinical prediction score was derived from the regression coefficients. The model had a good discriminative ability, with an area under the receiver operating characteristics curve of 0.8 (95% CI: 077-0.84). Using a threshold value of 5, the score had a 68% sensitivity, 79% specificity, a positive-predictive value of 33%, and a negative-predictive value of 94%. These results were validated on a validation sample using the bootstrap resampling technique. CONCLUSIONS: The authors developed a clinical score to facilitate the prediction of low- cardiac-output syndrome after adult cardiac surgery. This could help tailor patient management by contributing to the early identification of those at high risk of postoperative low cardiac output.

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Background: Low cardiac output syndrome (LCOS) remains a serious postoperative complication for children with tetralogy of Fallot (TOF), which often leads to increased morbidity and mortality. Early identification of LCOS and timely management are critical for better outcomes. This study aimed to develop a prediction model incorporating pre- and intraoperative characteristics for LCOS within 24 hours after surgical repair of TOF in children. Methods: The training dataset consisted of patients with TOF who underwent surgical repair in 2021, while the validation dataset consisted of patients in 2022. The univariable and multivariable logistic regression analyses were performed to recognize the risk factors of postoperative LCOS and a predictive model was established based on multivariable logistic regression analysis in the training dataset. Model predictive power was assessed using the area under the receiver operating characteristic curve (AUC). The calibration of the nomogram was evaluated and the Hosmer-Lemeshow test was used to assess the good fit. Decision curve analysis (DCA) was used to estimate the net benefits of the prediction model at different threshold probabilities. Results: In the multivariable logistic analysis, peripheral oxygen saturation, mean blood pressure, and central venous pressure were independent risk factors for postoperative LCOS. The AUC of the predictive model for postoperative LCOS was 0.84 (95% CI: 0.77-0.91) and 0.80 (95% CI: 0.70-0.90) in the training and validation datasets, respectively. The calibration curve for the probability of LCOS showed good agreement between the prediction by nomogram and actual observation both in the training and validation datasets. The Hosmer-Lemeshow test yielded nonsignificant statistics both in the training and validation datasets (P=0.69 and 0.54, respectively), indicating a good fit. The DCA revealed that more net benefits would be obtained by using the nomogram to predict LCOS than that achieved in either the treat-all-patient scheme or the treat-none scheme both in the training and validation datasets. Conclusions: This study is the first to incorporate pre- and intraoperative characteristics to develop a predictive model for LCOS after surgical repair of TOF in children. This model showed good discrimination, good fit and clinical benefits.

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The modern cardiothoracic intensive care unit (CTICU) developed as a result of advances in critical care, cardiology, and cardiac surgery. Patients undergoing cardiac surgery today are sicker, frailer, and have more complex cardiac and noncardiac morbidities. CTICU providers need to understand postoperative implications of different surgical procedures, complications that can occur in CTICU patients, resuscitation protocols for cardiac arrest, and diagnostic and therapeutic interventions such as transesophageal echocardiography and mechanical circulatory support. Optimum CTICU care requires a multidisciplinary team with collaboration between cardiac surgeons and critical care physicians with training and experience in the care of CTICU patients.

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OBJECTIVE: Our aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). METHODS: Prospectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. RESULTS: Reduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06-0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2-18.6] vs. 22.2 [14.4-28.8], P < 0.001, 7.7 [3.3-12.3] vs.16.3 [8.9-27.8], P < 0.001 and 2.4 [0-7] vs. 11.5 [3.1-26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. CONCLUSIONS: Elective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.

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