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Commentary: Postoperative time to arrest—A new metric?

2019; Elsevier BV; Volume: 157; Issue: 6 Linguagem: Inglês

10.1016/j.jtcvs.2019.02.009

1097-685X

Syed Murfad Peer, Can Yerebakan,

Aortic Disease and Treatment Approaches

Central MessagePostoperative cardiac arrest after congenital heart surgery: How much does its timing tell us?See Article page e401. Postoperative cardiac arrest after congenital heart surgery: How much does its timing tell us? See Article page e401. Refinement in surgical techniques, advances in cardiopulmonary bypass technology, and better perioperative cardiac critical care have led to continuous improvement in outcomes for patients undergoing congenital heart surgery.1Khairy P. Ionescu-Ittu R. Mackie A.S. Abrahamowicz M. Pilote L. Marelli A.J. Changing mortality in congenital heart disease.J Am Coll Cardiol. 2010; 56: 1149-1157Crossref PubMed Scopus (600) Google Scholar Today, most congenital cardiac surgical procedures have a surgical mortality of less than 5%.2Jacobs J.P. Mayer Jr., J.E. Pasquali S.K. Hill K.D. Overman D.M. St Louis J.D. et al.The Society of Thoracic Surgeons congenital heart surgery database: 2019 update on outcomes and quality.Ann Thorac Surg. January 11, 2019; ([Epub ahead of print])Google Scholar The risk of adverse events such as postoperative cardiac arrest, however, although low, has not been eliminated. In this issue of the Journal, Dagan and colleagues3Dagan M. Butt W. d'Udekem Y. Namachivayam S.P. Timing of in-hospital cardiac arrest after pediatric cardiac surgery: an important metric for quality improvement and prognostication?.J Thorac Cardiovasc Surg. 2019; 157: e401-e406Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar investigate the association between timing of in-hospital cardiac arrest and postoperative mortality.3Dagan M. Butt W. d'Udekem Y. Namachivayam S.P. Timing of in-hospital cardiac arrest after pediatric cardiac surgery: an important metric for quality improvement and prognostication?.J Thorac Cardiovasc Surg. 2019; 157: e401-e406Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar A retrospective chart review of pediatric patients undergoing congenital heart surgery during a period of 9 years at the Royal Children's Hospital in Melbourne, Australia, was conducted. Dagan and colleagues3Dagan M. Butt W. d'Udekem Y. Namachivayam S.P. Timing of in-hospital cardiac arrest after pediatric cardiac surgery: an important metric for quality improvement and prognostication?.J Thorac Cardiovasc Surg. 2019; 157: e401-e406Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar report a 4.2% incidence of postcardiotomy in-hospital cardiac arrest. The timing of arrest was within 12 hours after surgery in 38% of the patients, in 12 to 48 hours in 19% of the patients, and later than 48 hours in 43% of the patients. Multivariable analysis revealed the timing of cardiac arrest to affect the outcomes adversely. Patients who had a cardiac arrest occur later than 48 hours after surgery had an 86% decrease in survival. Comparing the 2 groups of patients who had a cardiac arrest between 12 and 48 hours after surgery and later than 48 hours after surgery, it appears that the incidences of cardiac tamponade, residual lesions, and need for extracorporeal cardiopulmonary resuscitation (E-CPR) were similar. The incidence of low cardiac output state was higher among patients who had arrest occur 12 to 48 hours after surgery; however, survival was significantly lower in patients who had arrest occur later than 48 hours after surgery. Although all the patients who had in-hospital cardiac arrests occurring within 48 hours were resuscitated in the intensive care unit, about 23% of the patients who had arrest occur later than 48 hours after surgery had been shifted out of the intensive care unit. E-CPR was needed by 50% of the patients who had arrest occur later than 48 hours after surgery. Although further details about E-CPR location and protocol have not been provided, these data do raise the question of efficacy of E-CPR in a non–intensive care unit setting. Although E-CPR does provide a final safety net in salvaging patients with reversible causes of cardiac arrest, it has significant implications on the overall outcome.4Werho D.K. Pasquali S.K. Yu S. Donohue J. Annich G.M. Thiagarajan R.R. et al.ELSO Member CentersEpidemiology of stroke in pediatric cardiac surgical patients supported with extracorporeal membrane oxygenation.Ann Thorac Surg. 2015; 100: 1751-1757Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar Not many studies have looked at the association between timing of postoperative arrest and survival in patients undergoing congenital heart surgery. With significant reduction in surgical mortality, the focus now has shifted to the effective use of health care resources and the optimization of long-term outcomes, that is, neurodevelopment and quality of life after congenital heart surgery. A low-risk and straightforward surgical repair could indeed be complicated by a postoperative adverse event such as a cardiac arrest, which may be challenging to predict with standard algorithms. One of the interesting findings of this study is that cardiac tamponade was the cause of cardiac arrest in about one-third of the patients. This underscores the importance of maintaining active vigilance to rule out and treat preventable causes of late cardiac arrests, which carry a considerably lower survival according to this study. It is obviously of utmost importance to rule out significant residual lesions and subsequent postoperative problems before patients can be safely transferred to the unit. The use of simple diagnostic tools, such as bedside echocardiography, at postoperative admission to the intensive care unit, as indicated during the intensive care stay and at discharge, may prevent some of the late arrests on the ward. Today, more patients with complex cardiac and extracardiac anomalies are being offered cardiac surgical repair worldwide. Despite the increased risk profile, there is an expectation of an excellent outcome in every case. More resources need to be directed toward risk stratification, preventive strategies, and treatment protocols aimed at the reduction and effective treatment of postoperative cardiac arrests. In the future, artificial intelligence and big data analytics could provide us with sophisticated software and tools for the accurate prediction of a postoperative cardiac arrest.5Gupta P. Gossett J.M. Kofos D. Rettiganti M. Creation of an empiric tool to predict ECMO deployment in pediatric respiratory or cardiac failure.J Crit Care. 2019; 49: 21-26Google Scholar, 6Sanchez-Pinto L.N. Luo Y. Churpek M.M. Big data and data science in critical care.Chest. 2018; 154: 1239-1248Abstract Full Text Full Text PDF PubMed Scopus (126) Google Scholar Dagan and colleagues3Dagan M. Butt W. d'Udekem Y. Namachivayam S.P. Timing of in-hospital cardiac arrest after pediatric cardiac surgery: an important metric for quality improvement and prognostication?.J Thorac Cardiovasc Surg. 2019; 157: e401-e406Abstract Full Text Full Text PDF PubMed Scopus (4) Google Scholar are to be congratulated for their transparent presentation of their less favorable outcomes and for their excellent analysis, which should trigger further studies on this topic. Timing of in-hospital cardiac arrest after pediatric cardiac surgery: An important metric for quality improvement and prognostication?The Journal of Thoracic and Cardiovascular SurgeryVol. 157Issue 6PreviewIn-hospital-cardiac-arrest (IHCA) occurs in 3% to 4% of children recovering from cardiac surgery with an associated mortality of 35% to 40%; a high proportion of survivors experience long-term neurodevelopmental disability.1,2 Understanding patterns of IHCA timing and its association with outcome can potentially lead to the development of risk stratification tools and targeted management protocols. Currently there are no reports linking timing of IHCA after pediatric cardiac surgery and outcome. Full-Text PDF Open Archive