Publications by authors named "Rakesh C Arora"

212 Publications

Ischemic and Hemorrhagic Stroke Among Critically Ill Patients With Coronavirus Disease 2019: An International Multicenter Coronavirus Disease 2019 Critical Care Consortium Study.

Crit Care Med 2021 Jul 28. Epub 2021 Jul 28.

Division of Neuroscience Critical Care, Departments of Neurology, Neurosurgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD. Griffith University School of Medicine, Gold Coast, Qld, Australia. Critical Care Research Group, The Prince Charles Hospital, Brisbane, Qld, Australia. Faculty of Medicine University of Queensland, Brisbane, Qld, Australia. Australian Centre for Health Services Innovation (AusHSI) and Centre for Healthcare Transformation, School of Public Health & Social Work, Queensland University of Technology (QUT), Brisbane, Qld, Australia. Cardiac Science Program, St Boniface General Hospital Research Centre, Winnipeg, MB, Canada. University of Toronto, Toronto, ON, Canada. University of Manitoba, Winnipeg, MB, Canada. Department of Surgical Science and Integrated Diagnostic, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa, Italy. Department of Medicine, University of Barcelona, Barcelona, Spain. Hospital Sao Camilo de Esteio, Esteio, Brazil. University of Texas Health Sciences Center, Houston, TX. Institut d'Investigacions Biomediques August Pi I Sunyer, Barcelona, Spain. St Andrew's War Memorial Hospital, UnitingCare, Spring Hill, Qld, Australia. Department of Anesthesiology, University of Utah, Salt Lake City, UT.

Objectives: Stroke has been reported in observational series as a frequent complication of coronavirus disease 2019, but more information is needed regarding stroke prevalence and outcomes. We explored the prevalence and outcomes of acute stroke in an international cohort of patients with coronavirus disease 2019 who required ICU admission.

Design: Retrospective analysis of prospectively collected database.

Setting: A registry of coronavirus disease 2019 patients admitted to ICUs at over 370 international sites was reviewed for patients diagnosed with acute stroke during their stay.

Patients: Patients older than 18 years old with acute coronavirus disease 2019 infection in ICU.

Interventions: None.

Measurements And Main Results: Of 2,699 patients identified (median age 59 yr; male 65%), 59 (2.2%) experienced acute stroke: 0.7% ischemic, 1.0% hemorrhagic, and 0.5% unspecified type. Systemic anticoagulant use was not associated with any stroke type. The frequency of diabetes, hypertension, and smoking was higher in patients with ischemic stroke than in stroke-free and hemorrhagic stroke patients. Extracorporeal membrane oxygenation support was more common among patients with hemorrhagic (56%) and ischemic stroke (16%) than in those without stroke (10%). Extracorporeal membrane oxygenation patients had higher cumulative 90-day probabilities of hemorrhagic (relative risk = 10.5) and ischemic stroke (relative risk = 1.7) versus nonextracorporeal membrane oxygenation patients. Hemorrhagic stroke increased the hazard of death (hazard ratio = 2.74), but ischemic stroke did not-similar to the effects of these stroke types seen in noncoronavirus disease 2019 ICU patients.

Conclusions: In an international registry of ICU patients with coronavirus disease 2019, stroke was infrequent. Hemorrhagic stroke, but not ischemic stroke, was associated with increased mortality. Further, both hemorrhagic stroke and ischemic stroke were associated with traditional vascular risk factors. Extracorporeal membrane oxygenation use was strongly associated with both stroke and death.
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http://dx.doi.org/10.1097/CCM.0000000000005209DOI Listing
July 2021

Diagnostic accuracy of the "4 A's Test" delirium screening tool for the postoperative cardiac surgery ward.

J Thorac Cardiovasc Surg 2021 Jun 1. Epub 2021 Jun 1.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Department of Cardiac Sciences, St Boniface Hospital, Winnipeg, Manitoba, Canada. Electronic address:

Background: Delirium is prevalent and underdetected among cardiac surgery patients on the postoperative ward. This study aimed to validate the 4 A's Test delirium screening tool and evaluate its accuracy both when used by research assistants and when subsequently implemented by nursing staff on the ward.

Methods: This single-center, prospective observational study evaluated the performance of the 4 A's Test administered by research assistants (phase 1) and nursing staff (phase 2). Assessments were undertaken during the patients' first 3 postoperative days on the postcardiac surgery ward along with previous routine nurse-led Confusion Assessment Method assessments. These index tests were compared with a reference standard diagnosis of delirium based on Diagnostic and Statistical Manual of Mental Disorders 5th Edition criteria. Surveys regarding delirium screening were administered to nurses pre- and postimplementation of the 4 A's Test in phase 2 of the study.

Results: In phase 1, a total of 137 patients were enrolled, of whom 24.8% experienced delirium on the postoperative cardiac ward. The 4 A's Test had a sensitivity of 85% (95% confidence interval, 73-93) and a specificity of 90% (95% confidence interval, 85-93) compared with the reference standard. The nurse-assessed Confusion Assessment Method had a sensitivity of 23% (95% confidence interval, 13-37) and specificity of 100% (95% confidence interval, 99-100). In phase 2, nurses (n = 51) screened 179 patients for delirium using the 4 A's Test. Compared with the reference rater, the 4 A's Test had a sensitivity of 58% (95% confidence interval, 28-85) and specificity of 94% (95% confidence interval, 85-98). Postimplementation, 64% of nurses thought that the 4 A's Test improved their confidence in delirium detection, and 76% of nurses would consider routine 4 A's Test use.

Conclusions: The 4 A's Test demonstrated moderate sensitivity and high specificity to detect delirium in a real-world setting after cardiac surgery on the postoperative ward. A modified model of use with less frequent administration, along with increased engagement of the postoperative team, is recommended to improve early delirium detection on the cardiac surgery postoperative ward.
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http://dx.doi.org/10.1016/j.jtcvs.2021.05.031DOI Listing
June 2021

Fighting against 'cancel culture' in cardiac surgery.

Eur J Cardiothorac Surg 2021 Jun 28. Epub 2021 Jun 28.

Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada.

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http://dx.doi.org/10.1093/ejcts/ezab304DOI Listing
June 2021

Frailty and pre-frailty in cardiac surgery: a systematic review and meta-analysis of 66,448 patients.

J Cardiothorac Surg 2021 Jun 25;16(1):184. Epub 2021 Jun 25.

Critical Care, St Michael's Hospital, University of Toronto, Toronto, Ontario, Canada.

Background: The burden of frailty on cardiac surgical outcomes is incompletely understood. Here we perform a systematic review and meta-analysis of studies comparing frail versus pre-frail versus non-frail patients following cardiac surgery.

Methods: We searched MEDLINE and EMBASE databases until July 2018 for studies comparing cardiac surgery outcomes in "frail", "pre-frail" and "non-frail" patients. Data was extracted in duplicate. Primary outcome was operative mortality.

Results: There were 19 observational studies with 66,448 patients. Frail patients were more likely female (risk ratio [RR]1.7; 95%CI:1.5-1.9), older (mean difference: 2.4; 95%CI:1.3-3.5 years older) with greater comorbidities and higher STS-PROM. Frailty (RR2.35; 95%CI:1.57-3.51; p < 0.0001) and pre-frailty (RR2.03; 95%CI:1.52-2.70; p < 0.00001) were associated with increased operative mortality compared with non-frail patients. Frailty was also associated with greater risk of prolonged hospital stay (RR1.83; 95%CI:1.61-2.08; p < 0.0001) and intermediate care facility discharge (RR2.71; 95%CI:1.45-5.05; p = 0.002). Frail (Hazard Ratio [HR]3.27; 95%CI:1.93-5.55; p < 0.0001) and pre-frail patients (HR2.30; 95%CI:1.29-4.09; p = 0.005) had worse mid-term mortality (median follow-up 1 years [range 0.5-4 years]). After adjustment for baseline imbalances, frailty was still associated with greater operative mortality (odds ratio [OR]1.97; 95%CI:1.51-2.57; p < 0.00001), intermediate care facility discharge (OR4.61; 95%CI:2.78-7.66; p < 0.00001) and midterm mortality (HR1.37; 95%CI:1.03-1.83; p = 0.03).

Conclusion: In patients undergoing cardiac surgery, frailty and pre-frailty were associated with 2-fold and 1.5-fold greater adjusted operative mortality, respectively, greater adjusted perioperative complications and frailty was associated with almost 5-fold risk of non-home discharge. Burden of frailty and pre-frailty on cardiac surgical outcomes.
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http://dx.doi.org/10.1186/s13019-021-01541-8DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8229742PMC
June 2021

Selecting Elements for a Cardiac Enhanced Recovery Protocol.

J Cardiothorac Vasc Anesth 2021 May 11. Epub 2021 May 11.

University of Massachusetts-Baystate, Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

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http://dx.doi.org/10.1053/j.jvca.2021.05.006DOI Listing
May 2021

Cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

J Card Surg 2021 Jun 12. Epub 2021 Jun 12.

Division of Cardiothoracic Surgery, UC Davis Medical Center, Sacramento, California, USA.

Background: The coronavirus disease 2019 (COVID-19) pandemic has had an unprecedented impact on health care and cardiac surgery. We report cardiac surgeons' concerns, perceptions, and responses during the COVID-19 pandemic.

Methods: A detailed survey was sent to recruit participating adult cardiac surgery centers in North America. Data regarding cardiac surgeons' perceptions and changes in practice were analyzed.

Results: Our study comprises 67 institutions with diverse geographic distribution across North America. Nurses were most likely to be redeployed (88%), followed by advanced care practitioners (69%), trainees (28%), and surgeons (25%). Examining surgeon concerns in regard to COVID-19, they were most worried with exposing their family to COVID-19 (81%), followed by contracting COVID-19 (68%), running out of personal protective equipment (PPE) (28%), and hospital resources (28%). In terms of PPE conservation strategies among users of N95 respirators, nearly half were recycling via decontamination with ultraviolet light (49%), followed by sterilization with heat (13%) and at home or with other modalities (13%). Reuse of N95 respirators for 1 day (22%), 1 week (21%) or 1 month (6%) was reported. There were differences in adoption of methods to conserve N95 respirators based on institutional pandemic phase and COVID-19 burden, with higher COVID-19 burden institutions more likely to resort to PPE conservation strategies.

Conclusions: The present study demonstrates the impact of COVID-19 on North American cardiac surgeons. Our study should stimulate further discussions to identify optimal solutions to improve workforce preparedness for subsequent surges, as well as facilitate the navigation of future healthcare crises.
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http://dx.doi.org/10.1111/jocs.15681DOI Listing
June 2021

Commentary: The A-B-C's of H-I-T.

Semin Thorac Cardiovasc Surg 2021 Jun 25. Epub 2021 Jun 25.

Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St. Boniface Hospital, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1053/j.semtcvs.2021.05.020DOI Listing
June 2021

Protocol for the WARM Hearts study: examining cardiovascular disease risk in middle-aged and older women - a prospective, observational cohort study.

BMJ Open 2021 05 25;11(5):e044227. Epub 2021 May 25.

Faculty of Kinesiology and Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada

Introduction: Cardiovascular disease (CVD) is a leading cause of death in women. Novel approaches to detect early signs of elevated CVD risk in women are needed. Enhancement of traditional CVD risk assessment approaches through the addition of procedures to assess physical function or frailty as well as novel biomarkers of cardiovascular, gut and muscle health could improve early identification. The Women's Advanced Risk-assessment in Manitoba (WARM) Hearts study will examine the use of novel non-invasive assessments and biomarkers to identify women who are at elevated risk for adverse cardiovascular events.

Methods And Analysis: One thousand women 55 years of age or older will be recruited and screened by the WARM Hearts observational, cohort study. The two screening appointments will include assessments of medical history, gender variables, body composition, cognition, frailty status, functional fitness, physical activity levels, nutritional status, quality of life questionnaires, sleep behaviour, resting blood pressure (BP), BP response to moderate-intensity exercise, a non-invasive measure of arterial stiffness and heart rate variability. Blood sample analysis will be used to assess lipid and novel biomarker profiles and stool samples will support the characterisation of gut microbiota. The incidence of the adverse cardiovascular outcomes will be assessed 5 years after screening to compare WARM Hearts approaches to the Framingham Risk Score, the current clinical standard of assessing CVD risk in Canada.

Ethics And Dissemination: The University of Manitoba Health Research Ethics Board (7 October 2019) and the St Boniface Hospital Research Review Committee (7 October 2019) approved the trial (Ethics Number HS22576 (H2019:063)). Recruitment started 10 October 2020. Data gathered from the WARM Hearts study will be published in peer-reviewed journals and presented at national and international conferences. Knowledge translation strategies will be created to share our findings with stakeholders who are positioned to implement evidence-informed CVD risk assessment programming.

Trial Registration Number: NCT03938155.
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http://dx.doi.org/10.1136/bmjopen-2020-044227DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8154968PMC
May 2021

2020 in review.

J Thorac Cardiovasc Surg 2021 Aug 24;162(2):628-632. Epub 2021 Apr 24.

Section of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada.

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http://dx.doi.org/10.1016/j.jtcvs.2021.04.049DOI Listing
August 2021

Perioperative management invited expert opinions in 2020 and 2021: Synopsis of 9 "must read" articles.

J Thorac Cardiovasc Surg 2021 08 24;162(2):633-636. Epub 2021 Apr 24.

Division of Cardiothoracic Surgery, University of Kentucky and Lexington VA Medical Center, Lexington, Ky.

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http://dx.doi.org/10.1016/j.jtcvs.2021.04.050DOI Listing
August 2021

Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis.

Age Ageing 2021 May;50(3):733-743

School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.

Objective: Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.

Methods: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.

Results: Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall.

Conclusions: The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection.

Prospero Registration Number: CRD42019133702.
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http://dx.doi.org/10.1093/ageing/afaa224DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC8099016PMC
May 2021

Randomised controlled trial protocol for the PROTECT-CS Study: PROTein to Enhance outComes of (pre)frail paTients undergoing Cardiac Surgery.

BMJ Open 2021 01 29;11(1):e037240. Epub 2021 Jan 29.

Institute of Cardiovascular Sciences, St. Boniface General Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada

Introduction: In the past 20 years, the increasing burden of heart disease in an ageing population has resulted in cardiac surgery (CS) being offered to more frail and older patients with multiple comorbidities. Frailty and malnutrition are key geriatric syndromes that impact postoperative outcomes, including morbidity, mortality and prolonged hospital length of stay. Enhanced recovery protocols (ERPs), such as prehabilitation, have been associated with a reduction in complications after CS in vulnerable patients. The use of nutritional ERPs may enhance short-term and long-term recovery and mitigate frailty progression while improving patient-reported outcomes.

Methods And Analysis: This trial is a two-centre, double-blinded, placebo, randomised controlled trial with blinded endpoint assessment and intention-to-treat analysis. One-hundred and fifty CS patients will be randomised to receive either a leucine-rich protein supplement or a placebo with no supplemented protein. Patients will consume their assigned supplement two times per day for approximately 2 weeks pre-procedure, during in-hospital postoperative recovery and for 8 weeks following discharge. The primary outcome will be the Short Physical Performance Battery score. Data collection will occur at four time points including baseline, in-hospital (pre-discharge), 2-month and 6-month time points post-surgery.

Ethics And Dissemination: The University of Manitoba Biomedical Research Ethics Board (20 March 2018) and the St Boniface Hospital Research Review Committee (28 June 2019) approved the trial protocol for the primary site in Winnipeg, Manitoba, Canada. The second site's (Montreal, Quebec) ethics has been submitted and pending approval from the Research Ethics and New Technology Development Committee for the Montreal Heart Institute (December 2020). Recruitment for the primary site started February 2020 and the second site will begin January 2021. Data gathered from the PROTein to Enhance outComes of (pre)frail paTients undergoing Cardiac Surgery Study will be published in peer-reviewed journals and presented at national and international conferences. Knowledge translation strategies will be created to share findings with stakeholders who are positioned to implement evidence-informed change.

Potential Study Impact: Malnutrition and frailty play a crucial role in post-CS recovery. Nutritional ERPs are increasingly being recognised as a clinically relevant aspect of perioperative care. As such, this trial is to determine if leucine-rich protein supplementation at key intervals can mitigate frailty progression and facilitate enhanced postoperative recovery.

Trial Registration Number: ClinicalTrials.gov Registry (NCT04038294).
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http://dx.doi.org/10.1136/bmjopen-2020-037240DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7849881PMC
January 2021

Commentary: Vita ex machina-life from the machine.

J Thorac Cardiovasc Surg 2021 04 24;161(4):1333-1334. Epub 2020 Nov 24.

Division of Cardiac Surgery, Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.11.066DOI Listing
April 2021

Expanding enhanced recovery protocols for cardiac surgery to include the patient voice: a scoping review protocol.

Syst Rev 2021 01 11;10(1):22. Epub 2021 Jan 11.

Health Services & Structural Determinants of Health Research, St. Boniface Research Centre, Winnipeg, Canada.

Background: Cardiac surgery is becoming increasingly common in older, more vulnerable adults. A focus on timely and complete medical and functional recovery has led to the development of enhanced recovery protocols (ERPs) for a number of surgical procedures and subspecialties, including cardiac surgery (ERAS® Cardiac). An element that is often overlooked in the development and implementation of ERPs is the involvement of key stakeholder groups, including surgery patients and caregivers (e.g., family and/or friends). The aim of this study is to describe a protocol for a scoping review of cardiac patient and caregiver preferences and outcomes relevant to cardiac surgery ERPs.

Methods: Using Arksey and O'Malley's et al six-stage framework for scoping review methodologies with adaptions from Levac et al. (Represent Interv: 1-18, 2012), a scoping review of existing literature describing patient- and caregiver-identified preferences and outcomes as they relate to care received in the perioperative period of cardiac surgery will be undertaken. The search for relevant articles will be conducted using electronic databases (i.e., the Cochrane Library, Medline, PsycINFO, Scopus, and Embase), as well as through a search of the grey literature (e.g., CPG Infobase, Heart and Stroke Foundation, ProQuest Theses and Dissertations, Google Advanced, and Prospero). Published and unpublished full-text articles written in English, published after the year 2000, and that relate to the research question will be included. Central to the design of this scoping review is our collaboration with two patient partners who possess lived experience as cardiac surgery patients.

Discussion: This review will identify strategies that can be integrated into ERPs for cardiac surgery which align with patient- and caregiver-defined values. Broadly, it is our goal to demonstrate the added value of patient engagement in research to aid in the success of system change processes.
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http://dx.doi.org/10.1186/s13643-020-01564-7DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7798193PMC
January 2021

Longitudinal Outcomes in Octogenarian Critically Ill Patients with a Focus on Frailty and Cardiac Surgery.

J Clin Med 2020 Dec 23;10(1). Epub 2020 Dec 23.

3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, D-52074 Aachen, Germany.

Cardiac surgery (CSX) can be lifesaving in elderly patients (age ≥ 80 years) but may still be associated with complications and functional decline. Frailty represents a determinant to outcomes in critically ill patients, but little is known about its influence on elderly CSX-patients. This is a secondary exploratory analysis of a multi-center, prospective observational cohort study of 610 elderly patients admitted to the ICU and followed for one year to document long-term outcomes. CSX-ICU-patients ( = 49) were compared to surgical ICU patients ( = 184) with regard to demographics, frailty, and outcomes. Of all surgical patients, 102 (43%) were considered vulnerable or frail. The subdistribution hazard ratio (SHR) of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.54 (95% confidence interval (CI), 0.34, 0.86, = 0.007). The -value for effect modification between surgery group (CSX vs. surgical ICU patients) and Clinical Frailty Scale (CFS) group was not significant ( = 0.37) suggesting that the observed difference in the CFS effect between the CSX and surgical ICU patients is consistent with random error. A further subgroup analysis shows that among surgical ICU patients, the SHR of time to discharge home (TTDH) for vulnerable/frail vs. fit/well patients was 0.49 (95% CI, 0.29, 0.83) while the corresponding SHR for CSX patients was 0.77 (0.32-1.88). In conclusion, preoperative frailty reduced the rate of discharge to home in both surgical and CSX patients, but a larger sample of CSX patients is needed to adequately address this question in this patient group.
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http://dx.doi.org/10.3390/jcm10010012DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7793078PMC
December 2020

Infective Endocarditis Secondary to Injection Drug Use: A Survey of Canadian Cardiac Surgeons.

Ann Thorac Surg 2021 Jan 6. Epub 2021 Jan 6.

Division of Cardiac Surgery, St Michael's Hospital, University of Toronto, Toronto, Canada. Electronic address:

Background: Injection drug use-associated infective endocarditis (IDU-IE) is a growing epidemic. The objective of this survey was to identify the beliefs and practice patterns of Canadian cardiac surgeons regarding surgical management of IDU-IE.

Methods: A 30-question survey was developed by a working group and distributed to all practicing adult cardiac surgeons in Canada. Data were analyzed using descriptive statistics.

Results: Of 146 surgeons, 94 completed the survey (64%). Half of surgeons (49%) would be less likely to operate on patients with IE if associated with IDU. In the case of prosthetic valve IE owing to continued IDU, 36% were willing to reoperate once and 14% were willing to reoperate twice or more. Most surgeons required commitments from patients before surgery (73%), and most referred patients to addiction services (81%). Some surgeons would offer a Ross procedure (10%) or homograft (8%) for aortic valve IE, and 47% would consider temporary mechanical circulatory support. Whereas only 17% of surgeons worked at an institution with an endocarditis team, 71% agreed that there was a need for one at each institution. Most surgeons supported the development of IDU-IE-specific guidelines (80%).

Conclusions: Practice patterns and surgical management of IDU-IE vary considerably across Canada. Areas of clinical unmet needs include the development of a formal addiction services referral protocol for patients, the development of an interdisciplinary endocarditis team, as well as the creation of IDU-IE clinical practice guidelines.
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http://dx.doi.org/10.1016/j.athoracsur.2020.12.003DOI Listing
January 2021

Cardiovascular Care Delivery During the Second Wave of COVID-19 in Canada.

Can J Cardiol 2021 05 9;37(5):790-793. Epub 2020 Dec 9.

Mazankowski Alberta Hearth Institute, University of Alberta, Edmonton, Alberta, Canada.

Hospitals and ambulatory facilities significantly reduced cardiac care delivery in response to the first wave of the COVID-19 pandemic. The deferral of elective cardiovascular procedures led to a marked reduction in health care delivery with a significant impact on optimal cardiovascular care. International and Canadian data have reported dramatically increased wait times for diagnostic tests and cardiovascular procedures, as well as associated increased cardiovascular morbidity and mortality. In the wake of the demonstrated ability to rapidly create critical care and hospital ward capacity, we advocate a different approach during the second and possible subsequent COVID-19 pandemic waves. We suggest an approach, informed by local data and experience, that balances the need for an expected rise in demand for health care resources to ensure appropriate COVID-19 surge capacity with continued delivery of essential cardiovascular care. Incorporating cardiovascular care leaders into pandemic planning and operations will help health care systems minimise cardiac care delivery disruptions while maintaining critical care and hospital ward surge capacity and continuing measures to reduce transmission risk in health care settings. Specific recommendations targeting the main pillars of cardiovascular care are presented: ambulatory, inpatient, procedural, diagnostic, surgical, and rehabilitation.
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http://dx.doi.org/10.1016/j.cjca.2020.11.016DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7836859PMC
May 2021

Commentary: Stronger together: Interinstitutional collaboration is a key step to improving patient outcomes after contemporary extracorporeal membrane oxygenation.

J Thorac Cardiovasc Surg 2020 Nov 6. Epub 2020 Nov 6.

Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.11.003DOI Listing
November 2020

Diagnostic accuracy of the 4AT for delirium detection in older adults: systematic review and meta-analysis.

Age Ageing 2020 Nov 11. Epub 2020 Nov 11.

School of Allied Health, Faculty of Education and Health Sciences, Ageing Research Centre, Health Research Institute, University of Limerick, Limerick, Ireland.

Objective: Detection of delirium in hospitalised older adults is recommended in national and international guidelines. The 4 'A's Test (4AT) is a short (<2 minutes) instrument for delirium detection that is used internationally as a standard tool in clinical practice. We performed a systematic review and meta-analysis of diagnostic test accuracy of the 4AT for delirium detection.

Methods: We searched MEDLINE, EMBASE, PsycINFO, CINAHL, clinicaltrials.gov and the Cochrane Central Register of Controlled Trials, from 2011 (year of 4AT release on the website www.the4AT.com) until 21 December 2019. Inclusion criteria were: older adults (≥65 years); diagnostic accuracy study of the 4AT index test when compared to delirium reference standard (standard diagnostic criteria or validated tool). Methodological quality was assessed using the Quality Assessment of Diagnostic Accuracy Studies-2 tool. Pooled estimates of sensitivity and specificity were generated from a bivariate random effects model.

Results: Seventeen studies (3,702 observations) were included. Settings were acute medicine, surgery, a care home and the emergency department. Three studies assessed performance of the 4AT in stroke. The overall prevalence of delirium was 24.2% (95% CI 17.8-32.1%; range 10.5-61.9%). The pooled sensitivity was 0.88 (95% CI 0.80-0.93) and the pooled specificity was 0.88 (95% CI 0.82-0.92). Excluding the stroke studies, the pooled sensitivity was 0.86 (95% CI 0.77-0.92) and the pooled specificity was 0.89 (95% CI 0.83-0.93). The methodological quality of studies varied but was moderate to good overall.

Conclusions: The 4AT shows good diagnostic test accuracy for delirium in the 17 available studies. These findings support its use in routine clinical practice in delirium detection.

Prospero Registration Number: CRD42019133702.
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http://dx.doi.org/10.1093/ageing/afaa224DOI Listing
November 2020

The Association of a Frailty Index and Incident Delirium in Older Hospitalized Patients: An Observational Cohort Study.

Clin Interv Aging 2020 2;15:2053-2061. Epub 2020 Nov 2.

Center of Innovation in Long Term Services and Supports, Providence Veterans Affairs Medical Center, Providence, RI, USA.

Introduction/background: Frailty identifies patients that have vulnerability to stress. Acute illness and hospitalization are stressors that may result in delirium and further accelerate the negative consequences of frailty.

Purpose: The purpose of this study was to determine whether frailty, identified at hospital admission and as measured by a frailty index, is associated with incident delirium.

Methods: A retrospective, observational, cohort study was done at a Veterans hospital between January 2013 and March 2014. English-speaking patients over 55 years were eligible. Exclusion criteria included inability to complete baseline assessments due to pre-existing cognitive impairment, emergent surgery; and/or admission from a nursing home, pre-existing delirium, and those with psychiatric disease or substance use disorder.

Main Outcomes And Measures: Frailty index (FI) variables included cognitive screening, physical function and comorbidities. The FI was calculated as a proportion of possible deficits (range 0 to 1; higher scores indicate increased frailty). Incident delirium was measured daily by an expert clinician interview.

Results: A total of 247 patients were admitted and 218 met inclusion/exclusion criteria, with a mean age of 71.54 years (SD = 9.53 years) and were predominantly white (92.7%) and male (91.7%). Participants were grouped using FI ranges as non-frail (FI <0.25, n=56 (26%)), pre-frail (FI =0.25-0.35, n=86 (39%)), and frail (FI >0.35, n=76 (35%)). Pre-frailty and frailty were associated with incident delirium (non-frail: 3.6% vs pre-frail: 20.9% vs frail: 29.3%, =0.001) and total delirium days (mean day =non-frail 0.04 vs pre-frail 0.35 vs frail 0.57, =0.003). After adjustment for sociodemographic factors, pre-frail (adjusted OR=5.64, 95% CI: 1.23, 25.99) and frail status (adjusted OR=6.80, 95% CI: 1.38, 33.45) were independently associated with delirium.

Conclusion: This study demonstrates that a frailty index is independently associated with incident delirium and suggests that admission assessments for frailty may identify patients at high risk of developing delirium.
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http://dx.doi.org/10.2147/CIA.S249284DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7646464PMC
March 2021

Two-year outcomes from the PARTNER 3 trial: where do we stand?

Curr Opin Cardiol 2021 03;36(2):141-147

Department of Surgery, Max Rady College of Medicine, University of Manitoba.

Purpose Of Review: The PARTNER 3 trial was conducted to compare outcomes after transcatheter aortic valve replacement (TAVR) with a balloon-expandable valve and surgical aortic valve replacement (SAVR) in individuals at low surgical risk with aortic stenosis. Recently reported rates of death, stoke and valve thrombosis in the TAVR arm have raised concerns about the longevity of this intervention in low-risk individuals. It is incumbent on all members of the Heart Team to understand the potential consequences of these findings.

Recent Findings: TAVR was initially superior to SAVR at 1 year for a primary composite endpoint of death, stroke and rehospitalization. Results at 2 years now indicate noninferiority. Potential causative factors, comparisons with other transcatheter valves and implications for patients, providers and trainees are explored. Recommendations are additionally provided regarding TAVR and SAVR in individuals with aortic stenosis.

Summary: Concerns regarding the longevity of TAVR in low-risk individuals notwithstanding, results from PARTNER 3 indicate that TAVR is at least noninferior to SAVR out to 2 years. Longer follow-up will be required to determine whether these newly founded concerns are justifiable.
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http://dx.doi.org/10.1097/HCO.0000000000000813DOI Listing
March 2021

Commentary: The high cost of low output.

J Thorac Cardiovasc Surg 2020 Aug 15. Epub 2020 Aug 15.

Department of Surgery, Max Rady College of Medicine, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada. Electronic address:

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http://dx.doi.org/10.1016/j.jtcvs.2020.08.037DOI Listing
August 2020

Delirium Prevention in Postcardiac Surgical Critical Care.

Crit Care Clin 2020 Oct;36(4):675-690

Cardiac Sciences Program, St. Boniface Hospital, CR3015-369 Tache Avenue, Winnipeg, Manitoba R2H 2A6, Canada; Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

This review provides an overview for health care teams involved in the perioperative care of cardiac surgery patients. The intention is to summarize key determinants of delirium, its impact on short- and long-term outcomes as well as to discuss effective management strategies. The first component of this review examines the prevalence and the factors associated with an increased risk of postoperative delirium. A multitude of predisposing (eg, baseline vulnerability and comorbidities) and precipitating (eg, type of cardiac surgery and postoperative care) factors that contribute to the occurrence of delirium are discussed.
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http://dx.doi.org/10.1016/j.ccc.2020.06.001DOI Listing
October 2020

Preoperative Treatment of Malnutrition and Sarcopenia in Cardiac Surgery: New Frontiers.

Crit Care Clin 2020 Oct 14;36(4):593-616. Epub 2020 Aug 14.

Department of Intensive Care Medicine, 3CARE-Cardiovascular Critical Care & Anesthesia Evaluation and Research, University Hospital RWTH Aachen, Pauwelsstraße 30, Aachen D-52074, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Hospital Würzburg, Würzburg, Germany.

Cardiac surgery is performed more often in a population with an increasing number of comorbidities. Although these surgeries can be lifesaving, they disturb homeostasis and may induce a temporary overall loss of physiologic function. The required postoperative intensive care unit and hospital stay often lead to a mid- to long-term decline of nutritional and physical status, mental health, and health-related quality of life. Prehabilitation before elective surgery might be an opportunity to optimize the state of the patient. This article discusses current evidence and potential effects of preoperative optimization of nutrition and physical status before cardiac surgery.
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http://dx.doi.org/10.1016/j.ccc.2020.06.002DOI Listing
October 2020

Cardiac Surgery-Enhanced Recovery Programs Modified for COVID-19: Key Steps to Preserve Resources, Manage Caseload Backlog, and Improve Patient Outcomes.

J Cardiothorac Vasc Anesth 2020 Dec 10;34(12):3218-3224. Epub 2020 Aug 10.

University of Massachusetts-Baystate and Medical Director of the Heart, Vascular and Critical Care Units, Baystate Medical Center, Springfield, MA.

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http://dx.doi.org/10.1053/j.jvca.2020.08.007DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7416680PMC
December 2020

Are maladaptive brain changes the reason for burnout and medical error?

J Thorac Cardiovasc Surg 2020 Jul 25. Epub 2020 Jul 25.

Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada; Cardiac Sciences Program, St Boniface Hospital, Winnipeg, Manitoba, Canada.

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http://dx.doi.org/10.1016/j.jtcvs.2020.06.146DOI Listing
July 2020

Delirium definition influences prediction of functional survival in patients one-year postcardiac surgery.

J Thorac Cardiovasc Surg 2020 Jul 16. Epub 2020 Jul 16.

Cardiac Science Program, St Boniface General Hospital Research Centre, Winnipeg, Manitoba, Canada; Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

Background: Delirium after cardiac surgery is associated with prolonged intensive care unit (ICU) and hospital length of stay and elevated rates of mortality. The Society of Thoracic Surgery National Database (STS-ND) includes delirium in routine data collection but restricts its definition to hyperactive symptoms. The objective is to determine whether the Confusion Assessment Method for ICU (CAM-ICU), which includes hypo- and hyperactive symptoms, is associated with improved prediction of poor 1-year functional survival following cardiac surgery.

Methods: Clinical and administrative databases were used to determine the influence of postoperative delirium on 1-year poor functional survival, defined as being institutionalized or deceased at 1 year. Patients experiencing postoperative delirium using the STS-ND definition (2007-2009) were compared with patients with delirium identified by the CAM-ICU (2010-2012). A propensity score match was undertaken, and multivariable Cox proportional hazards regression models were generated to determine risk of poor 1-year functional survival.

Results: There were 2756 and 2236 patients in the STS-ND and CAM-ICU cohorts, respectively. Propensity matching resulted in a cohort of 1835 patients (82.1% matched). The overall rate of delirium in the matched study population was 7.6% in the STS-ND cohort and 13.0% in the CAM-ICU cohort (P < .001). Delirium in the CAM-ICU cohort was independently associated with poor 1-year functional survival (hazard ratio, 2.58; 95% confidence interval, 1.20-5.54; P = .02); delirium in the STS-ND cohort was not associated with poor 1-year functional survival (hazard ratio, 0.92; 95% confidence interval, 0.49-1.71; P = .79).

Conclusions: A systematic screening tool identifies postoperative delirium with improved prediction of poor 1-year functional survival following cardiac surgery.
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http://dx.doi.org/10.1016/j.jtcvs.2020.07.028DOI Listing
July 2020

Frailty and the failing heart do not travel alone.

Eur J Heart Fail 2020 11 20;22(11):2120-2122. Epub 2020 Aug 20.

Department of Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Canada.

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http://dx.doi.org/10.1002/ejhf.1973DOI Listing
November 2020

Frailty status and cardiovascular disease risk profile in middle-aged and older females.

Exp Gerontol 2020 10 16;140:111061. Epub 2020 Aug 16.

Faculty of Kinesiology & Recreation Management, University of Manitoba, Winnipeg, Manitoba, Canada; Institute of Cardiovascular Sciences, St. Boniface Hospital Albrechtsen Research Centre, Winnipeg, Manitoba, Canada; Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, Manitoba, Canada. Electronic address:

Objective: Frailty and pre-frailty are known to increase the risk of developing cardiovascular disease (CVD). However, the risk profiles of females are not well characterized. The aim of this study is to characterize the CVD risk profiles of robust, pre-frail and frail females.

Methods: Cross-sectional analysis of 985 females ≥55 years with no self-reported history of CVD were recruited. Frailty was assessed using the Fried Criteria with the cut-points standardized to the cohort. Framingham risk scores (FRS), the 4-test Rasmussen Disease Score (RDS), and the CANHEART health index were used to characterize composite CVD risk. Individual measures of CVD risk included blood lipids, artery elasticity assessments, exercise blood pressure response, 6-min walk test (6MWT), sedentary time and PHQ-9 score.

Results: The cohort comprised of 458 (46.4%) robust, 464 (47.1%) pre-frail and 63 (6.4%) frail females with a mean age of 66 ± 6 (SD) years. Pre-frail females were at increased odds of taking diabetes medications (OR 3.04; 95% CI 1.27-7.27), hypertension medications (OR 2.02; 95% CI 1.44-2.82), having an exaggerated blood pressure response to exercise (OR 1.878; 95% CI 1.39-2.50), mild depression symptoms (OR 2.38; 95% CI 1.68-338), and lower fitness as assessed by 6MWT (OR 5.74; 95% CI 3.18-10.37), even after controlling for age and relevant medications. Pre-frail females were also at increased odds for having CVD risk scores indicating higher risk with the FRS (OR 1.52; 95% CI 1.12-2.05), the RDS (OR 1.60; 95% CI 1.21-2.10) and the CANHEART risk score (OR 3.07; 95% CI 2.04-4.62). These odds were higher when frail females were compared to their robust peers.

Conclusion: Frailty and pre-frailty were associated with higher odds of presenting with CVD risk factors as compared to robust females, even after controlling for age.
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http://dx.doi.org/10.1016/j.exger.2020.111061DOI Listing
October 2020

Reply: Have we done the best that we could have done?

J Thorac Cardiovasc Surg 2020 09;160(3):e149-e151

Department of Cardiac Surgery, University of Michigan, Ann Arbor, Mich.

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http://dx.doi.org/10.1016/j.jtcvs.2020.05.071DOI Listing
http://www.ncbi.nlm.nih.gov/pmc/articles/PMC7423581PMC
September 2020
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