Management of the emergency response to the SARS-CoV-2 (COVID-19) outbreak in Stockholm, Sweden, and winter preparations.

INTRODUCTION Sweden is unique in adopting a 'no-lockdown' public health approach to the SARS-CoV-2 (COVID-19) outbreak. There were fears that health services would not be able to care for high numbers of COVID-19 patients. AIM To describe and review the emergency response of a public primary and community health-care organisation in Stockholm, Sweden, to the demand for care for COVID-19 and non-COVID-19 patients during March-July 2020, and summarise preparations for the months to follow.

Guideline for the surgical treatment of atrial fibrillation.

Atrial fibrillation (AF) is the most common sustained cardiac arrhythmia and its prevalence is ∼1-2% of the general population, but higher with increasing age and in patients with concomitant heart disease. The Cox-maze III procedure was a groundbreaking development and remains the surgical intervention with the highest cure rate, but due to its technical difficulty alternative techniques have been developed to create the lesions sets. The field is fast moving and there are now multiple energy sources, multiple potential lesion sets and even multiple guidelines addressing the issues surrounding the surgical treatment of AF both for patients undergoing this concomitantly with other cardiac surgical procedures and also as stand-alone procedures either via sternotomy or via videothoracoscopic techniques.

Mortality and reoperations in survivors operated on for acute type A aortic dissection and implications for catheter-based or hybrid interventions.

Objective: This study investigated late outcomes (mortality, reoperations) and their associated predictors after operations for acute type A aortic dissection. The role catheter-based and hybrid interventions is discussed.

Methods: All hospital survivors operated on for acute type A aortic dissection from 1990 through 2009 were reviewed, with cross-sectional follow-up.

EACTS guidelines for the use of patient safety checklists.

The Safety Checklist concept has been an integral part of many industries that face high-complexity tasks for many decades and in industries such as aviation and engineering checklists have evolved from their very inception. Investigations of the causes of surgical deaths around the world have repeatedly pointed to medical errors that could be prevented as an important cause of death and disability. As a result, the World Health Organisation developed and evaluated a three-stage surgical checklist in 2007 demonstrating that complications were significantly reduced, including surgical infection rates and even mortality.

EuroSCORE II.

Objectives: To update the European System for Cardiac Operative Risk Evaluation (EuroSCORE) risk model.

Methods: A dedicated website collected prospective risk and outcome data on 22,381 consecutive patients undergoing major cardiac surgery in 154 hospitals in 43 countries over a 12-week period (May-July 2010). Completeness and accuracy were validated during data collection using mandatory field entry, error and range checks and after data collection using summary feedback confirmation by responsible officers and multiple logic checks.

Mortality in acute type A aortic dissection: validation of the Penn classification.

Background: Intraoperative and in-hospital mortality after surgery for acute type A dissection depends largely on preoperative conditions, specifically the presence of localized or generalized ischemia. Recently, the Penn classification of patients with acute type A aortic dissection has been described. The primary aim was to validate the Penn classification and to investigate preoperative variables related to mortality.

Deep hypothermia and aortic regurgitation without left ventricular venting, an animal model.

Objective: Omitting ventricular decompression in resternotomy during cardiopulmonary bypass with deep hypothermia and circulatory arrest in patients with aortic regurgitation (AR) has recently been reported. The consequences of the dilated and non-dilated heart in conjunction with rapid and profound cooling were further studied in this randomized animal model.

Methods: In five pigs (group A) AR was induced before cooling to 15°C and circulatory arrest of 30 minutes without left ventricular decompression.

Resternotomy using hypothermic arrest.

Background: Resternotomy during closed chest cardiopulmonary bypass in hypothermia with or without circulatory arrest has been the preferred method for cardiac reoperations with adherent structures to the sternum. Here, we report our experience with this method and the effects of omitting ventricular decompression during the cooling procedure.

Methods: Twenty reoperations were performed in 19 patients.

Multi-organ expression profiling uncovers a gene module in coronary artery disease involving transendothelial migration of leukocytes and LIM domain binding 2: the Stockholm Atherosclerosis Gene Expression (STAGE) study.

Environmental exposures filtered through the genetic make-up of each individual alter the transcriptional repertoire in organs central to metabolic homeostasis, thereby affecting arterial lipid accumulation, inflammation, and the development of coronary artery disease (CAD). The primary aim of the Stockholm Atherosclerosis Gene Expression (STAGE) study was to determine whether there are functionally associated genes (rather than individual genes) important for CAD development. To this end, two-way clustering was used on 278 transcriptional profiles of liver, skeletal muscle, and visceral fat (n = 66/tissue) and atherosclerotic and unaffected arterial wall (n = 40/tissue) isolated from CAD patients during coronary artery bypass surgery.

Guideline for resuscitation in cardiac arrest after cardiac surgery.

The Clinical Guidelines Committee of the European Association for Cardio-Thoracic Surgery provides this professional view on resuscitation in cardiac arrest after cardiac surgery. This document was created using a multimodal methodology for evidence generation including the extrapolation of existing guidelines from the International Liaison Committee on Resuscitation where possible, our own structured literature reviews on issues particular to cardiac surgery, an international survey on resuscitation hosted by CTSNet and manikin simulations of potential protocols. This protocol differs from existing generic guidelines in a number of areas, the most import of which are the following: successful treatment of cardiac arrest after cardiac surgery is a multi-practitioner activity with six key roles that should be allocated and rehearsed on a regular basis; in ventricular fibrillation, three sequential attempts at defibrillation (where immediately available) should precede external cardiac massage; in asystole or extreme bradycardia, pacing (where immediately available) should precede external cardiac massage; where the above measures fail, and in pulseless electrical activity, early resternotomy is advocated; adrenaline should not be routinely given; protocols for excluding reversible airway and breathing complications and for safe emergency resternotomy are given.

If a patient arrests after cardiac surgery is it acceptable to delay cardiopulmonary resuscitation until you have attempted either defibrillation or pacing?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is acceptable to delay cardiopulmonary resuscitation if a patient arrests after cardiac surgery in order to attempt defibrillation or pacing, prior to performing external cardiac massage. Altogether 550 papers were found in Medline and 990 in Embase using the reported search, of which 22 represented the best evidence to answer the clinical question.

Guideline on antiplatelet and anticoagulation management in cardiac surgery.

This document presents a professional view of evidence-based recommendations around the issues of antiplatelet and anticoagulation management in cardiac surgery. It was prepared by the Audit and Guidelines Committee of the European Association for Cardio-Thoracic Surgery (EACTS). We review the following topics: evidence for aspirin, clopidogrel and warfarin cessation prior to cardiac surgery; perioperative interventions to reduce bleeding including the use of aprotinin and tranexamic acid; the use of thromboelastography to guide blood product usage; protamine reversal of heparin; the use of factor VIIa to control severe bleeding; anticoagulation after mechanical, tissue valve replacement and mitral valve repair; the use of antiplatelets and clopidogrel after cardiac surgery to improve graft patency and reduce thromboembolic complications and thromboprophylaxis in the postoperative period.

Apicoaortic valved conduit: potential for progress?

Objective: The number of elderly patients who require aortic valve replacement is growing, as is the increase of complicating factors, such as previous coronary bypass grafting and atherosclerotic disease of the ascending aorta. An uncommon surgical option to aortic valve replacement is the apicoaortic valved conduit. In this article the techniques and outcomes of 13 cases of apicoaortic valved conduit insertions in high-risk patients are described.

Cardiac rupture during vacuum-assisted closure therapy.

Vacuum-assisted closure therapy is a recently introduced technique for treatment of deep sternal wound infections after cardiac surgery. We present five cases of vacuum-assisted closure therapy-related major bleeding complications due to rupture of the right ventricle. This potentially lethal complication may be avoided by covering the heart with protective layers of paraffin gauze dressings.

The mid-term outcome of the Cox maze III procedure and complex concomitant cardiac surgery.

Objective: Many surgeons do not deal with atrial fibrillation or choose modifications of the maze procedure when performing additional cardiac surgery. The Cox maze III procedure as an adjunct to other sometimes very complex cardiac surgery was examined.

Design: 40 patients (27 men), 36 to 76 years, underwent a full Cox maze III operation in combination with other cardiac surgery, reflecting the case mix of a modern practice.

A prospective study of medically treated acute type B aortic dissection.

Objective: To study prospectively aneurysm formation, need of surgery, incidence of rupture and mortality in patients with conservatively treated acute type B aortic dissection.

Methods: All patients referred to us with acute type B dissection between January 1990 and December 2001 were candidates for this prospective treatment and follow-up study. Patients deemed not to be in need of acute surgical repair were included after aggressive antihypertensive treatment.

Reversal of ventricular dilatation in aortic regurgitation after valve replacement and cardiac support implant surgery using the CorCap cardiac support device.

The effects of combined aortic valve replacement, coronary bypass surgery, and passive containment surgery in a patient with long-standing aortic regurgitation and marked ventricular dilatation are described. After surgery there was a rapid decrease in left ventricular size and maintained ventricular function.

Endothelin and effects of endothelin-receptor activation in the mammary and radial artery.

Objective: To determine the tissue content and endothelin-receptor characteristics of endothelin-1 in the radial artery in relation to the internal mammary artery.

Design: Endothelin-1 content was quantified in the radial artery and the internal mammary artery. Both arteries were exposed to endothelin-1 and agonists of the endothelin A and B receptors.

Early results with cardiac support device implant in patients with ischemic and non-ischemic cardiomyopathy.

Objective: To evaluate the possible beneficial echocardiographic, functional and quality of life improving effects of passive containment surgery using the CorCap Cardiac Support Device in heart failure patients with dilated cardiomyopathy.

Design: Eight patients with dilated cardiomyopathy subjected to cardiac surgery received the Cardiac Support Device. Patients with ischemic cardiomyopathy (n = 4) underwent coronary artery bypass surgery receiving one to three bypass grafts.

Splanchnic metabolism during gut ischemia and short-term endotoxin and hemorrhagic shock as evaluated by intravasal microdialysis.

The splanchnic area is of considerable interest in different types of shock. To characterize the metabolic changes in the splanchnic region in response to different types of shock we used a model where shock-induced metabolic changes in the splanchnic region were studied by the use of intravasal microdialysis. 23 anesthetized domestic pigs were randomized into four groups: Group I, serving as controls (n = 5); Group II, mesenteric ischemia for 180 followed by 120 min of reperfusion (n = 5); Group III, endotoxin shock for 5 h (n = 5); and Group IV, hemorrhagic shock for 180 min followed by re-transfusion of shed blood (n = 8).