Postoperative atrial fibrillation (POAF) occurring after cardiac surgery is associated with adverse outcomes. Whether POAF persists beyond discharge is not well defined.
Objective
To determine whether continuous cardiac rhythm monitoring enhances detection of POAF among cardiac surgical patients during the first 30 days after hospital discharge compared with usual care.
Design, Setting, and Participants
This study is an investigator-initiated, open-label, multicenter, randomized clinical trial conducted at 10 Canadian centers. Enrollment spanned from March 2017 to March 2020, with follow-up through September 11, 2020. As a result of the COVID-19 pandemic, enrollment stopped on July 17, 2020, at which point 85% of the proposed sample size was enrolled. Cardiac surgical patients with CHA2DS2-VASc (congestive heart failure, hypertension, age ≥75 years, diabetes, prior stroke or transient ischemic attack, vascular disease, age 65-74 years, female sex) score greater than or equal to 4 or greater than or equal to 2 with risk factors for POAF, no history of preoperative AF, and POAF lasting less than 24 hours during hospitalization were enrolled.
Interventions
The intervention group underwent continuous cardiac rhythm monitoring with wearable, patch-based monitors for 30 days after randomization. Monitoring was not mandated in the usual care group within 30 days after randomization.
Main Outcomes and Measures
The primary outcome was cumulative AF and/or atrial flutter lasting 6 minutes or longer detected by continuous cardiac rhythm monitoring or by a 12-lead electrocardiogram within 30 days of randomization. Prespecified secondary outcomes included cumulative AF lasting 6 hours or longer and 24 hours or longer within 30 days of randomization, death, myocardial infarction, ischemic stroke, non–central nervous system thromboembolism, major bleeding, and oral anticoagulation prescription.
Results
Of the 336 patients randomized (163 patients in the intervention group and 173 patients in the usual care group; mean [SD] age, 67.4 [8.1] years; 73 women [21.7%]; median [interquartile range] CHA2DS2-VASc score, 4.0 [3.0-4.0] points), 307 (91.4%) completed the trial. In the intent-to-treat analysis, the primary end point occurred in 32 patients (19.6%) in the intervention group vs 3 patients (1.7%) in the usual care group (absolute difference, 17.9%; 95% CI, 11.5%-24.3%;P < .001). AF lasting 6 hours or longer was detected in 14 patients (8.6%) in the intervention group vs 0 patients in the usual care group (absolute difference, 8.6%; 95% CI, 4.3%-12.9%;P < .001).
Conclusions and Relevance
In post–cardiac surgical patients at high risk of stroke, no preoperative AF history, and AF lasting less than 24 hours during hospitalization, continuous monitoring revealed a significant increase in the rate of POAF after discharge that would otherwise not be detected by usual care. Studies are needed to examine whether these patients will benefit from oral anticoagulation therapy.
<p>This article presents the results of an arts-informed narrative study of patients’ experiences of the home period of recovery. Sixteen adults, 59 to 85 years of age, scheduled for coronary artery bypass graft and/or valve repair or replacement were recruited from a preoperative clinic. Individual interviews were conducted at 48–96 hours following surgery, and between 4–6 weeks following discharge. The methodological approach is new, and extensive details of the analytic and creative process appear elsewhere.</p>
Objective The number of adults with congenital heart disease (CHD) has increased substantially because of medical advances that are extending life expectancy beyond childhood. A historical investigation is timely not only because of this significant demographic shift, but also because stakeholder engagement is increasingly important in shaping research directions. The study questions were: From the perspective of stakeholders, what is known about the medical treatment for the adult CHD cohort in Canada and how has it changed over time? Design/Methods We harnessed the use of historical research methods and conducted interviews with 21 key informants in order to articulate a contextualized understanding of the evolution of adult CHD treatment in Canada. The informants recruited were currently or previously located in and/or involved in treatment in seven provinces and two territories across Canada including patients, families, advocates, researchers, and practitioners located in disciplines that included cardiology, cardiovascular surgery, nursing, psychology, dietetics, and kinesiology. Results Alongside findings that highlighted the significant demographic shift, the findings highlight key themes related to temporal shifts in treatment, emergence of organizational structures and use of evidence, comprehensive approaches to care, and future directions. A critical finding that requires immediate attention is the significantly disproportionate resources to the number of adults living with CHD, and as a result, the real risk of premature death for this population. Conclusions The insights provided behoove the community of stakeholders to think creatively on how to draw attention to the inadequacy of resources and the unique and diverse needs of this population.
Current therapies for congestive heart failure are limited in efficacy or in applicability. Cardiac cell transplantation offers a novel therapeutic approach to improve heart function. Although significant progress has been made over the past decade in the development of cell transplantation, only recently have investigators studied the changes in ventricular function following cell transplantation. This review article describes the latest research developments, evaluates recent studies of ventricular function after cell transplantation, and discusses the future directions of cell transplantation as a new therapy to 'repair broken hearts'.
Optimal patient recovery from open-heart surgery relies on effective discharge planning and education. However, the nature of the discharge experience has not been clearly described.The study purpose is to explore patients' and nurses' narrative accounts of the facilitators and barriers of heart surgery discharge.A qualitative study was employed using a narrative methodology that elicited and analyzed stories. This research was conducted in a large, urban hospital in Ontario, Canada. A total of 17 patients and nurses were recruited. Five female and 5 male patients were recruited from a preoperative clinic. Ages ranged from 37 to 80 years. Seven nurses were recruited from inpatient cardiovascular units. They had 2 to 19 years of cardiovascular nursing experience. Semistructured, narrative-based interviews were conducted. Two interviews were conducted with each patient at 1 week after discharge and at 4 to 6 weeks. One interview was conducted with each nurse.Findings indicate that although the preoperative period was identified as an effective time for discharge preparation, the patient's cognitive capacity was limited during the postoperative phase of surgery. Both nurses and patients also found that insufficient time impeded the discharge process and limited individualized discussions. The structured and standardized delivery of discharge information affected patients' capacity to apply it to the particularities in their own lives and homes. The fostering of therapeutic relationships created a space where patients felt comfortable sharing their concerns and nurses learned more about patients and thus could better tailor the discharge approach.Study recommendations include group and scenario-based education in which patients and nurses brainstorm about how to apply the discharge information to the particularities of patients' lives and homes. Provision of support needs to be bolstered during the home period, where patients have timely opportunities to discuss their concerns and questions with practitioners or possibly peers.
Introduction —Patients with congenital heart disease frequently require graft material for repair of cardiac defects. However, currently available grafts lack growth potential and are noncontractile and thrombogenic. We have developed a viable cardiac graft that contracts spontaneously in tissue culture by seeding cells derived from fetal rat ventricular muscle into a biodegradable material. We report our investigations of the in vitro and in vivo survival and function of this bioengineered cardiac graft. Methods and Results —A cardiomyocyte-enriched cell inoculum derived from fetal rat ventricular muscle was seeded into a piece of Gelfoam (Upjohn, Ontario, Canada), a biodegradable gelatin mesh, to form the graft. For in vitro studies, growth patterns of the cells within the graft were evaluated by constructing growth curves and by histologic examination; in in vivo studies, the graft was cultured for 7 days and then implanted either into the subcutaneous tissue of adult rat legs or onto myocardial scar tissue in a cryoinjured rat heart. Five weeks later, the graft was studied histologically. The inoculated cells attached to the gelatin mesh and grew in 3 dimensions in tissue culture, forming a beating cardiac graft. In both the subcutaneous tissue and the myocardial scar, blood vessels grew into the graft from the surrounding tissue. The graft implanted into the subcutaneous tissue contracted regularly and spontaneously. When implanted onto myocardial scar tissue, the cells within the graft survived and formed junctions with the recipient heart cells. Conclusions —Fetal rat ventricular cells can grow 3-dimensionally in a gelatin mesh. The cells in the graft formed cardiac tissue and survived and contracted spontaneously both in tissue culture and after subcutaneous implantation. Future versions of this bioengineered cardiac graft may eventually be used to repair cardiac defects.
Background: The knowledge translation capacity of cardiovascular research has had little impact on systems of care following discharge specific to the home period of recovery. Aims: The focus of this article is to provide an arts-informed dissemination in the form of a poem, to provide readers with the opportunity to engage with patients’ experiences on an emotive and visceral level. Methods: In order to explore 16 patients’ experiences of recovery from heart surgery, a narrative methodology was employed using journal writing and interviews. Research findings were reconstructed by the lead author into poetry, using words taken directly from interviews, to create a composite story of participants’ experiential accounts of recovery in the home. Results: Findings provide an intimate account of recovery as an emotional and physical experience that occurs in the isolation of one's home, interwoven with contemplations of mortality and unanswered questions. Conclusion: There is a need to implement and test interventions aimed at the care of cardiovascular patients during the home period of recovery.
