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Published on: June 12, 2021
Shock Stages in Cardiac Surgical Patients: Implications for Post-Cardiotomy Shock and Mortality
Nicolas Brozzi1, Federico Napoli1, Rene Aleman1
1Department of Cardio-Thoracic Surgery at Heart, Thoracic & Vascular Institute at Cleveland Clinic Florida, Weston, Florida, USA.
Insights
The CS-SCAI staging system effectively predicts mortality risk in cardiac surgery patients. Worsening CS-SCAI stage post-surgery significantly increases 30-day mortality, highlighting its prognostic value.
Area of Science:
- Cardiovascular Surgery
- Critical Care Medicine
- Health Outcomes Research
Background:
- Accurate risk prognostication is crucial for identifying patients at high risk of mortality after cardiac surgery.
- The Society for Cardiac Angiography and Intervention (SCAI) shock construct provides a framework for assessing shock severity.
Purpose of the Study:
- To adapt the SCAI shock construct for cardiac surgical patients, creating the CS-SCAI staging system.
- To evaluate the correlation of CS-SCAI staging at various time points with patient survival following cardiac surgery.
Main Methods:
- Retrospective analysis of the Society of Thoracic Surgeons adult cardiac surgery database (January 2015 - December 2019).
- Utilized multivariate logistic analysis to examine factors influencing 30-day survival.
- Defined CS-SCAI stages A-E based on clinical parameters including heart failure, urgent surgery, resuscitation, vasoactive use, and mechanical support.
Main Results:
- Included 1,164,015 patients; preoperative CS-SCAI stages A-E showed a graded increase in mortality from 1.2% to 42.1%.
- CS-SCAI stage was the strongest predictor of mortality both preoperatively and postoperatively.
- 6,508 patients transitioned to a worse CS-SCAI stage postoperatively, with a 51.6% 30-day mortality rate. Predictors included bypass time, preoperative stage, and cross-clamp time.
Conclusions:
- The CS-SCAI staging system effectively facilitates risk prognostication before and after cardiac surgery.
- Stage transitions are linked to a spectrum of high mortality and can refine the definition of post-cardiotomy shock.
Background:
Risk prognostication is essential to identify patients at risk of higher mortality following cardiac surgery.
Objectives:
The Society for Cardiac Angiography and Intervention (SCAI) shock construct was adapted to cardiac surgical patients to create the CS-SCAI staging and it was applied at various time points and correlated with survival.
Methods:
Retrospective analysis of Society of Thoracic Surgeons adult cardiac surgery database from January 2015 to December 2019. The focus was 30-day survival and multivariate logistic analysis was used to examine factors. CS-SCAI E indicates extracorporeal life support or biventricular devices, CS-SCAI D patients receive vasoactive(s) and a single device whereas CS-SCAI C patients have either one device or a vasoactive but not both. CS-SCAI B has heart failure, urgent surgery, or cardiopulmonary resuscitation, otherwise CS-SCAI A is assigned.
Results:
A total of 1,164,015 patients were included. Preoperatively 35.9%, 54.9%, 8.3%, 0.7%, and 0.2% of patients were in Stages A, B, C, D, and E, respectively, with corresponding mortality of 1.2%, 2.12%, 9.84%, 17.06%, and 42.1% (chi-square P < 0.0001). In the preoperative and postoperative setting, CS-SCAI stage was the strongest predictor of mortality. Transition to worsened CS-SCAI stage postoperatively occurred in 6,508 patients with 30-day mortality 51.6%. The strongest predictors of stage transition were cardiopulmonary bypass time, preoperative CS-SCAI stage, and aortic cross clamp time.
Conclusions:
CS-SCAI facilitates risk prognostication prior to and following cardiac surgery. Transitions of stage are associated with a spectrum of high mortality and could be used to better define post-cardiotomy shock.
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