In this number of the journal, the study “Mechanical ventilation time and mortality after coronary artery bypass grafting: A cohort study” evaluated retrospectively 110 patients of a single center, who had no previous lung or kidney disease, submitted to elective open bypass surgery between January 2018 and February 2020. Their aim was to evaluate the impact of mechanical ventilation (MV) on mortality using multivariate analysis of MV time, age, sex and cardiopulmonary bypass (CPB) time. The patients were divided into two groups: patients who needed more than eight hours on MV and those who needed less than eight hours on MV. There was no difference in weaning protocol or in demographic data except for CPB bypass time: 90 ± 12 minutes in the first group (less than eight hours on MV) and 112 ± 16 minutes in the second group (more than eight hours on MV) (p = 0.03). In the univariate analysis, MV time was associated with mortality (HR 0.7 (0.3-0.9), p = 0.01). The authors concluded that MV time longer than eight hours was a predictor of mortality after cardiac surgery.

I wish things could be simple in intensive care, however it is not. Let’s have a deeper approach and make a fair judgement if MV is the real foe. Let’s begin from the beginning: MV is a key part of advanced life support that may directly interfere with patient’s prognosis, for good and for bad. This is not only because of the duration of MV, but also why and how it is used. First, we must evaluate patient’s characteristics: gender, age, body mass index, frailty, EuroSCORE, transfusion, immunosuppression, previous lung disease (which was excluded in the present study), extravascular lung water (to determine lung edema) and both local (bronchoalveolar lavage) and systemic mediators of inflammatory response. Genetics also play an important role and it is worthwhile to mention that CPB, MV (alveolar pressure and/or mechanical distension), transfusion, sepsis, shock and trauma may increase the risk for lung injury.

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Abstract

Background

The SHARPEN score was developed to predict in-hospital mortality in patients hospitalized for infective endocarditis (IE), undergoing or not undergoing cardiac surgery. A comparison with other available scores has not yet been carried out.

Objective

To evaluate the performance of the SHARPEN score in predicting in-hospital mortality in patients hospitalized for IE undergoing cardiac surgery and compare it with that of both nonspecific and IE-specific surgical scores.

Methods

Retrospective cohort study including all admissions of patients ≥18 years who underwent cardiac surgery due to active IE (modified Duke criteria) at a tertiary care university hospital between 2007 and 2016. The SHARPEN score was compared to the EuroSCORE, EuroSCORE II, STS-IE, PALSUSE, AEPEI, EndoSCORE and RISK-E scores. Differences P<0.05 were considered statistically significant.

Results

A total of 105 hospitalizations of 101 patients (mean age 57.4±14.6 years; 75.2% male) were included. The median SHARPEN score was 11 (9-13) points. The observed in-hospital mortality was 29.5%. There was no statistically significant difference in observed vs. estimated mortality (P = 0.147), with an area under the ROC curve of 0.66 (P = 0.008). In comparison with the other scores, no difference was observed in discriminative ability. The statistics of the SHARPEN score at a cutoff >10 points — positive predictive value (PPV): 38.1%, 95%CI:30.4-46.6; negative predictive value (NPV): 80.0%, 95%CI:69.8-87.4; and accuracy: 58.1%, 95%CI:48.1-67.6 — showed overlapping 95%CIs, indicating no significant difference between scores.

Conclusions

The SHARPEN score did not present parameters with a significant difference in relation to the other scores analyzed; despite the easy obtainment of its few variables, it has limited applicability in clinical practice, like other existing scores.

Abstract

Background:

Postoperative atrial fibrillation (POAF) is a common complication associated with undesirable outcomes; hence, the provision of appropriate tools is important to help identify patients at risk.

Objectives:

To evaluate the predictive capacity of the CHADS₂ and CHA₂DS₂-VASc scores, alone and combined with left atrial (LA) size, for the onset of POAF in patients undergoing coronary artery bypass grafting and/or valvular surgery.

Methods:

We performed a retrospective cohort study on 144 patients. A decision tree was used to identify the cut-off values of the CHADS₂ and CHA₂DS₂-VASc scores and LA size in order to calculate sensitivity, specificity, predictive-value positive (PVP), and predictive-value negative (PVN), in addition to regression models. The receiver operating characteristic (ROC) curve was used to estimate the accuracy of the models. The level of significance adopted was 5%.

Results:

Patients who developed POAF were older (p = 0.050), had reduced left ventricular ejection fraction (p = 0.045), longer hospital length of stay (p = 0,018), but their mean CHADS₂ (p = 0.077) and CHA₂DS₂-VASc (p = 0.109) scores were similar to those of patients with no arrhythmia. LA size improved the predictive capacity of the CHADS₂ score, in terms of specificity and PVP, and of the CHA₂DS₂-VASc score, in terms of sensitivity and PVN. However, the CHADS₂ (OR = 1.198; CI95% = 0.859-1.156) and CHA₂DS₂-VASc (OR = 1.047; CI95% = 0.784-1.401) scores were not predictors of POAF, either alone or in combination with LA size (OR = 1.163; CI95% = 0.829-1.648 and OR = 1.065; CI95% = 0.795-1.433).

Conclusion:

The CHADS₂ and CHA₂DS₂-VASc scores alone or in combination with LA size did not show good predictive capacity for POAF.