Peri-operative SARS-CoV-2 infection increases postoperative mortality. The aim of this study was to determine the optimal duration of planned delay before surgery in patients who have had SARS-CoV-2 infection. This international, multicentre, prospective cohort study included patients undergoing elective or emergency surgery during October 2020. Surgical patients with pre-operative SARS-CoV-2 infection were compared with those without previous SARS-CoV-2 infection. The primary outcome measure was 30-day postoperative mortality. Logistic regression models were used to calculate adjusted 30-day mortality rates stratified by time from diagnosis of SARS-CoV-2 infection to surgery. Among 140,231 patients (116 countries), 3127 patients (2.2%) had a pre-operative SARS-CoV-2 diagnosis. Adjusted 30-day mortality in patients without SARS-CoV-2 infection was 1.5% (95%CI 1.4-1.5). In patients with a pre-operative SARS-CoV-2 diagnosis, mortality was increased in patients having surgery within 0-2 weeks, 3-4 weeks and 5-6 weeks of the diagnosis (odds ratio (95%CI) 4.1 (3.3-4.8), 3.9 (2.6-5.1) and 3.6 (2.0-5.2), respectively). Surgery performed ≥ 7 weeks after SARS-CoV-2 diagnosis was associated with a similar mortality risk to baseline (odds ratio (95%CI) 1.5 (0.9-2.1)). After a ≥ 7 week delay in undertaking surgery following SARS-CoV-2 infection, patients with ongoing symptoms had a higher mortality than patients whose symptoms had resolved or who had been asymptomatic (6.0% (95%CI 3.2-8.7) vs. 2.4% (95%CI 1.4-3.4) vs. 1.3% (95%CI 0.6-2.0), respectively). Where possible, surgery should be delayed for at least 7 weeks following SARS-CoV-2 infection. Patients with ongoing symptoms ≥ 7 weeks from diagnosis may benefit from further delay.

SARS-CoV-2 has been associated with an increased rate of venous thromboembolism in critically ill patients. Since surgical patients are already at higher risk of venous thromboembolism than general populations, this study aimed to determine if patients with peri-operative or prior SARS-CoV-2 were at further increased risk of venous thromboembolism. We conducted a planned sub-study and analysis from an international, multicentre, prospective cohort study of elective and emergency patients undergoing surgery during October 2020. Patients from all surgical specialties were included. The primary outcome measure was venous thromboembolism (pulmonary embolism or deep vein thrombosis) within 30 days of surgery. SARS-CoV-2 diagnosis was defined as peri-operative (7 days before to 30 days after surgery); recent (1-6 weeks before surgery); previous (≥7 weeks before surgery); or none. Information on prophylaxis regimens or pre-operative anti-coagulation for baseline comorbidities was not available. Postoperative venous thromboembolism rate was 0.5% (666/123,591) in patients without SARS-CoV-2; 2.2% (50/2317) in patients with peri-operative SARS-CoV-2; 1.6% (15/953) in patients with recent SARS-CoV-2; and 1.0% (11/1148) in patients with previous SARS-CoV-2. After adjustment for confounding factors, patients with peri-operative (adjusted odds ratio 1.5 (95%CI 1.1-2.0)) and recent SARS-CoV-2 (1.9 (95%CI 1.2-3.3)) remained at higher risk of venous thromboembolism, with a borderline finding in previous SARS-CoV-2 (1.7 (95%CI 0.9-3.0)). Overall, venous thromboembolism was independently associated with 30-day mortality ). In patients with SARS-CoV-2, mortality without venous thromboembolism was 7.4% (319/4342) and with venous thromboembolism was 40.8% (31/76). Patients undergoing surgery with peri-operative or recent SARS-CoV-2 appear to be at increased risk of postoperative venous thromboembolism compared with patients with no history of SARS-CoV-2 infection. Optimal venous thromboembolism prophylaxis and treatment are unknown in this cohort of patients, and these data should be interpreted accordingly.

Levosimendan is a safe and efficient choice in the management of low-output syndrome during and after open-heart surgery. The shortening of hospitalisation and the trend for better outcome confirm its clear superiority when the infusion starts from the operating theatre.

P Pu ur rp po os se e: : Severe pulmonary hypertension (PH) is a major cause of right ventricular (RV) dysfunction. Various iv vasodilator modalities have been used with limited results because of lack of pulmonary selectivity. The aim of the present controlled study was to evaluate the efficacy of inhaled iloprost, a synthetic prostacyclin analogue, in patients with elevated pulmonary vascular resistance (PVR) immediately after separation from cardiopulmonary bypass (CPB).M Me et th ho od ds s: : Twelve patients with persistent PH after discontinuation of CPB were included in the study. In all patients standard hemodynamic monitoring was used. Inhaled iloprost was administered via nebulized aerosol at a cumulative dose of 0.2 µg·kg -1 for a total duration of 20 min. Complete sets of hemodynamic measurements were performed before inhalation (baseline), during and after cessation of the inhalation period. Echocardiographic monitoring of RV function was also used.R Re es su ul lt ts s: : Inhaled iloprost induced a reduction in the transpulmonary gradient at the end of the inhalation period in comparison to baseline (9.33 ± 3.83 mmHg vs 17.09 ± 6.41 mmHg, P < 0.05). The mean pulmonary artery pressure to systemic artery pressure ratio decreased over this period (0.28 ± 0.08 vs 0.45 ± 0.17, P < 0.05). A statistically significant decrease of the PVR to systemic vascular resistance ratio was also observed (0.15 ± 0.05 vs 0.21 ± 0.05, P < 0.05). Improved indices of RV function were observed in echocardiographic monitoring.C Co on nc cl lu us si io on n: : Inhaled iloprost appears to be a selective pulmonary vasodilator and may be effective in the initial treatment of PH and the improvement of RV performance in the perioperative setting. (9,33 ± 3,83 mmHg vs 17,09 ± 6,41 mmHg, P < 0,05). Le ratio de la pression artérielle pulmonaire moyenne sur la pression artérielle systémique a diminué pendant cette période (0,28 ± 0,08 vs 0,45 ± 0,17, P < 0,05). Une baisse statistiquement significative du ratio de la RVP sur la résistance vasculaire générale a été aussi observée (0,15 ± 0,05 vs 0,21 ± 0,05, P < 0,05 Objectif : L'hypertension pulmonaire sévère (HP) est une cause majeure de dysfonction du ventricule droit (VD). Diverses modalités vasodilatatrices iv ont été utilisées et ont donné des résultats limités, étant donné le manque de sélectivité pulmonaire. Notre but était d'é-valuer l'efficacité de l'inhalation d'iloprost, un analogue de la prostacycline synthétique, chez des patients qui présentent une résistance vasculaire pulmonaire (RVP) élevée immédiatement après le sevrage de la circulation extracorporelle (CEC). Méthode : Douze patients présentant une HP persistante après l'interruption de la CEC ont été inclus dans l'étude. Une surveillance standard des paramètres hémodynamiques a été utilisée pour tous les patients. L'administration d'iloprost a été faite à l'aide d'un nébuliseur Résultats : L'iloprost inhalé a provoqué une réduction du gradient transpulmonaire à la fin de l'inhalation, en comparaison avec les m...

Pulmonary hypertension (PH) is an independent risk factor for increased mortality in patients undergoing heart surgery. Existing chronic PH may be exacerbated by acute post-bypass PH, and this can lead to acute right ventricular failure. The prevention and treatment of right ventricular failure in cardiac surgery is based on three principles: optimize right ventricular preload, improve right ventricular contractility, minimize right ventricular afterload. The last of these may involve specific measures such as the inhalation of nitric oxide (NO) or of the stable prostacyclin analogue iloprost. The advantage of these inhalable substances is their pulmonary selectivity, and the subsequent reduction in systemic side effects. In order to avoid disastrous results in high-risk cardiac surgical patients, intra- and post-operative monitoring with pressure lines, a qualified team that pays attention to details, and an aggressive and early treatment in the operating room with inhaled iloprost and/or NO is necessary. The philosophy of ‘wait and see’ should be abandoned in favour of ‘be suspicious and act early’. In a prospective randomized trial, the efficacies of inhaled iloprost and of inhaled NO in the therapy of PH immediately following weaning from cardiopulmonary bypass in cardiac surgical patients were compared. Iloprost proved to be significantly more effective with respect to mean pulmonary arterial pressure, pulmonary vascular resistance, and cardiac output than inhaled NO.