Praveen Kerala Varma

Background: Thirty-day unplanned readmission following coronary artery bypass grafting (CABG) affects 10%-20% of patients and is a key quality indicator, particularly in low- and middle-income countries (LMICs) where access to cardiac rehabilitation is limited. Existing risk models are static, lack real-time engagement, and no validated large language model (LLM)–based clinical decision support (CDS) system exists for post-CABG readmission prevention. Objective: This protocol describes the development, validation, and evaluation of Smart CABGuard, a nurse-led, LLM-based CDS chatbot with continuous remote electrocardiographic (ECG) monitoring, to predict and prevent postoperative complications, and 30-day unplanned readmission after isolated CABG. Methods: This multiphase translational study is conducted at Amrita Institute of Medical Sciences, Kochi, India, following TRIPOD-LLM (Transparent Reporting of a Multivariable Prediction Model for Individual Prognosis or Diagnosis–Large Language Model) and CONSORT (Consolidated Standards of Reporting Trials) AI reporting guidelines. Phase I uses an ambispective design (retrospective: January 2020 to December 2024; prospective needs survey: June 2025 to January 2026) to develop a logistic regression-based Complication Risk Index (CRI), assessed via receiver operating characteristic area under the curve, Brier score, and decision curve analysis. Phase II refines Smart CABGuard by integrating a frozen Mistral-7B LLM (low-rank adaptation fine-tuned), the CRI engine, explainable AI, and single-lead ECG telemetry (Amrita Spandanam device), with a usability threshold of ≥80%. Phase III is a prospective, parallel-group, open-label randomized controlled trial (RCT). Adults aged ≥18 years undergoing isolated CABG with smartphone access are randomized 1:1 via permuted block randomization, with allocation concealment. The intervention arm receives Smart CABGuard–assisted care (daily chatbot check-ins, CRI-based risk stratification, ECG monitoring, and nurse-led triage) for approximately 24 days postdischarge plus standard care; the control arm receives standard care with structured telephone follow-up for outcome ascertainment only. Outcome assessors and statisticians are blinded; analyses follow the intention-to-treat principle. The primary outcome is 30-day all-cause unplanned readmission. Based on a baseline rate of 10.71%, a 50% relative reduction, α=.10, and 80% power, the target sample size is 800 patients (400 per arm, including 10% attrition). Results: Ethics approval was granted by the Institutional Ethics Committee of Amrita Institute of Medical Sciences on April 16, 2025. Funding was awarded by Sigma Theta Tau International Honor Society of Nursing, Small Grants Program (grant 21650) in June 2025. Phase I data extraction commenced in May 2025 and is projected to be completed by April 2026; the patient needs survey (June 2025 to January 2026) is ongoing. Phase II usability evaluation is projected from May to July 2026. Phase III recruitment is anticipated from August 2026 to September 2027. Results are expected to be published in early 2028. Conclusions: Smart CABGuard is the first RCT protocol of an LLM-based nurse-led CDS system for post-CABG readmission prevention in an LMIC setting, aiming to establish the usefulness, safety, and feasibility of AI-augmented postoperative surveillance.

Trichosporon is a type of non-candida yeast-like fungus. At one time, it was commonly reported in immunocompromised patients, but after the introduction of fluconazole as prophylaxis and for the treatment of fungal infections, there was a decrease in the incidence of the disease. With the introduction of echinocandins as the first line of treatment for fungal infections, and the intrinsic resistance of Trichosporon to the drug, there has been a small but increased reported incidence of the disease. Trichosporon usually causes skin infections, but invasive disease can occur in vulnerable patients. Endocarditis due to Trichosporon has been reported rarely, and usually occurs in prosthetic valves. In this paper, we report a patient with dialysis-dependent chronic kidney disease who presented with fever and was found to have native aortic valve endocarditis. In view of the large vegetation, he underwent early aortic valve replacement. Both the blood and tissue cultures grew Trichosporon spp. Post-operatively, he developed fungal septic shock, deteriorated, and died. Invasive Trichosporon disease has been associated with high rates of mortality ranging from 30 to 90%. There is limited literature on endocarditis resulting from Trichosporon. Specific treatment recommendations are unavailable, and a combination of surgery and prolonged antifungal medication will generally be required.

Background: Constrictive pericarditis is characterized by diffuse thickening, fibrosis, and calcification of the pericardium, leading to diastolic dysfunction and heart failure. Echocardiographic assessment typically focuses on trans-mitral and trans-tricuspid inflows as well as venous flows in the superior vena cava, pulmonary veins, and hepatic veins. The diagnostic and perioperative utility of hepatic and portal venous Doppler assessment in constrictive pericarditis, however, remains insufficiently explored. Case summary: We present a case series of patients with constrictive pericarditis in whom portal and hepatic venous Doppler interrogation was performed alongside conventional echocardiographic evaluation. The Doppler findings were integrated into the perioperative management strategy, contributing to a comprehensive understanding of venous return dynamics in these patients. Discussion: Our experience highlights the potential role of portal and hepatic venous Doppler assessment in the perioperative evaluation of constrictive pericarditis. These parameters may provide incremental value by complementing standard echocardiographic indices, thereby offering additional haemodynamic insights and facilitate tailored perioperative management. Further studies are warranted to validate their diagnostic and prognostic significance in this context.

Background There is a paucity of data regarding early- and long-term outcomes of coronary artery bypass grafting (CABG) in left main coronary artery disease (LMCAD) in comparison to non-LMCAD patients. Methods From November 2014 to December 2022, 2605 consecutive patients underwent isolated CABG procedure in our institution. Six hundred and twenty-five patients (24%) had LMCAD. Retrospective data collection from case files was combined with prospective patient follow-up. Since the baseline characteristics of the two groups were not similar, we used propensity matching with a single hidden layer neural network using a one-to-one nearest neighbor to generate matched 1:1 pairs. We compared the outcomes of 556 LMCAD patients with 556 non-LMCAD patients. We compared the 30-day outcomes, overall long-term survival, event-free survival, major adverse cardiovascular and cerebral event (MACCE) survival, and hazard of cardiovascular deaths. Results The median follow-up period was 4.9 years. The 30-day outcomes were similar in the matched cohort. However, overall survival was diminished in LMCAD patients. (The mean survival time in the non-LMCAD group was 3199.99 ± 38.96 days and in the LMCAD group, it was 3085.60 ± 47.34 (p-value 0.025).) LMCAD patients also had a higher hazard of cardiovascular death (p-value of 0.037). But the event-free survival and MACCE-free survival were similar in both groups. Multivariate Cox regression analysis in the matched cohort showed that LMCAD was an independent predictor of long-term mortality (hazard ratio (HR) 1.74; confidence interval (CI) 1.2–2.51). Conclusion Our study showed that LMCAD patients had increased cardiovascular mortality and inferior overall survival compared to non-LMCAD patients in a propensity-matched sample. Further multi-center studies or analyses of large registry data are needed to confirm the findings of this study. Graphical Abstract

Background This comprehensive review consolidates existing research about postoperative outcomes after coronary artery bypass grafting (CABG), a prevalent yet high-risk cardiac procedure. Notwithstanding improvements in surgical methods and perioperative management, CABG patients often encounter multisystem problems, including cardiac arrhythmias, pulmonary dysfunction, renal impairment, neurological impairments, and infections. These problems correlate with extended hospitalizations, elevated readmission rates, and increased healthcare expenditures. Materials and Methods A thorough literature search was performed in the Cochrane Library, MEDLINE, EMBASE, and CINAHL databases in accordance with PRISMA-ScR criteria and the Arksey and O’Malley methodological approach. Studies comprising adult CABG patients with follow-up durations of up to six months were incorporated. Data extraction concentrated on complication profiles, detection timeframes, hospital stay duration, and recovery metrics. Results Narrative synthesis indicated a significant correlation between the early identification of problems and decreased hospital durations. The review highlighted significant deficiencies in the current literature, including inconsistencies in monitoring techniques, insufficient focus on long-term outcomes, and inadequate representation of older and female patients. Conclusion Recent evidence indicates that artificial intelligence-based monitoring systems could improve early intervention and recovery. This analysis highlights the necessity for standardized postoperative care protocols and additional research into long-term recovery, quality of life, and cost-effective surveillance measures to enhance CABG results.

Background Literature is not clear whether women experience increased mortality and adverse events after coronary artery bypass grafting (CABG). Studies have shown that women had comparative outcomes to men in off-pump CABG (OPCAB). Hence, we undertook this study to understand the short- and long-term outcomes of women compared to men after OPCAB. Methods Two thousand two hundred patients who underwent OPCAB from November 2014 to December 2021 were included in the study. Median follow-up period was 4.8 years. We performed propensity matching to match 404 women to 404 men. Results In the unmatched cohort, women had increased cardiovascular mortality and inferior major adverse cardiovascular and cerebral event (MACCE)–free survival. In the matched cohorts, there was no difference in the 30-day mortality, long-term survival, MACCE-free survival, and cardiovascular mortality between the sexes. Cox proportional hazard showed post-operative renal failure (p-value < 0.001; hazard ratio (HR) 11.469) (confidence interval (CI) 2.911–45.180), post-operative stroke (p-value 0.023, HR 6.473) (CI 1.295–32.356), EuroSCORE II > 6 (p-value 0.022, HR 3.561) (1.204–10.531), emergency surgery (p-value 0.022, HR 3.498) (CI 1.202–10.177), and ventilation hours (p-value 0.004, HR 3.327) (CI 1.455–7.607) were the risk factors associated with long-term mortality in women. Conclusion Our study showed that the increased risk profile of women was the reason for inferior MACCE-free survival and increased cardiovascular mortality in women in the long term after OPCAB. When the risk factors were matched, women had comparable outcomes to men. Graphical Abstract

Patients who undergo coronary artery bypass graft (CABG) surgery in ischemic cardiomyopathy have a survival advantage over medical therapy at 10 years. The survival advantage of CABG over medical therapy is due to its ability to reduce future myocardial infarction, and by conferring electrical stability. The presence of myocardial viability does not provide a differential survival advantage for CABG over medical therapy. Presence of angina and inducible ischemia are also less predictive of outcome. Moreover, CABG is associated with significant early mortality. Hence, careful patient selection is more important for reducing the early mortality and improving the long-term outcome than relying on results of myocardial viability. Younger patients with good exercise tolerance benefit the most, while patients who are frail and patients with renal dysfunction and dysfunctional right ventricle seem to have very high operative mortality. Elderly patients, because of poor life expectancy, do not benefit from CABG, but the age cutoff is not clear. Patients also need to have revascularizable targets, but this decision is often based on experience of the surgical team and heart team discussion. These recommendations are irrespective of the myocardial viability tests. Optimal medical treatment remains the cornerstone for management of ischemic cardiomyopathy.