TOP TEN SELECTED PAPERS
|
- |
January 2010 |
|
|
Pediatr Crit Care Med. 2010 Jan 29. [Epub ahead of print]
Challenge of predicting resting energy expenditure in children undergoing surgery
for congenital heart disease.
De Wit B, Meyer R, Desai A, Macrae D, Pathan N.
From the Paediatric Intensive Care Unit (BDW, AD, DM, NP), The Royal Brompton
Hospital, London, UK; Department of Paediatrics (BDW), Erasmus University
Rotterdam, Erasmus Medical College, Sophia Children's Hospital, Rotterdam,
Netherlands; and the Departments of Paediatrics and Cardiac Medicine (RM, NP),
Imperial College London, London, UK.
OBJECTIVES:: To determine pre- and postoperative predictors of energy expenditure
in children with congenital heart disease requiring open heart surgery; and to
compare measured resting energy expenditure with current predictive equations.
DESIGN:: Prospective resting energy expenditure data were collected, using
indirect calorimetry, for ventilated children admitted consecutively to the
pediatric intensive care unit after surgery for congenital heart disease. A
30-min steady-state measurement was performed in suitable patients. Resting
energy expenditure was compared to pre- and postoperative clinical variables, and
to predicted energy expenditure, using currently used predictive equations.
SETTING:: Pediatric intensive care unit at the Royal Brompton Hospital, London.
PATIENTS:: Children ventilated in the pediatric intensive care unit post surgery
for congenital heart disease. INTERVENTIONS:: - MEASUREMENTS AND MAIN RESULTS::
Twenty-one mechanically ventilated children (n = 17 boys, 4 girls) were enrolled
in the study. Mean +/- sd measured resting energy expenditure was 67.8 +/- 15.4
kcal/kg/day. Most children had inadequate delivery of nutrients compared with
actual requirements. Cardiopulmonary bypass had a significant influence on energy
expenditure after surgery; in patients who underwent cardiopulmonary bypass
during surgery, mean resting energy expenditure was 73.6 +/- 14.45 kcal/kg/day
vs. 58.3 +/- 10.29 kcal/kg/day in patients undergoing nonbypass surgery. Children
who were malnourished preoperatively had greater resting energy expenditure
postoperatively. There was also a significant difference between measured energy
expenditure and the Schofield (p = .006), World Health Organization (p = .002),
and pediatric intensive care unit-specific formula (p < .0001). However, energy
expenditure or a relative energy deficit in the early postoperative period was
not associated with severity or duration of organ dysfunction. CONCLUSIONS:: Poor
nutritional status preoperatively and cardiopulmonary bypass were associated with
a greater energy expenditure post cardiac surgery. None of the current predictive
equations predicted energy requirements within acceptable clinical accuracy.
Asian Cardiovasc Thorac Ann. 2010 Jan;18(1):22-6.
Simultaneous use of argatroban and heparin during cardiopulmonary bypass.
Okamura T, Shin'oka T, Ishibashi N, Ishii H, Kurosawa H.
Department of Cardiovascular Surgery, Tokyo Women's Medical University, 8-1
Kawada-cho, Shinjyuku, Tokyo 162-8666, Japan. tokamura@hotmail.co.jp
Heparin is the routine anticoagulant for cardiopulmonary bypass, but
complications due to heparin are often reported. This study assessed argatroban
as an alternative to heparin. Normothermic cardiopulmonary bypass with
hemodilution was performed for 2 h in 15 dogs (mean weight, 9.8 kg) randomly
assigned to 3 groups of 5 each. The controls were given heparin 200 IU x kg(-1)
before cardiopulmonary bypass; group A had argatroban infused continuously at a
rate of 20 microg x kg(-1) x min(-1); group H/A had half doses of both heparin
(100 IU x kg(-1)) and argatroban (10 microg x kg(-1) x min(-1)). Blood samples
were collected at 5 time points during the experiment. Activated clotting time,
hemoglobin level, platelet counts, and serum concentrations of fibrinogen,
antithrombin III, and thrombin-antithrombin III complex were measured. The
platelet count was reduced significantly, and the production of
thrombin-antithrombin III complex was inhibited in group H/A. Activated clotting
time remained <300 sec at all time points in group A, but it was maintained at
approximately 400 sec in group H/A. Fibrinogen and antithrombin III levels were
reduced to half in all groups after initiation of cardiopulmonary bypass. The
simultaneous use of heparin and argatroban infusion might be useful for
cardiopulmonary bypass with hemodilution.
J Thorac Cardiovasc Surg. 2010 Jan 30. [Epub ahead of print]
Efficacy of a novel bipolar radiofrequency ablation device on the beating heart
for atrial fibrillation ablation: A long-term porcine study.
Voeller RK, Zierer A, Lall SC, Sakamoto SI, Schuessler RB, Damiano RJ Jr.
Division of Cardiothoracic Surgery, Washington University School of Medicine,
Barnes-Jewish Hospital, St Louis, Mo.
OBJECTIVE: Over recent years, a variety of energy sources have been used to
replace the traditional incisions of the Cox maze procedure for the surgical
treatment of atrial fibrillation. This study evaluated the safety and efficacy of
a new bipolar radiofrequency ablation device for atrial ablation in a long-term
porcine model. METHODS: Six pigs underwent a Cox maze IV procedure on a beating
heart off cardiopulmonary bypass using the AtriCure Isolator II bipolar ablation
device (AtriCure, Inc, Cincinnati, Ohio). In addition, 6 pigs underwent median
sternotomy and pericardiotomy alone to serve as a control group. All animals were
allowed to survive for 30 days. Each pig underwent induction of atrial
fibrillation and was then humanely killed to remove the heart en bloc for
histologic assessment. Magnetic resonance imaging scans were also obtained
preoperatively and postoperatively to assess atrial and ventricular function,
pulmonary vein anatomy, valve function, and coronary artery patency. RESULTS: All
animals survived the operation. Electrical isolation of the left atrial appendage
and the pulmonary veins was documented by pacing acutely and at 30 days in all
animals. No animal that underwent the Cox maze IV procedure was able to be
induced into atrial fibrillation at 30 days postoperatively, compared with all
the sham animals. All 257 ablations examined were discrete, linear, and
transmural, with a mean lesion width of 2.2 +/- 1.1 mm and a mean lesion depth of
5.3 +/- 3.0 mm. CONCLUSIONS: The AtriCure Isolator II device was able to create
reliable long-term transmural lesions of the modified Cox maze procedure on a
beating heart without cardiopulmonary bypass 100% of the time. There were no
discernible effects on ventricular or valvular function. Copyright © 2010 The
American Association for Thoracic Surgery. Published by Mosby, Inc. All rights
reserved.
Crit Care. 2010 Jan 21;14(1):104. [Epub ahead of print]
Activated partial thromboplastin time waveform analysis as specific sepsis marker
in cardiopulmonary bypass surgery.
Schneider CP, Angele MK, Hartl WH.
Department of Surgery, Munich University Hospital, Campus Grosshadern,
Ludwig-Maximilians-University, Marchioninistrasse 15, 80933 Munich, Germany.
christian.schneider@med.uni-muenchen.de.
ABSTRACT: Throughout the last years, several new diagnostic biomarkers have been
introduced into clinical routine to identify a systemic inflammatory response
syndrome (SIRS) or a septic state and to discriminate between these two entities.
According to studies in selected patients, measurement of these biomarkers may be
advantageous under certain clinical conditions. On an individual basis, however,
these sepsis markers usually lack an adequate negative or positive predictive
power. Therefore, physicians in charge still have to rely on a combination of
personal experience and results from clinical or laboratory tests when deciding
on a patient's therapy. For surgical patients, a key problem consists of the time
delay which is associated with the diagnosis of serious postoperative infections
and which may negatively affect outcome. It is in this context where the
activated partial thromboplastin time waveform analysis may represent a promising
new method to discriminate between SIRS and sepsis, thereby shortening the time
to therapy. Nevertheless, studies involving large patient populations will be
necessary to prove the efficacy of this new diagnostic concept either as a single
tool or in combination with the measurement of other biomarkers.
Eur J Cardiothorac Surg. 2010 Jan 28. [Epub ahead of print]
Predonation of autologous blood reduces perioperative allogenic transfusion
requirement in grown-up patients with congenital heart disease.
Hörer J, Bening C, Vogt M, Martin K, Cleuziou J, Tassani-Prell P, Schreiber C,
Lange R.
Department of Cardiovascular Surgery, Deutsches Herzzentrum München an der
Technischen Universität München, Munich, Germany.
Background: Adults with congenital heart diseases have a substantial risk for
bleeding upon re-operations. Due to the detrimental effects of allogeneic blood
transfusion, reduction of transfusion requirement is a major concern. To
investigate the efficacy of autologous blood predonation (ABP), we focussed on a
homogeneous subgroup of patients, with right ventricular outflow tract
reconstruction. Methods: Prospectively collected data included 76 patients older
than 16 years with repeated right ventricular outflow tract reconstruction from
May 1995 to November 2006. In 27 patients, ABP was performed without any
complication. Results: Primary diagnoses included Tetralogy of Fallot in 50
patients and others in 26 patients. All patients had at least one previous
operation, 62% had more than one. All patients received a homograft conduit
between the right ventricle and the pulmonary artery. Preoperative haemoglobin
was 123+/-15gl(-1) in patients with ABP and 134+/-22gl(-1) in the remainder
(p=0.037), but was not significantly different after cardiopulmonary bypass until
discharge from the intensive care unit. Significantly more patients without ABP
required transfusion of allogeneic packed red cells (PRCs) (26 of 49 patients
(53%) vs 4 of 27 patients (15%), p=0.001) and allogeneic fresh frozen plasma
(FFP) (30 of 49 patients (61%) vs 6 of 27 patients (22%), p=0.002) than patients
with ABP. Of 27 patients, 23 (85%) and 25 (93%) with ABP received their
predonated PRC and FFP, respectively. Logistic regression analysis identified no
ABP (p=0.005, odds ratio (OR) 5.4, 95% confidence interval (CI) 1.7-17.7) and
time on extracorporeal circulation >83min (p=0.009, OR 5.0, 95% CI 1.5-16.8) to
be predictive for allogeneic blood transfusion. Conclusion: ABP can be safely
performed in grown-up patients with congenital heart disease without
complications. Patients without predonation of autologous blood exhibit a
fivefold increased risk for requiring allogeneic blood transfusion. Copyright ©
2009 European Association for Cardio-Thoracic Surgery. Published by Elsevier B.V.
All rights reserved.
Can J Anaesth. 2010 Jan 29. [Epub ahead of print]
Cardiopulmonary bypass does not affect plasma concentration of preoperatively
administered gabapentin.
Parlow J, Gilron I, Milne B, Dumerton-Shore D, Orr E, Phelan R.
Department of Anesthesiology & Perioperative Medicine, Queen's University &
Kingston General Hospital, 76 Stuart Street, Kingston, Ontario, K7L 2V7, Canada,
parlowj@queensu.ca.
PURPOSE: Drug effects can be unpredictable during cardiac surgery due to factors
that may influence drug concentration, such as extracorporeal oxygenation and
hemodilution. The primary aim of the current investigation was to determine
whether plasma gabapentin concentration is altered by cardiopulmonary bypass
(CPB). METHODS: Following approval from the Research Ethics Board and written
informed consent, we conducted this open-label prospective cohort investigation.
A convenience sample of 16 patients, who were scheduled for coronary bypass
surgery, received oral gabapentin 600 mg as follows: 90 min prior to induction of
anesthesia, following tracheal extubation, and then every eight hours for a total
of four doses. Plasma gabapentin concentration, as well as pain and sedation
scores, were documented. RESULTS: Plasma gabapentin concentrations were unaltered
during CPB (31.9 +/- 12.7 mumol.L(-1) prior to CPB, 35.6 +/- 12.9 to 37.2 +/- 9.6
mumol.L(-1) during CPB). However, using the current protocol, drug accumulation
(reflected by increased drug concentrations) was observed following the third
(58.2 +/- 19.5 mumol.L(-1)) and the fourth (71.9 +/- 34.3 mumol.L(-1)) doses.
Pain and sedation scores and opioid requirements were comparable with those found
in other studies. CONCLUSION: Plasma gabapentin concentration is unaltered during
CPB following preoperative administration. Drug accumulation following third and
fourth postoperative doses suggests the need for therapeutic drug monitoring in
future trials. Gabapentin is well established as an effective adjunct analgesic
in a number of surgical settings. Randomized controlled trials are necessary to
evaluate analgesic efficacy, optimal dosing, and adverse effects in the setting
of cardiac surgery. (ClinicalTrials.gov number, NCT01022736).
Can J Anaesth. 2010 Jan 27. [Epub ahead of print]
Combined heart and liver transplantation on cardiopulmonary bypass: report of
four cases.
Hennessey T, Backman SB, Cecere R, Lachapelle K, de Varennes B, Ergina P,
Metrakos P, Schricker T.
Department of Anaesthesia, Royal Victoria Hospital, McGill University Health
Centre, 687 Pine Avenue West, Rm. C5.20, Montreal, Quebec, H3A 1A1, Canada.
PURPOSE: Combined heart and liver transplant is a rare procedure to treat
end-stage cardiac and liver disease. First performed during cardiopulmonary
bypass and anticoagulation, subsequent concerns about increased bleeding changed
the strategy to performing liver implantation following separation from
cardiopulmonary bypass. Considering the overall decrease in transfusion
requirements during liver transplant and the potential benefits to the
transplanted heart to remain on cardiopulmonary bypass during liver implantation,
we revised the strategy for combined heart and liver transplant. We report the
clinical course of four consecutive patients who underwent this procedure in our
institution. CLINICAL FEATURES: Patient 1 was a 53-yr-old male with familial
hypertrophic cardiomyopathy and congestive cirrhosis. Patient 2 was a 57-yr-old
male with hypertrophic restrictive cardiomyopathy and congestive cirrhosis.
Patient 3 was a 48-yr-old male with dilated cadiomyopathy and hepatitis B
cirrhosis. Patient 4 was a 57-yr-old male with ischemic cardiomyopathy and
congestive cirrhosis. Each patient underwent combined heart and liver transplant,
with liver implantation performed during cardiopulmonary bypass and
anticoagulation. Estimated blood loss ranged from 1,000 to 3,000 mL.
Intraoperative transfusion included 2-5 U of packed red blood cells, 4-12 U of
fresh frozen plasma, 0-20 U of cryoprecipitate, and 5-23 U of platelets. All
patients remain well 25-38 months after surgery. CONCLUSION: Combined heart and
liver transplant during cardiopulmonary bypass is a viable strategy that may
confer benefit to this unique type of patient.
J Thorac Cardiovasc Surg. 2010 Jan;139(1):170-3.
Cardiopulmonary bypass flow rate: a risk factor for hyperlactatemia after
surgical repair of secundum atrial septal defect in children.
Abraham BP, Prodhan P, Jaquiss RD, Bhutta AT, Gossett JM, Imamura M, Johnson CE,
Schmitz ML, Morrow WR, Dyamenahalli U.
Department of Pediatrics, Section of Pediatric Cardiology, University of Arkansas
for Medical Sciences, College of Medicine, Little Rock, AR, USA.
OBJECTIVE: Early postoperative hyperlactatemia is seen in some children after
surgical repair of secundum atrial septal defect despite apparently normal
cardiac output. The objective of the study was to investigate the intraoperative
risk factors for hyperlactatemia in patients undergoing atrial septal defect
repair. METHODS AND RESULTS: A retrospective review of 68 consecutive patients
who underwent isolated atrial septal defect repair at Arkansas Children's
Hospital between January 2001 and March 2006 was performed. Perioperative factors
in the high lactate group (lactate >3 mmol/L, n = 26) were compared with those in
the low lactate group (n = 42). Early hyperlactatemia was seen in 38% of the
cohort. The high lactate group showed significantly lower weight-indexed
cardiopulmonary bypass flow rate (101 + or - 6.5 mL/kg(-1)/min(-1) vs 131 + or -
6.0 mL/kg(-1)/min(-1), P = .0013), oxygen delivery during cardiopulmonary bypass
(mean 12.7 + or - 0. 7 mL/kg(-1)/min(-1) vs 17.0 + or - 1 mL/kg(-1)/min(-1), P =
.0009), and higher postoperative glucose (191 + or - 8.6 mg/dL vs 151 + or - 5.4
mg/dL, P = .003) compared with the LL group. Multivariate logistic regression
analysis showed that weight-indexed cardiopulmonary bypass flow rate (P = .007)
and average mean arterial blood pressure during cardiopulmonary bypass (P = .009)
were independent risk factors for postoperative hyperlactatemia. Cardiopulmonary
bypass flow rate less than 100 mL/kg(-1)/min(-1) was associated with an odds
ratio of 7.67 (95% confidence interval, 1.28-45.86; P = .026) for postoperative
hyperlactatemia. CONCLUSION: Lower weight-indexed cardiopulmonary bypass flow
rate is an independent risk factor for early postoperative hyperlactatemia in
children after atrial septal defect repair. Copyright 2010 The American
Association for Thoracic Surgery. Published by Mosby, Inc. All rights reserved.
Ann Thorac Surg. 2010 Jan;89(1):105-11.
Preoperative and intraoperative factors associated with long-term survival in
octogenarian cardiac surgery patients.
Rohde SL, Baker RA, Tully PJ, Graham S, Cullen H, Knight JL.
Department of Cardiac and Thoracic Surgery, Flinders Medical Centre, Adelaide,
South Australia, Australia.
BACKGROUND: The proportion of octogenarians undergoing cardiac surgery is
increasing though few studies have examined the simultaneous impact of
preoperative and intraoperative factors on long-term survival in this age group.
This study aimed to describe the preoperative clinical and demographic
characteristics associated with long-term mortality risk and determine whether
intraoperative factors related to surgical and cardiopulmonary bypass techniques
impacted upon these. METHODS: Octogenarians undergoing coronary artery bypass
grafting (CABG) +/- concomitant valvular procedure between 1992 and 2005 from
three institutions were included in this study. The survival data of 606
octogenarians (414 isolated CABG, 192 concomitant valve procedures) were analyzed
with multivariable proportional hazard models. RESULTS: There were 271 deaths and
2,675 person years of survival for analysis, and median follow-up was 7.15 years
(95% confidence interval 6.47 to 7.82 years). Five-year survival for isolated
CABG and concomitant valve procedures was 66.5% and 61.5%, respectively. An
increase in mortality risk was attributable to older age, hypercholesterolemia,
severely impaired left ventricular function, tobacco smoking history and high
creatinine (> or = 0.15 mmol/L). Time spent on cardiopulmonary bypass was the
only intraoperative risk factor associated with an increase in mortality risk
(hazard ratio 1.01, 95% confidence interval: 1.00 to 1.02; p < 0.001).
CONCLUSIONS: This study showed that from the intraoperative parameters examined
only time spent on cardiopulmonary bypass was associated with long-term survival.
Surgeons may be assisted in patient selection by identifying the factors that
influence long-term survival among octogenarians and development of a
preoperative risk model specific for this age group. 2010 The Society of Thoracic
Surgeons. Published by Elsevier Inc. All rights reserved.
J Cardiothorac Surg. 2010 Jan 18;5(1):3. [Epub ahead of print]
Human cardiac tissue in a microperfusion chamber simulating extracorporeal
circulation - ischemia and apoptosis studies.
Usta E, Renovanz M, Mustafi M, Ziemer G, Aebert H.
ABSTRACT: BACKGROUND: After coronary artery bypass grafting ischemia/reperfusion
injury inducing cardiomyocyte apoptosis may occur. This surgery-related
inflammatory reaction appears to be of extreme complexity with regard to its
molecular, cellular and tissue mechanisms and many studies have been performed on
animal models. However, finding retrieved from animal studies were only partially
confirmed in humans. To investigate this phenomenon and to evaluate possible
therapies in vitro, adequate human cardiomyocyte models are required. We
established a tissue model of human cardiomyocytes preserving the complex tissue
environment. To our knowledge human cardiac tissue has not been investigated in
an experimental setup mimicking extracorporeal circulation just in accordance to
clinical routine, yet. METHODS: Cardiac biopsies were retrieved from the right
auricle of patients undergoing elective coronary artery bypass grafting before
cardiopulmonary bypass. The extracorporeal circulation was simulated by
submitting the biopsies to varied conditions simulating cardioplegia (cp) and
reperfusion (rep) in a microperfusion chamber. Cp/rep time sets were 20/7, 40/13
and 60/20 min. For analyses of the calcium homoeostasis the fluorescent calcium
ion indicator FURA-2 and for apoptosis detection PARP-1 cleavage immunostaining
were employed. Further the anti-apoptotic effect of carvedilol [10 uM] was
investigated by adding into the perfusate. RESULTS: Viable cardiomyocytes
presented an intact calcium homoeostasis under physiologic conditions. Following
cardioplegia and reperfusion a time-dependent elevation of cytosolic calcium as a
sign of disarrangement of the calcium homoeostasis occurred. PARP-1 cleavage also
showed a time-dependence whereas reperfusion had the highest impact on apoptosis.
Cardioplegia and carvedilol could reduce apoptosis significantly, lowering it
between 60-70% (p < 0.05). CONCLUSIONS: Our human cardiac preparation served as a
reliable cellular model tool to study apoptosis in vitro. Decisively cardiac
tissue from the right auricle can be easily obtained at nearly every cardiac
operation avoiding biopsying of the myocardium or even experiments on animals.
The apoptotic damage induced by the ischemia/reperfusion stimulus could be
significantly reduced by the cold crystalloid cardioplegia. The additional
treatment of cardiomyocytes with a non-selective beta-blocker, carvedilol had
even a significantly higher reduction of apoptotis.
Back to Homepage
Back to Index
Footer
PERFUSION LINE - THE LARGEST COLLECTION OF PERFUSION RESOURCES
|
|
|
|
|
|
|
|
|
|
|
|
|
|
|
Perfusion Line - Copyright © 1997-2012
International Page on Extracorporeal Technology
