TOP TEN SELECTED PAPERS
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January 2011 |
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Paediatr Anaesth. 2011 Jan 12. doi: 10.1111/j.1460-9592.2010.03514.x. [Epub ahead
of print]
Cisatracurium pharmacokinetics and pharmacodynamics during hypothermic
cardiopulmonary bypass in infants and children.
Withington D, Ménard G, Varin F.
Department of Anesthesia, McGill University, Montreal Children's Hospital,
Montreal, QC, Canada Faculté de Pharmacie, Université de Montréal, Montréal, QC,
Canada Department of Anesthesia, McGill University, Montreal, QC, Canada.
Background: Hypothermia potentiates neuromuscular blockade in adults during
cardiopulmonary bypass (CPB) but the pediatric literature is sparse.
Temperature-dependent Hoffman degradation of cisatracurium may allow reduction in
infusion rate (IR) during hypothermia. The effect of hypothermic CPB on the
pharmacokinetics (PK) and pharmacodynamics (PD) of cisatracurium has not been
described in children. Methods and materials: Using neuromuscular monitoring
with a Datex Relaxograph, cisatracurium IR was adjusted to obtain a pseudo-steady
state during each phase of surgery (pre-CPB, CPB, post-CPB). Paired samples were
taken at each phase. Cisatracurium plasma concentrations (Cpss) were determined
by HPLC. Core and skin temperatures were recorded. Results: Data from ten
infants were analyzed: Group 1: mean 33.6°C; Group 2: mean 21.9°C. To maintain
T1% between 5% and 10% in Group 2, the IR was decreased by a mean of 89%
(P < 0.001). IR was not significantly different in Group 1. Post-CPB IR
approximated pre-CPB rates in both groups. During CPB, Cpss fell by 27% in Group
1 and by 50% in Group 2 (P = 0.039). Post-CPB Cpss was not significantly
different to pre-CPB in either group. Clearance did not change significantly in
Group 1 but fell significantly in Group 2 during CPB (P = 0.002). Clearance
post-CPB was unchanged from pre-CPB. Conclusions: Cisatracurium IR may be
decreased by around 60% during CPB with moderate hypothermia but can be
maintained at baseline during mild hypothermia.
Crit Care Med. 2011 Jan 7. [Epub ahead of print]
Prevention of post-cardiopulmonary bypass acute kidney injury by endothelin A
receptor blockade*
Patel NN, Toth T, Jones C, Lin H, Ray P, George SJ, Welsh G, Satchell SC, Sleeman
P, Angelini GD, Murphy GJ.
From the Bristol Heart Institute (NNP, CJ, HL, SJG, PS, GDA, GJM), University of
Bristol, Bristol Royal Infirmary, Bristol; Department of Histopathology (TT),
North Bristol NHS Trust, Southmead Hospital, Bristol; Department of Anaesthesia
and Critical Care (PR), Weston General Hospital, Weston-Super-Mare; and Academic
Renal Unit (GW, SCS), University of Bristol, Southmead Hospital, Bristol, United
Kingdom.
OBJECTIVE:: The aim of this study was to determine whether administration of a
specific endothelin A receptor antagonist, sitaxsentan sodium, would prevent the
development of post-cardiopulmonary bypass acute kidney injury in swine. DESIGN::
Experimental study. SETTING:: Cardiovascular Research Institute. INTERVENTIONS::
None. MEASUREMENTS AND MAIN RESULTS:: Adult pigs (n = 8 per group) were
randomized to undergo a sham procedure, cardiopulmonary bypass, or
cardiopulmonary bypass plus administration of endothelin A receptor antagonist,
with recovery and reassessment at 24 hrs. Cardiopulmonary bypass resulted in a
significant reduction in creatinine clearance relative to sham pigs (mean
difference for cardiopulmonary bypass vs. sham, -50.3 mL/min [95% confidence
interval -89.2 to -11.4 mL/min], p = .008). This was reversed by the
administration of endothelin A receptor antagonist during cardiopulmonary bypass
(mean difference for cardiopulmonary bypass + endothelin A receptor antagonist
vs. cardiopulmonary bypass, +43.3 mL/min [95% confidence interval +3.3 to +83.4
mL/min], p = .030). Cardiopulmonary bypass also resulted in a significant rise in
the urinary biomarker of interleukin-18 compared to sham procedures (mean
difference +209 pg/mL [95% confidence interval +119 to +299 pg/mL], p < .001)
that was reversed by endothelin A receptor antagonist administration.
Post-cardiopulmonary bypass kidney injury was associated with vascular
endothelial injury and dysfunction, reduced nitric oxide bioavailability,
inflammation, and a significant increase in the expression of the paracrine
vasoconstrictors adenosine and endothelin-1. In post-cardiopulmonary bypass
kidneys at 24 hrs, there was persistent hypoxia at the level of the outer
medulla, cortical adenosine triphosphate depletion, and evidence of proximal
tubule epithelial cell stress manifest as phenotypic change. There was no
evidence of acute tubular necrosis. Administration of endothelin A receptor
antagonist to cardiopulmonary bypass pigs reversed endothelial dysfunction,
regional hypoxia, inflammation, and tubular changes. CONCLUSION:: In this model,
post-cardiopulmonary bypass acute kidney injury is associated with endothelial
dysfunction, regional tissue hypoxia, and proximal tubular epithelial cell stress
but not acute tubular necrosis. Antagonism of the endothelin-1 A receptor
reversed these changes and may represent a therapeutic target for the prevention
of post-cardiac surgery acute kidney injury.
J Heart Lung Transplant. 2011 Jan 4. [Epub ahead of print]
Tricuspid valve repair with left ventricular assist device implantation: Is it
warranted?
Saeed D, Kidambi T, Shalli S, Lapin B, Malaisrie SC, Lee R, Cotts WG, McGee EC
Jr.
Division of Cardiac Surgery, Center for Heart Failure, Bluhm Cardiovascular
Institute, Northwestern Memorial Hospital, Chicago, Illinois.
BACKGROUND: Tricuspid regurgitation is common in patients with advanced heart
failure. The ideal operative strategy for managing tricuspid valve regurgitation
(TR) in patients undergoing left ventricular assist device (LVAD) implantation is
unclear. This study was designed to evaluate the effect on outcomes of
concomitant tricuspid valve repair (TVR) for moderate to severe (3(+)/4(+)) TR at
the time of LVAD implantation. METHODS: Patients with >3(+) TR who underwent LVAD
implantation from 2005 to 2009 were retrospectively evaluated. Pre-, intra- and
post-operative data, including hemodynamics, inotrope requirements and end-organ
function parameters, were considered. Outcomes of patients receiving TVR were
compared with those who did not receive TVR (NTVR). RESULTS: Seventy-two LVADs
were implanted during the study period. Forty-two (58%) patients had =3(+) TR
prior to LVAD implantation. Eight patients underwent TVR and 34 patients did not
undergo TVR (NTVR). There were no significant differences in baseline
characteristics or severity of TR between the two groups. The TVR group had a
longer cardiopulmonary bypass time (p < 0.01) and required more blood products (p
< 0.05). Higher post-operative creatinine and blood urea nitrogen (BUN) values
were noted in the TVR group. One patient in the TVR group and 3 patients in the
NTVR group required right-sided mechanical assistance (p = 0.6). There was no
significant difference in short- or long-term mortality between the two groups.
CONCLUSIONS: TVR for =3(+) TR prolonged operative time and showed similar
outcomes compared with LVAD implantation alone. A benefit of performing TVR was
not demonstrated. As such, TVR may not be necessary at the time of LVAD
implantation.
Pacing Clin Electrophysiol. 2011 Jan 5. doi: 10.1111/j.1540-8159.2010.02972.x.
[Epub ahead of print]
Long-Term Mortality and Pacing Outcomes of Patients with Permanent Pacemaker
Implantation after Cardiac Surgery.
Raza SS, Li JM, John R, Chen LY, Tholakanahalli VN, Mbai M, Adabag AS.
Divisions of Cardiology Cardiothoracic Surgery, Veterans Affairs Medical Center,
Minneapolis, Minnesota Division of Cardiology, University of Minnesota,
Minneapolis, Minnesota.
Background: Approximately 20,000 permanent pacemakers (PPMs) are implanted
annually for bradycardia or atrioventricular (AV) block after cardiac surgery.
Little is known about the long-term pacing and mortality outcomes and the
temporal trends of these patients. Methods: We examined 6,268 consecutive
patients who underwent cardiac surgery at the Minneapolis Veterans Administration
Medical Center between 1987 and 2010. Patients who had a PPM within 30 days of
cardiac surgery were identified. Pacemaker interrogation records were
retrospectively reviewed and mortality was ascertained. Results: Overall, 141
(2.2%) patients underwent PPM implantation for high-degree AV block (55%) and
bradycardia (45%), 9 ± 6 days after surgery. Age, diuretic use, cardiopulmonary
bypass time (CPBT), and valve surgery were independent predictors of PPM
requirement. After 5.6 ± 4.2 years of follow-up, 40% of the patients were PPM
dependent. Longer CPBT (P = 0.03), PR interval >200 ms (P = 0.03), and QRS
interval > 120 ms (P = 0.04) on baseline electrocardiogram predicted PPM
dependency . In univariable analysis, PPM patients had a higher long-term
mortality than those without PPM (45% vs 36%; P = 0.02). However, after adjusting
for age, sex, type of surgery, and CPBT, PPM requirement was not associated with
long-term mortality (hazard ratio 1.3; 95% confidence interval 0.9-1.9; P =
0.17). Compared to before, incidence of PPM implantation increased after the year
2000 (1.9% vs 2.6%; P = 0.04). Conclusion: The majority of patients who require
PPM after cardiac surgery are not PPM dependent in the long term. Requiring a PPM
after surgery is not associated with long-term mortality after adjustment for
patient-related risk factors and cardiac surgical procedure. (PACE 2010; 1-8).
Ann Pharmacother. 2011 Jan 4. [Epub ahead of print]
Preoperative Statins and Acute Kidney Injury After Cardiac Surgery: Utilization
of a Consensus Definition of Acute Kidney Injury (January).
Bolesta S, Uhrin LM, Guzek JR.
Department of Pharmacy, Mercy Hospital, Scranton, PA.
BACKGROUND: Previous trials investigating preoperative statin use for prevention
of acute kidney injury following cardiovascular surgery were limited to patients
undergoing a specific procedure and many used nonconsensus definitions of acute
kidney injury. OBJECTIVE: To use a consensus definition of acute kidney injury
for evaluating the association of preoperative statin use with the development of
acute kidney injury following cardiac surgery utilizing cardiopulmonary bypass.
METHODS: We retrospectively evaluated a cohort of 667 patients =18 years who
underwent any cardiac surgery on cardiopulmonary bypass between April 2007 and
May 2009 at Mercy Hospital in Scranton, PA. Patients were excluded if they were
receiving preoperative renal replacement therapy, had stage 5 chronic kidney
disease, or did not have a postoperative serum creatinine level assessed. The
primary outcome was the odds of developing acute kidney injury given the use of
preoperative statins. Acute kidney injury was defined based on the Acute Kidney
Injury Network criteria as either an absolute increase in serum creatinine of
=0.3 mg/dL or 1.5 times baseline, or the need for postoperative renal replacement
therapy. RESULTS: The final analysis included 563 patients; 356 were receiving
preoperative statins. The incidence of acute kidney injury was 35.1% in the
statin group and 26.1% in the non-statin group. On univariate analysis statins
were associated with an increase in the odds of acute kidney injury (OR 1.53; 95%
CI 1.05 to 2.24). Multivariate logistic regression did not demonstrate an
association of statins with acute kidney injury (OR 1.36; 95% CI 0.904 to 2.05).
Repeating the analysis using 312 propensity score-matched patients also showed no
association of statins with acute kidney injury (OR 1.17; 95% CI 0.715 to 1.93).
CONCLUSIONS: Our findings do not support the hypothesis that preoperative statin
use is associated with a decrease in the incidence of acute kidney injury
following cardiac surgery utilizing cardiopulmonary bypass.
Ann Card Anaesth. 2011 Jan-Apr;14(1):13-8.
Ketamine has no effect on oxygenation indices following elective coronary artery
bypass grafting under cardiopulmonary bypass.
Parthasarathi G, Raman SP, Sinha PK, Singha SK, Karunakaran J.
Department of Anesthesiology, Sree Chitra Tirunal Institute for Medical Sciences
and Technology, Trivandrum - 695 011, India.
Cardiopulmonary bypass is known to elicit systemic inflammatory response syndrome
and organ dysfunction. This can result in pulmonary dysfunction and deterioration
of oxygenation after cardiac surgery and cardiopulmonary bypass. Previous studies
have reported varying results on anti-inflammatory strategies and oxygenation
after cardiopulmonary bypass. Ketamine administered as a single dose at induction
has been shown to reduce the pro-inflammatory serum markers in patients
undergoing cardiopulmonary bypass. Therefore we investigated if ketamine can
result in better oxygenation in these patients. This was a prospective randomized
blinded study. Eighty consecutive adult patients undergoing elective coronary
artery bypass grafting under cardiopulmonary bypass were included in the study.
Patients were divided into two groups. Patients in ketamine group received 1mg/kg
of ketamine intravenously at induction of anesthesia. Control group patients
received an equal volume of saline. All patients received standard anesthesia,
operative and postoperative care.Paired t test and independent sample t test were
used to compare the inter-group and between group oxygenation indices
respectively. Oxygenation index and duration of ventilation were analyzed.
Deterioration of oxygenation index was noted in both the groups after
cardiopulmonary bypass. However, there was no significant difference in the
oxygenation index at various time points after cardiopulmonary bypass or the
duration of ventilation between the two groups. This study shows that the
administered as a single dose at induction does not result in better oxygenation
after cardiopulmonary bypass.
Surg Today. 2011 Jan;41(1):67-71. Epub 2010 Dec 30.
Surgical outcome of simultaneous carotid and cardiac surgery.
Yoda M, Hata M, Sezai A, Minami K.
Department of Cardiovascular Surgery, The Cardiovascular Institute Hospital,
7-3-10 Roppongi, Minato-ku, Tokyo, 106-0032, Japan.
PURPOSE: The surgical outcome of a simultaneous carotid endarterectomy and
cardiac surgery has not been clarified. This study retrospectively reviewed
short- and mid-term outcomes after a carotid endarterectomy combined with
valvular surgery or coronary artery bypass grafting (CABG).
METHODS: Fifteen patients (12 males and 3 females, mean age 68.9 ± 6.7, range
59-86 years) underwent a carotid endarterectomy combined with cardiac surgery.
The main indication for carotid endarterectomy was more than 75% carotid stenosis
with or without cerebral ischemic symptom. Eight patients had a history of stroke
or transient ischemic attack. Endarterectomy was performed under mild hypothermia
and controlled hemodynamics with pulsatile perfusion with cardiopulmonary bypass
in all cases. Concomitant cardiac procedures were aortic valve replacement in 1
patient and CABG in 14 patients.
RESULTS: There was no early death. Early neurological complications occurred in
only 1 patient (6.7%). The ratio of heart-type fatty acid binding protein
increased significantly in those that suffered postoperative neurological
complications. One patient died 6 months after the operation due to pneumonia.
There was no myocardial infarction, and no events were observed in the late
postoperative periods.
CONCLUSIONS: Carotid endarterectomy can be safely performed in combination with
cardiac surgery. Furthermore, the heat-type fatty acid binding protein levels
might be useful for predicting early neurological complications.
Anesthesiology. 2011 Jan;114(1):58-69.
Preoperative cerebral oxygen saturation and clinical outcomes in cardiac surgery.
Heringlake M, Garbers C, Käbler JH, Anderson I, Heinze H, Schön J, Berger KU,
Dibbelt L, Sievers HH, Hanke T.
Cardiac Anesthesia Unit, Department of Anesthesiology, University of Lübeck,
Lübeck, Germany. heringlake@t-online.de
Comment in:
Anesthesiology. 2011 Jan;114(1):12-3.
BACKGROUND: The current study was designed to determine the relation between
preoperative cerebral oxygen saturation (Sco2), variables of cardiopulmonary
function, mortality, and morbidity in a heterogeneous cohort of cardiac surgery
patients.
METHODS: In this study, 1,178 consecutive patients scheduled for on-pump surgery
were prospectively studied. Preoperative Sco2, demographics, N-terminal
pro-B-type natriuretic peptide, high-sensitive troponin T, clinical outcomes, and
30-day and 1-yr mortality were recorded.
RESULTS: Median additive EuroSCORE was 5 (range: 0-19). Thirty-day and 1-yr
mortality and major morbidity (at least two major complications and/or a
high-dependency unit stay of at least 10 days) were 3.5%, 7.7%, and 13.3%,
respectively. Median minimal preoperative oxygen supplemented Sco2 (Sco2min-ox)
was 64% (range: 15-92%). Sco2min-ox was correlated (all: P value <0.0001) with
N-terminal pro-B-type natriuretic peptide (?: -0.35), high-sensitive troponin T
(?: -0.28), hematocrit (?: 0.34), glomerular filtration rate (?: 0.19), EuroSCORE
(t: 0.20), and left ventricular ejection fraction class (t: 0.12). Thirty-day
nonsurvivors had a lower Sco2min-ox than survivors (median 58% [95% CI, 50.7-62%]
vs. 64% [95% CI, 64-65%]; P < 0.0001). Receiver-operating curve analysis of
Sco2min-ox and 30-day mortality revealed an area-under-the-curve of 0.71 (95% CI,
0.68-0.73%; P < 0.0001) in the total cohort and an area-under-the-curve of 0.77
(95% CI, 0.69-0.86%; P < 0.0001) in patients with a EuroSCORE more than 10.
Logistic regression based on different EuroSCORE categories (0-2; 3-5, 6-10,
>10), Sco2min-ox, and duration of cardiopulmonary bypass showed that a Sco2min-ox
equal or less than 50% is an independent risk factor for 30-day and 1-yr
mortality.
CONCLUSIONS: Preoperative Sco2 levels are reflective of the severity of
cardiopulmonary dysfunction, associated with short- and long-term mortality and
morbidity, and may add to preoperative risk stratification in patients undergoing
cardiac surgery.
Ann Thorac Surg. 2011 Jan;91(1):131-6.
Outcomes of off-pump aortic valve bypass surgery for the relief of aortic
stenosis in adults.
Thourani VH, Keeling WB, Guyton RA, Dara A, Hurst SD, Lattouf OM.
Division of Cardiothoracic Surgery, Joseph B. Whitehead Department of Surgery,
Clinical Research Unit, Emory University School of Medicine, Atlanta, Georgia
30308, USA. vthoura@emory.edu
BACKGROUND: Elderly patients with aortic stenosis presenting for an aortic valve
replacement with a hostile ascending aorta remain a challenging patient cohort.
The purpose of this study was to assess outcomes after the use of an aortic valve
bypass performed without cardiopulmonary bypass.
METHODS: A retrospective review was performed on 21 high-risk patients who
underwent primary, isolated aortic valve bypass from September 2004 to June 2009
at Emory Healthcare Hospitals. Aortic valve bypass was used for a porcelain aorta
alone in 6 (28.6%) patients, previous coronary artery bypass grafting in 4
(19.0%), or both in 10 (47.6%). One patient (4.8%) was thought not to be a
candidate for cardiopulmonary bypass secondary to a severe cirrhosis.
RESULTS: Mean age was 73.9±7.0 years (median, 75.0 years), and 15 patients
(71.4%) were male. Mean New York Heart Association classification was 3.0±1.0
(median, 3.0), and preoperative ejection fraction was 0.460±0.163 (median,
0.500). Preoperative comorbidities included peripheral vascular disease (n=10;
47.6%), chronic lung disease (n=16; 76.2%), diabetes mellitus (n=10; 47.6%), and
dialysis-dependence (n=2; 9.5%). Either an 18-mm (n=11; 52.4%) or 20-mm (n=10;
47.6%) conduit was used, with an interposed Freestyle 21 porcine root in all
patients. All operations were performed without cardiopulmonary bypass. There
were no intraoperative mortalities. The mean intensive care unit stay was
133.7±161.3 hours (median, 80.2 hours), and overall postoperative length of stay
was 12.9±10.8 days (median, 9.0 days). In-hospital mortality occurred in 3
patients (14.3%). Mid-term follow-up shows an additional 4 patients died at a
median follow-up of 1.3 years.
CONCLUSIONS: Aortic valve bypass without cardiopulmonary bypass is a feasible
alternative for the treatment of severe aortic stenosis with acceptable
short-term morbidity and minimal mortality in this extremely high-risk surgical
population.
Anesth Analg. 2011 Jan;112(1):37-45. Epub 2010 Dec 2.
Enhanced thrombin generation after cardiopulmonary bypass surgery.
Lison S, Dietrich W, Braun S, Boehm J, Schuster T, Englhard A, Perchuc A,
Spannagl M, Busley R.
Working Group of Perioperative Hemostasis, Ludwig Maximilians Universitaet,
Munich, Germany.
BACKGROUND: Thrombin generation has a key role in the pathophysiology of
hemostasis. Research has focused on the intraoperative course of hemostasis,
while little is known about postoperative hemostatic activation. Thrombin
generation assays quantify the potential for thrombin generation ex vivo and may
be useful for determining hypercoagulability. The thrombin dynamics test (TDT)
assesses the initial kinetics of thrombin formation. We hypothesized that there
would be an increase in thrombin generation as well as thrombin capacity after
cardiac surgery.
METHODS: Two hundred twenty patients undergoing primary coronary artery bypass
grafting or aortic valve replacement (AVR) surgery were prospectively enrolled.
Patients undergoing AVR received warfarin beginning on the second postoperative
day. In addition to prothrombin fragment (F(1+2)), TDT, d-dimer, and troponin T
were assessed. Blood samples were obtained preoperatively, at the end of the
operation, 4 hours postoperatively, and the morning of postoperative days (PODs)
1, 3, and 5. The primary end point was the change of thrombin dynamics on POD 1.
RESULTS: In all patients, F(1+2) peaked at the end of the operation and remained
significantly elevated until POD 5. Compared with baseline and after an initial
decrease, TDT was found to be significantly elevated on POD 1. After coronary
artery bypass graft, TDT remained significantly elevated, whereas in AVR patients
with warfarin treatment, TDT was significantly reduced on PODs 3 and 5.
CONCLUSIONS: After cardiac surgery, thrombin generation continues, accompanied by
a high thrombin-generating capacity and elevated fibrinogen levels. This
constellation suggests a marked procoagulopathic state in the postoperative
period with the potential to aggravate the risk of thromboembolic complications.
Warfarin treatment after AVR significantly reduced thrombin-generating capacity.
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