TOP TEN SELECTED PAPERS
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February 2010 |
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J Card Surg. 2010 Feb 23. [Epub ahead of print]
Resternotomy Using Hypothermic Arrest.
Möller F, Liska J, Lockowandt U, Samuelsson S, Franco-Cereceda A.
Department of Molecular Medicine and Surgery, Karolinska Institutet, Karolinska
University Hospital, Stockholm, Sweden.
Abstract Background: Resternotomy during closed chest cardiopulmonary bypass in
hypothermia with or without circulatory arrest has been the preferred method for
cardiac reoperations with adherent structures to the sternum. Here, we report our
experience with this method and the effects of omitting ventricular decompression
during the cooling procedure. Methods: Twenty reoperations were performed in 19
patients. In half (n = 10) of the procedures aortic regurgitation was present.
Cardiopulmonary bypass was instituted in all patients before resternotomy, and
the re-entry into the chest was performed either under hypothermic low-flow
cardiopulmonary bypass or circulatory arrest. The reason for this choice of
technique was adherent structures to the sternum posing a substantial risk for
rupture during resternotomy in all patients. Results: Rupture upon re-entry into
the chest occurred in five operations. No patient died due to re-entry injury.
The overall hospital mortality was 15%. No differences in postoperative outcomes
including heart failure, biochemical markers indicating myocardial damage, and
three-month follow-up assessment of cardiac function were found between patients
with aortic regurgitation and patients without aortic regurgitation. Conclusions:
Based on our experience, omitting ventricular decompression in resternotomy in
hypothermia and arrested circulation or low-flow cardiopulmonary bypass can be
safely used, and the presence of aortic regurgitation does not seem to influence
the outcome.
Chin Med J (Engl). 2010 Feb;123(3):269-73.
Extracorporeal membrane oxygenation during double-lung transplantation: single
center experience.
Xu LF, Li X, Guo Z, Xu MY, Gao CX, Zhu JH, Ji BY.
Department of Cardiopulmonary Bypass, Shanghai Chest Hospital, Shanghai 200030,
China.
BACKGROUND: For patients with end-stage lung diseases, lung transplantation is
the final therapeutic option. Sequential double-lung transplantation is
recognized as an established procedure to avoid cardiopulmonary bypass (CPB). But
some of the sequential double-lung transplantations require CPB support during
the surgical procedure for various reasons. However, conventional CPB may
increase the risk of bleeding and early allograft dysfunction. Extracorporeal
membrane oxygenation (ECMO) is more advantageous than conventional CPB during the
perioperative period of transplantation. Replacing traditional CPB with ECMO is
promising for those patients needing cardiopulmonary support during a sequential
double-lung transplantation procedure. This study aimed to summarize the
preliminary experience of ECMO practice in lung transplantation. METHODS: Between
November 2002 and October 2008, twelve patients with end-stage lung diseases
undergoing sequential double-lung transplantation were subjected to ECMO during
the surgical procedure. Eleven patients were prepared for the procedure via
transverse thoracostomy (clamshell) and cannulated through the ascending aorta
and right atrium for ECMO. The first patient who underwent bilateral thoracotomy
for bilateral sequential lung transplantation required emergency ECMO via the
femoral artery and vein during the second lung implantation. The Medtronic
centrifugal pump and ECMO package (CB1V97R1, Medtronic, Inc., USA) were used for
all of the patients. RESULTS: During ECMO, the blood flow rate was set between
1.8 - 2.0 Lxm(-2)xmin(-1) to keep hemodynamic and oxygen saturation stable;
colloid oncotic pressure was maintained at more than 18 mmHg with albumin and
hematocrit (HCT) kept at 28% or more. Two patients died early in this series and
the other 10 patients were weaned from ECMO successfully. The duration of ECMO
was 1.38 - 67.00 hours, and postoperative intubation was 10.5 - 67.0 hours.
CONCLUSIONS: As an established technique of cardiopulmonary support, ECMO is
helpful to keep hemodynamics stable, while reducing risk factors such as
ischemia-reperfusion injury, anticoagulation requirement and systemic
inflammatory response for sequential double-lung transplantation compared with
conventional CPB.
Cardiovasc Pathol. 2010 Feb 24. [Epub ahead of print]
Ischemic myocardial injuries after cardiac malformation repair in infants may be
associated with oxidative stress mechanisms.
Oliveira MS, Floriano EM, Mazin SC, Martinez EZ, Vicente WV, Peres LC, Rossi MA,
Ramos SG.
Department of Pathology, Faculty of Medicine of Ribeirão Preto, University of São
Paulo, 14049-900 Ribeirão Preto, SP, Brazil.
BACKGROUND: Despite advances in pediatric cardiac surgery, perioperative
myocardial injury can be the major determinant of postoperative dysfunction after
cardiac surgery. This study investigated the pathology-related differences in 29
infants with congenital heart disease that led to death. The infants were treated
at the University Hospital of Ribeirão Preto, Brazil. METHODS: The patients were
divided into four groups: Group 1, 16 infants who underwent operations for
congenital heart disease on cardiopulmonary bypass; Group 2, four infants who
underwent off-cardiopulmonary bypass operations for congenital heart disease;
Group 3, nine infants who died from congenital heart disease prior to surgical
treatment; and Group 4 (control group), five infants with no congenital heart
disease and who died from other causes. The myocardial injuries and oxidative
stress mechanisms were assessed by histopathology and immunohistochemistry and
were quantified by morphometrical analyses. RESULTS: Contraction band necrosis
and dystrophic calcification were found primarily in infants of Group 1.
Coagulation necrosis and healing were prominent in Group 2, while infants without
repair (Group 3) showed mainly colliquative myocytolysis. Apoptotic cells were
more prominent in the operative groups. The control group showed no significant
myocardial lesions. Lipid peroxidation was the principal mechanism of oxidative
stress accounting for the myocardial lesions. CONCLUSION: The diversity of the
lesions observed in these hearts seemed to indicate a large spectrum of cell
damage due to inadequate myocardial perfusion, especially when these infants
underwent surgery. Oxidative mechanisms could be a common mediator in the
pathogenesis of myocardial injuries, mediated by peroxidation of the membrane
phospholipids and resulting in changes in the permeability of the cell membrane,
cell death, and intracellular calcium overload. Furthermore, an immature and
often hypertrophied myocardium may promote unfavorable conditions, leading to
heart failure and a lethal outcome. Copyright © 2010 Elsevier Inc. All rights
reserved.
Kidney Int. 2010 Feb 24. [Epub ahead of print]
Hemolysis is associated with acute kidney injury during major aortic surgery.
Vermeulen Windsant IC, Snoeijs MG, Hanssen SJ, Altintas S, Heijmans JH, Koeppel
TA, Schurink GW, Buurman WA, Jacobs MJ.
[1] Department of Surgery, Maastricht University Medical Center, Maastricht, The
Netherlands [2] NUTRIM School for Nutrition, Toxicology and Metabolism,
Maastricht University Medical Center, Maastricht, The Netherlands [3] European
Vascular Center Aachen-Maastricht, Department of Vascular Surgery, University
Hospital Aachen, Aachen, Germany.
Hemolysis is an inevitable side effect of cardiopulmonary bypass resulting in
increased plasma free hemoglobin that may impair tissue perfusion by scavenging
nitric oxide. Acute kidney injury after on-pump cardiovascular surgery arises
from a number of causes and severely affects patient morbidity and mortality.
Here, we studied the effect of acute hemolysis on renal injury in 35 patients
undergoing on-pump surgical repair of thoracic and thoracoabdominal aortic
aneurysms of whom 19 experienced acute kidney injury. During surgery, plasma free
hemoglobin increased, as did urinary excretion of the tubular injury marker
N-acetyl-beta-D-glucosaminidase, in patients with and without acute kidney
injury, reaching peak levels at 2 h and 15 min, respectively, after reperfusion.
Furthermore, plasma free hemoglobin was independently and significantly
correlated with the urine biomarker, which, in turn, was independently and
significantly associated with the later postoperative increase in serum
creatinine. Importantly, peak plasma free hemoglobin and urine
N-acetyl-beta-D-glucosaminidase concentrations had significant predictive value
for postoperative acute kidney injury. Thus, we found an association between
increased plasma free hemoglobin and renal injury casting new light on the
pathophysiology of acute kidney injury. Therefore, free hemoglobin is a new
therapeutic target to improve clinical outcome after on-pump cardiovascular
surgery.
Perfusion. 2010 Feb 23. [Epub ahead of print]
Miniaturized versus conventional cardiopulmonary bypass in high-risk patients
undergoing coronary artery bypass surgery.
Koivisto SP, Wistbacka JO, Rimpiläinen R, Nissinen J, Loponen P, Teittinen K,
Biancari F.
Department of Anesthesiology, Vaasa Central Hospital, Vaasa, Finland.
OBJECTIVE: To review our results with the use of miniaturized cardiopulmonary
bypass (Mini-CPB) versus conventional cardiopulmonary bypass (C-CPB) in high-risk
patients (additive EuroSCORE>/=6) who have undergone coronary artery bypass graft
surgery (CABG). Patients and methods: This study includes a consecutive series of
236 patients with an additive EuroSCORE>/=6 who underwent CABG, employing either
C-CPB or Mini-CPB. Propensity score analysis was performed. RESULTS: The study
groups had similar EuroSCOREs. Stroke rate was significantly higher among C-CPB
patients (5.4% vs. 0%, p=0.026). In-hospital mortality (4.8% vs. 3.4%, p=0.75)
and combined adverse end-point rate were higher in C-CPB patients (20.4% vs.
13.5%, p=0.18). Postoperative bleeding and need for transfusion were similar in
the study groups, but re-sternotomy for bleeding was more frequent among C-CPB
patients (4.8% vs. 1.1%, p=0.26). Seventy-four propensity matched pairs had
similar immediate postoperative results: C-CPB patients had higher mortality
(6.8% vs. 4.1%, p=0.72), stroke (5.4% vs. 0%, p=0.12) and combined adverse
end-point rates (27.0% vs. 16.2%, p=0.11), but such differences failed to reach
statistical significance. CONCLUSIONS: Mini-CPB achieved somewhat better results
than C-CPB in these high-risk patients undergoing isolated CABG. This study
confirmed that cerebral protection could be the main benefit associated with the
use of Mini-CPB.
Interact Cardiovasc Thorac Surg. 2010 Feb 19. [Epub ahead of print]
Effect of mild renal dysfunction (s-crea 1.2-2.2 mg/dl) on presentation
characteristics and short- and long-term outcomes of on-pump cardiac surgery
patients.
Jyrala A, Weiss RE, Jeffries RA, Kay GL.
Heart Institute at Good Samaritan Hospital, Department of Cardiothoracic Surgery,
Los Angeles, USA.
Objectives: The objective of this study is to evaluate differences in patient
presentation and short- and long-term outcomes between patients dichotomized by
the level of preoperative s-creatinine (s-crea) without renal failure and to use
EuroSCORE (ES) risk stratification for validating differences and for predictive
purposes. Methods: A thousand consecutive cardiac surgery patients from January
1999 through May 2000 were analyzed. Patients with off-pump surgery or s-crea
>200 mmol/l (>2.2 mg/dl) were excluded leaving 885 patients for analysis. Group 1
(n=703) had s-crea 0.5-1.2 mg/dl and Group 2 (n=182) had elevated s-crea 1.3-2.2
mg/dl but no renal insufficiency. Results: Group 2 patients were older
(P<0.0001), had a higher percentage of males (P=0.008), had lower left
ventricular ejection fraction (LVEF) (P=0.001), had higher New York Heart
Association (NYHA) classification (P<0.0001), had more diabetics (P=0.001) and
had more patients with a history of congestive heart failure (CHF) (P<0.0001).
Both additive ES (AES) and logistic ES (LES) variables were higher in Group 2
patients, AES 8.45+/-4.28% vs. 6.05+/-3.80% (P<0.0001) and LES 17.7+/-19.1% vs.
9.57+/-13.3% (P<0.0001). Proportions of emergency operations and use of
intra-aortic balloon pulsation (IABP) support did not differ. There were more
coronary artery bypass grafting (CABG) with or without concomitant procedures in
Group 1 but otherwise the procedures performed were similar. Cardiopulmonary
bypass (CPB) times did not differ (P=0.1). Operative mortality was similar
(P=0.06) but hospital mortality was higher in Group 2: 19/10.4% vs. 25/3.6%
(P<0.0001), odds ratio (OR) 3.16. Total length of stay (LOS) and length of stay
in the postoperative intensive care unit (ICU) did not differ. Postoperative
renal failure (PORF) (s-crea increase to >2.25 mg/dl or >200 mmol/l) developed in
38/4.5% patients in Group 1 and in 41/22.5% patients in Group 2 (P<0.0001),
OR=5.08. Follow-up all-cause mortality was higher in Group 2: 68/37.4% vs.
167/23.8% (P<0.0001), OR=1.91. Both ES definitions predicted hospital mortality,
LOS, ICU, PORF and long-term mortality well, while increased s-crea predicted
PORF and long-term mortality in both groups. Conclusions: Mild increase in s-crea
is a marker for patients with increased cardiac risk factors and the risk for
poor outcomes. Both ES definitions are highly predictive of the outcomes.
Keywords: Serum creatinine; Cardiac surgery; Outcomes; EuroSCORE.
Rev Bras Anestesiol. 2010 Feb;60(1):84-9.
Uncommon causes of hemodynamic instability during myocardial revascularization
without cardiopulmonary bypass.
[Article in English, Portuguese]
Santos LM, Carmona MJ, Kim SM, Dias RR, Auler JO Jr.
Serviço de Anestesiologia, HC, FMUSP, Ribeirão Preto. maria.carmona@incor.usp.br
BACKGROUND AND OBJECTIVES: Myocardial revascularization (MR) in patients with
ventricular hypertrophy and/or dysfunction is frequently performed without
cardiopulmonary bypass (CB), since it can be difficult to wean those patients off
CB. Intraoperative control demands strict hemodynamic adjustment, as well as
partial clamping of the aorta to minimize hemodynamic changes. The objective of
this study was to report two cases of hemodynamic instability during MR without
CB after partial clamping of the aorta. CASE REPORT: The first case is a female
patient, whose aortic diameter was slightly reduced (2.8 cm); the second case
refers to a patient with left ventricular ejection fraction (LVEF) of 24% on the
echocardiogram. In both cases, significant hypotension and increase in pulmonary
blood pressure were observed immediately after clamping of the aorta. The
surgical teams were informed of the problem, and in both cases the hemodynamic
instability was reverted after unclamping of the aorta. Afterwards, smaller areas
of the aorta were clamped and proximal anastomoses were performed without
intercurrence. CONCLUSIONS: Although cardiac manipulation and changes in
ventricular preload represent the most common causes of hemodynamic instability
during MR without CB, in the cases presented here, hypotension and pulmonary
hypertension were most likely secondary to a reduction in cardiac output due to
the increase in afterload in patients with a relatively small aortic diameter or
ventricular dysfunction even with partial clamping. Adequate intraoperative
monitoring and immediate correction of the hemodynamic changes can minimize
surgical morbidity and mortality.
J Thorac Cardiovasc Surg. 2010 Feb 10. [Epub ahead of print]
Predictors of low cardiac output syndrome after isolated mitral valve surgery.
Maganti M, Badiwala M, Sheikh A, Scully H, Feindel C, David TE, Rao V.
Division of Cardiovascular Surgery, Peter Munk Cardiac Center, Toronto General
Hospital and the Department of Surgery, University of Toronto.
BACKGROUND: Low cardiac output syndrome is defined as the need for a
postoperative intra-aortic balloon pump or inotropic support for longer than 30
minutes in the intensive care unit. Mitral valve surgery is increasingly being
performed in high-risk patients who might require mechanical circulatory support
for low cardiac output syndrome. Therefore the aim of this study was to identify
the preoperative predictors of low cardiac output syndrome after mitral valve
surgery. METHODS: We conducted a retrospective review of data prospectively
entered into an institutional database. Between 1990 and February 2008, 3039
patients underwent isolated mitral valve surgery with or without coronary bypass
surgery. The independent predictors of low cardiac output syndrome and operative
mortality were determined by means of stepwise logistic regression analysis.
RESULTS: The overall prevalence of low cardiac output syndrome was 7%. The
independent predictors of low cardiac output syndrome were urgency of the
operation (odds ratio, 2.9), earlier year of operation (odds ratio, 2.4), left
ventricular ejection fraction of less than 40% (odds ratio, 2.1), New York Heart
Association class IV (odds ratio, 2), body surface area of 1.7 m(2) or less (odds
ratio, 1.6), ischemic mitral valve pathology (odds ratio, 1.6), and
cardiopulmonary bypass time (odds ratio, 1.02). The operative mortality was
higher in patients with low cardiac output syndrome (30% vs 1.3%, P < .001).
Overall operative mortality was 3.4%. The independent predictors of mortality
were urgency of the operation (odds ratio, 7.1), renal failure (odds ratio, 4.3),
nonuse of polytetrafluoroethylene sutures (Gore-Tex; W. L. Gore & Associates,
Inc, Austin, Tex; odds ratio, 2.1), any reoperative surgical intervention (odds
ratio, 1.8), increasing age (odds ratio, 1.03), and cardiopulmonary bypass time
(odds ratio, 1.02). CONCLUSIONS: Low cardiac output syndrome is associated with
significantly increased morbidity and mortality. Novel strategies to preserve
renal function, optimization of pre-existing heart failure symptoms, and use of
artificial polytetrafluoroethylene sutures might reduce the incidence of low
cardiac output syndrome and lead to improved results after mitral valve surgery.
Copyright © 2010 The American Association for Thoracic Surgery. Published by
Mosby, Inc. All rights reserved.
Eur J Cardiothorac Surg. 2010 Feb 11. [Epub ahead of print]
Anti-inflammatory haemoglobin scavenging monocytes are induced following coronary
artery bypass surgery.
Philippidis P, Athanasiou T, Nadra I, Ashrafian H, Haskard DO, Landis RC, Taylor
KM.
Cardiothoracic Surgery and Cardiovascular Medicine Units, Imperial College
Healthcare NHS Trust, Imperial College London, London, UK.
Objective: Circulating monocytes may counter systemic pro-inflammatory and
haemolytic insults through the expression and shedding of the haemoglobin
scavenger receptor (CD163). This prospective study aims to assess the effects of
coronary artery bypass grafting with and without cardiopulmonary bypass (CPB) on
haemoglobin scavenging and anti-inflammatory monocyte behaviour. Methods: Forty
consecutive patients underwent coronary surgery using CPB (n=20) and off-pump
(n=20) techniques. Peri-operative blood samples were taken until the fifth day
following surgery and statistical comparison performed to baseline using group-
and subject-based analysis. Monocyte receptor expression and plasma
concentrations of anti-inflammatory molecules were measured by flow cytometry and
enzyme-linked immunosorbent assay, respectively. Results: Monocyte CD163
expression was significantly elevated post-operatively in both surgical groups
with (p=0.001) and without CPB (p=0.000) at 24-48h. By contrast, shed CD163
(p=0.02) and haemoglobin-haptoglobin complexes (p=0.000) in plasma were only
significantly elevated in the on-pump group at 2-4h. Subject-based analysis
demonstrated that CPB is an independent predictor of monocyte CD163 (p=0.002) and
plasma sCD163 (p=0.01) concentration adjusting for the measurement timing.
Significant downregulation of the monocyte major histocompatibility complex II
receptor was observed in both surgical groups, whereas lipopolysaccharide
receptor (CD14) expression only declined following on-pump surgery. The
anti-inflammatory cytokine interleukin (IL)-10 was elevated post-operatively in
both surgical groups peaking earlier in the on-pump group (2h) versus off-pump
group (4h). The immunoregulatory IL-6 cytokine was significantly upregulated at
4h in both groups. Conclusion: Coronary artery bypass surgery induces
monocyte-associated anti-inflammatory and immunoregulatory responses. There was
no significant difference in haemolysis although the effect on monocyte CD163 and
plasma sCD163 concentration was significantly different between the two groups.
Compensation for varying pro-inflammatory and haemolytic insults may explain the
differences observed. Therapeutic strategies for inducing such desirable
circulating monocytes may potentially improve surgical outcome and patient
recovery. Copyright © 2010. Published by Elsevier B.V.
Eur J Cardiothorac Surg. 2010 Feb 4. [Epub ahead of print]
Cerebral functions and metabolism after antegrade selective cerebral perfusion in
aortic arch surgery.
Pacini D, Di Marco L, Leone A, Tonon C, Pettinato C, Fonti C, Manners DN, Di
Bartolomeo R.
Department of Cardiac Surgery, S. Orsola-Malpighi Hospital, University of
Bologna, Bologna, Italy.
Objectives: Antegrade selective cerebral perfusion (ASCP) represents the best
method of cerebral protection during surgery of the thoracic aorta. However,
brain integrity and metabolism after antegrade cerebral perfusion have not yet
been investigated. We assessed cerebral positron emission tomography (PET),
diffusion-weighted imaging, proton magnetic resonance spectroscopy and cognitive
functions in patients undergoing either ASCP or coronary artery bypass grafting
(CABG) to elucidate whether cerebral perfusion was associated with postoperative
neuronal alterations, metabolic deficit or cognitive decline. Methods: Seventeen
patients undergoing aortic arch surgery using ASCP with moderate hypothermia (26
degrees C) (ASCP group) and 15 patients undergoing elective on-pump CABG (CABG
group) were prospectively enrolled in the study. Brain PET, diffusion-weighted
imaging, proton magnetic resonance spectroscopy and neuropsychometric testing
were performed preoperatively, and at 1 week and 6 months postoperatively (T1, T2
and T3, respectively). Patient data were compared for statistic analysis with a
normal database made up of healthy subjects. Results: One patient in each group
was excluded because they refused postoperative evaluation. There were neither
strokes nor hospital deaths. Two patients suffered from temporary neurological
dysfunction (one in each group). Proton magnetic resonance spectroscopy did not
reveal significant alterations in cortical N-acetyl-aspartate (NAA) content
within and between the groups at T2 and T3. In the ASCP group, brain
diffusion-weighted magnetic resonance showed a significant increase of the
apparent diffusion coefficient values, reflecting vasogenic cerebral oedema, at
T2, that disappeared at T3. Magnetic resonance detected new focal brain lesions
in two CABG group patients. In seven ASCP group patients, PET scan showed glucose
hypometabolism in the occipital lobes at T2, which disappeared in five patients
at successive examination (T3). Significant cognitive decline was not observed in
any patient. Test score changes between and within groups were not significant.
Conclusions: There was no evidence of ischaemic brain injury after ASCP even if
some degree of reversible brain oedema secondary to cardiopulmonary bypass (CPB)
was present. The cognitive outcomes in patients undergoing ASCP were comparable
to patients undergoing coronary artery bypass. The lack of left subclavian artery
perfusion during cerebral perfusion leads to temporary glucose hypometabolism in
the occipital lobes without neuronal injury. Copyright © 2009 European
Association for Cardio-Thoracic Surgery. Published by Elsevier B.V. All rights
reserved.
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