TOP TEN SELECTED PAPERS
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February 2011 |
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Heart. 2011 Feb 28. [Epub ahead of print]
Neurocognitive outcome after coronary artery bypass surgery using minimal versus
conventional extracorporeal circulation: a randomised controlled pilot study.
Anastasiadis K, Argiriadou H, Kosmidis MH, Megari K, Antonitsis P, Thomaidou E,
Aretouli E, Papakonstantinou C.
Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki,
Greece.
Objective Neurocognitive impairment can be a debilitating complication after
cardiac surgery. The aim of this study was to assess the effect of minimal
extracorporeal circulation (MECC) versus conventional extracorporeal circulation
(CECC) on neurocognitive function after elective coronary artery bypass grafting
(CABG) and whether this can be attributed to improved cerebral perfusion
intraoperatively. Methods and results 64 patients scheduled for elective CABG
surgery were prospectively randomly assigned to surgical revascularisation with
MECC versus CECC. All patients were continuously monitored for changes in
cerebral oxygenation with near-infrared spectroscopy during the procedure.
Neurocognitive assessment was performed before surgery, on the day of discharge
and at 3 months postoperatively using a battery of standardised
neurocognitive tests. Both groups were comparable in terms of demographic and
clinical data. MECC was associated with improved cerebral perfusion during
cardiopulmonary bypass (CPB). Eleven patients operated on with MECC and 17 with
CECC experienced at least one episode of cerebral desaturation (38% vs 55%,
p=0.04) with similar duration (10 vs 12.3 min, p=0.1). At discharge
patients operated on with MECC showed a significantly improved performance on
complex scanning, visual tracking, focused attention and long-term memory. At
3 months significantly improved performance was also evident on
visuospatial perception, executive function, verbal working memory and short-term
memory. Patients operated on with MECC experienced a significantly lower risk of
early cognitive decline both at discharge (41% vs 65%, p=0.03) and at 3-month
evaluation (21% vs 61%, p<0.01). Conclusions Use of MECC attenuates early
postoperative neurocognitive impairment after coronary surgery compared with
conventional CPB. This finding may have important implications on the surgical
management strategy for coronary artery disease. Clinical Trial Registration
Number The study is registered at ClinicalTrials.gov, number NCT01213511.
Eur J Cardiothorac Surg. 2011 Feb 23. [Epub ahead of print]
Warm-blood cardioplegia with low or high magnesium for coronary bypass surgery: a
randomised controlled trial.
Caputo M, Santo KC, Angelini GD, Fino C, Agostini M, Grossi C, Suleiman MS,
Reeves BC.
Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol,
BS2 8HW, UK.
Objective: Magnesium (Mg(2+)) is cardioprotective and has been routinely used to
supplement cardioplegic solutions during coronary artery bypass graft (CABG)
surgery. However, there is no consensus about the Mg(2+) concentration that
should be used. The aim of this study was to compare the effects of intermittent
antegrade warm-blood cardioplegia supplemented with either low- or
high-concentration Mg(2+). Methods: This study was a randomised controlled trial
carried out in two cardiac surgery centres, Bristol, UK and Cuneo, Italy.
Patients undergoing isolated CABG with cardiopulmonary bypass were eligible.
Patients were randomised to receive warm-blood cardioplegia supplemented with 5
or 16mmoll(-1) Mg(2+). The primary outcome was postoperative atrial fibrillation.
Secondary outcomes were serum biochemical markers (troponin I, Mg(2+), potassium,
lactate and creatinine) and time-to-plegia arrest. Intra-operative and
postoperative clinical outcomes were also recorded. Results: Data from two
centres for 691 patients (342 low and 349 high Mg(2+)) were analysed. Baseline
characteristics were similar for both groups. There was no significant difference
in the frequency of postoperative atrial fibrillation in the high (32.8%) and low
(32.0%) groups (risk ratio 1.03, 95% confidence interval, CI, 0.82-1.28).
However, compared with the low group, troponin I release was 28% less (95% CI
55-94%, p=0.02) in the high-Mg(2+) group. The 30-day mortality was 0.72% (n=5);
all deaths occurred in the high-Mg(2+) group but there was no significant
difference between the groups (p=0.06). Frequencies of other major complications
were similar in the two groups. Conclusions: Warm-blood cardioplegia supplemented
with 16mmoll(-1) Mg(2+), compared with 5mmoll(-1) Mg(2+), does not reduce the
frequency of postoperative atrial fibrillation in patients undergoing CABG but
may reduce cardiac injury. (This trial was registered as ISRCTN95530505.).
Eur J Cardiothorac Surg. 2011 Feb 24. [Epub ahead of print]
Open cardiac surgery in the first hours of life using autologous umbilical cord
blood.
Fedevych O, Chasovskyi K, Vorobiova G, Zhovnir V, Makarenko M, Kurkevych A,
Maksymenko A, Yemets I.
Ukrainian Children Cardiac Clinic, Chornovola str. 28/1, 1135 Kyiv, Ukraine.
Objective: This article describes the first clinical experience of complete
repair of complex critical congenital heart diseases (CHDs) in the first hours of
life using autologous umbilical cord blood (UCB). Prenatal diagnosis and
harvesting of autologous UCB allow to modify perioperative management and to
perform corrective surgery in the first hours of a patient's life. This approach
can afford avoiding homologous blood transfusion and preventing development of
hypoxemia and heart failure due to hemodynamic changes of complex critical CHD.
Methods: The study group included 14 consecutive prenatally diagnosed patients
with critical complex CHD during the period from September 2009 to August 2010.
Autologous UCB was harvested in accordance to NetCord-FACT International
Standards for Cord Blood Collection and was used during the surgery with
cardiopulmonary bypass (CPB). In all cases, complete repair was performed during
the first hours of life: arterial switch operation (n=9); arterial switch
operation with total anomalous pulmonary venous communication repair (n=1);
arterial switch operation with interruption of the aortic arch repair (n=1);
Ebstein's repair (n=2); and aortopulmonary window repair with interruption of the
aortic arch repair (n=1). All procedures were performed using moderate
hypothermia with cold-crystalloid cardioplegia, except one case that required
deep hypothermic circulatory arrest. Results: A mean of 92±16ml of UCB was
harvested. Autologous UCB was used during the surgery in all 14 cases. Mean age
of newborns at operation was 4.7±2h (3-8). No patients required intensive care
unit (ICU) admission, interventional procedures, mechanical ventilation, or
medications before surgery. Twelve patients underwent bloodless open heart
surgery; eight of them completely avoided homologous blood transfusion during the
perioperative period. There was one postoperative death in our study (Ebstein's
anomaly). Conclusions: The use of autologous umbilical cord blood is feasible in
neonatal open heart surgery. Complete surgical repair of complex critical CHD can
be applied successfully to neonates within the first hours of life.
Transfusion. 2011 Feb 25. doi: 10.1111/j.1537-2995.2011.03066.x. [Epub ahead of
print]
A comparison of fibrinogen measurement methods with fibrin clot elasticity
assessed by thromboelastometry, before and after administration of fibrinogen
concentrate in cardiac surgery patients.
Solomon C, Cadamuro J, Ziegler B, Schöchl H, Varvenne M, Sørensen B, Hochleitner
G, Rahe-Meyer N.
From the Department of Anaesthesiology and Intensive Care and the Institute of
Medical and Chemical Laboratory Diagnostics, Salzburger Landeskliniken SALK,
Salzburg, Austria; the Department of Anaesthesiology and Intensive Care Medicine
and the Department of Haematology, Hannover Medical School, Hannover, Germany;
the Boltzmann Institute of Experimental and Clinical Traumatology, Vienna,
Austria; the Department of Anaesthesiology and Intensive Care, AUVA Trauma
Centre, Salzburg, Austria; the Haemostasis Research Unit, Centre for Haemostasis
and Thrombosis, Guy's and St Thomas NHS Foundation Trust and King's College
London School of Medicine, London, United Kingdom; the Centre for Haemophilia and
Thrombosis, Aarhus University Hospital, Skejby, Denmark; CSL Behring, Vienna,
Austria; and the Department of Anaesthesiology and Intensive Care Medicine,
Franziskus Hospital, Bielefeld, Germany.
BACKGROUND: Fibrinogen concentrate administration can be guided by measuring
fibrinogen concentration or quality of the fibrin-based clot. This study compared
different fibrinogen concentration measurement methods with maximum clot firmness
(MCF) of the fibrin clot, assessed by thromboelastometry (FIBTEM), in 33
cardiovascular surgery patients receiving fibrinogen concentrate for hemostatic
therapy. STUDY DESIGN AND METHODS: Blood samples were collected after
cardiopulmonary bypass (CPB) and after fibrinogen concentrate administration.
FIBTEM MCF was measured using a rotational thromboelastometry device (ROTEM, Tem
International). Fibrinogen concentration was measured using photo-optical
(CA-7000, Siemens Healthcare Diagnostics), mechanical (KC-10 steel ball,
Schnitger and Gross hook, Amelung GmbH), and electromechanical (STA-R,
Diagnostica Stago) coagulometers. Assessments included agreement between
fibrinogen concentration measurements and correlations between fibrinogen
concentration and FIBTEM MCF. RESULTS: After CPB, correlations were significant
(p < 0.001) between FIBTEM MCF and fibrinogen concentration determined by steel
ball (r = 0.71), hook (r = 0.73), STA-R (r = 0.81), and CA-7000 (r = 0.82)
coagulometers. After fibrinogen concentrate administration, agreement between
fibrinogen measurement methods was severely impaired, and correlations with
FIBTEM MCF were 0.39 (steel ball), 0.33 (hook), 0.59 (STA-R), and 0.33 (CA-7000).
CONCLUSION: Agreement between fibrinogen concentration measurement methods
decreased considerably after fibrinogen concentrate administration. All methods
correlated acceptably with FIBTEM MCF at the end of CPB, but not after hemostatic
therapy. Further investigation is needed to explain these findings.
Heart Surg Forum. 2011 Feb 1;14(1):E28-39.
Management of intraoperative fluid balance and blood conservation techniques in
adult cardiac surgery.
Vretzakis G, Kleitsaki A, Aretha D, Karanikolas M.
Cardiac Anaesthesia Unit, University Hospital of Larissa, Greece.
Blood transfusions are associated with adverse physiologic effects and increased
cost, and therefore reduction of blood product use during surgery is a desirable
goal for all patients. Cardiac surgery is a major consumer of donor blood
products, especially when cardiopulmonary bypass (CPB) is used, because
hematocrit drops precipitously during CPB due to blood loss and blood cell
dilution. Advanced age, low preoperative red blood cell volume (preoperative
anemia or small body size), preoperative antiplatelet or antithrombotic drugs,
complex or re-operative procedures or emergency operations, and patient
comorbidities were identified as important transfusion risk indicators in a
report recently published by the Society of Cardiovascular Anesthesiologists.
This report also identified several pre- and intraoperative interventions that
may help reduce blood transfusions, including off-pump procedures, preoperative
autologous blood donation, normovolemic hemodilution, and routine cell saver
use.A multimodal approach to blood conservation, with highrisk patients receiving
all available interventions, may help preserve vital organ perfusion and reduce
blood product utilization. In addition, because positive intravenous fluid
balance is a significant factor affecting hemodilution during cardiac surgery,
especially when CPB is used, strategies aimed at limiting intraoperative fluid
balance positiveness may also lead to reduced blood product utilization.This
review discusses currently available techniques that can be used intraoperatively
in an attempt to avoid or minimize fluid balance positiveness, to preserve the
patient's own red blood cells, and to decrease blood product utilization during
cardiac surgery.
Acta Anaesthesiol Scand. 2011 Feb 22. doi: 10.1111/j.1399-6576.2011.02405.x.
[Epub ahead of print]
Cardiac outcome after sevoflurane versus propofol sedation following coronary
bypass surgery: a pilot study.
Hellström J, Owall A, Bergström J, Sackey PV.
Institution of Molecular Medicine and Surgery, Section of Cardiothoracic Surgery
and Anesthesiology Department of LIME, Section of Medical Statistics Institution
of Physiology and Pharmacology, Section of Anesthesiology and Intensive Care
Medicine, Karolinska Institutet, Stockholm, Sweden.
Background: Studies of volatile anesthetic administration during coronary artery
bypass grafting (CABG) report reduced serum levels of post-operative cardiac
troponin-T (cTnT). Our primary objective was to evaluate whether short-term
sedation with sevoflurane in the intensive care unit (ICU) - after CABG - could
affect the release of cTnT, compared with propofol sedation. Methods: Following
isolated CABG with cardiopulmonary bypass, 100 patients were randomized to either
sevoflurane via the Anesthetic Conserving Device (AnaConDa(®) ) or propofol for
ICU sedation. Study drugs were administered for 2 h during mechanical ventilation
and thereafter until extubation criteria were met. The primary endpoint was cTnT
12 h post-operatively. Crude cTnT data were not normally distributed and
therefore compared with the Mann-Whitney U-test. Because of the skewed
pre-operative and post-operative cTnT data, we performed a post hoc analysis of
the change in cTnT between pre-operative values and 12 h post-operatively.
Results: There was no statistically significant difference between groups in the
primary endpoint cTnT values at 12 h post-operatively, cardiac events or the need
for hemodynamic support. In the post hoc analysis, the cTnT increase from
pre-operative values to 12 h post-operatively was less pronounced in the
sevoflurane group (P=0.008). Conclusion: Post-operative short-term sevoflurane
sedation following CABG, in comparison with propofol, did not affect the cTnT
values at 12 h post-operatively and clinical outcome was equal between groups.
The result from the post hoc analysis, with less cTnT change over time, is
nevertheless hypothesis-generating and warrants a larger study.
Perfusion. 2011 Feb 21. [Epub ahead of print]
Non invasive cerebral oximetry monitoring during cardiopulmonary bypass in
congenital cardiac surgery: a starting point.
Quarti A, Manfrini F, Oggianu A, D'Orfeo F, Genova S, Silvano R, Pozzi M.
Paediatric and Congenital Cardiac Surgery and Cardiology, Azienda Ospedaliera
Ospedali Riuniti, Ancona Via Conca 71, 60128, Ancona, Italy.
INTRODUCTION: Non-invasive cerebral monitoring with the INVOS cerebral oximeter
is an accepted good indicator of cerebral metabolism. In recent years, it has
been used in the monitoring of patients who underwent cardiac surgery. Herein, we
describe the INVOS trend during cardiopulmonary bypass (CPB) in a cohort of
patients operated in our institution for congenital heart disease. Patients and
methods: Between December 2009 and March 2010, 40 patients (mean age 8.4 years;
range 11 days-60 years) underwent cardiac surgical procedures using CPB. Values
of INVOS cerebral parameter, pH, oxygen saturation, and CO(2) level were
collected pre CPB, during cooling, re-warming and weaning, and post CPB. INVOS
parameters were evaluated according to CPB priming, age and preoperative oxygen
saturation. RESULTS: Patients were divided according to CPB priming (haematic vs
clear), age (=1 vs >1 year of age) and oxygen saturation (=92% vs >92%). During
the operations, the trend demonstrated a reduction in INVOS value at the
institution of CPB and a further reduction during the cooling phase in all
groups. This has been correlated to the loss of pulsatile flow. However, the
value recovered during re-warming, weaning and CPB discontinuation. Cyanotic
patients presented a lower cerebral oximetry compared to acyanotic patients
during the whole CPB period. Between age and priming groups, we noticed a
statistical difference in cerebral oximetry, with a lower value in the younger
patients and in the haematic priming group. This might be interrelated because
all patients younger than 1 year old always received haematic CPB priming.
CONCLUSIONS: We demonstrated that cerebral oximetry decreases with the loss of
pulsatile flow regardless of the mean arterial pressure and, furthermore, is not
directly related to the haematocrit value in patients with reduced pulmonary
blood flow.
Crit Care Med. 2011 Feb 17. [Epub ahead of print]
Incidence, risk factors, and outcomes of acute kidney injury after pediatric
cardiac surgery: A prospective multicenter study*
Li S, Krawczeski CD, Zappitelli M, Devarajan P, Thiessen-Philbrook H, Coca SG,
Kim RW, Parikh CR; for the TRIBE-AKI Consortium.
From the Department of Pediatrics (SL), Division of Pediatric Critical Care
Medicine, Department of Medicine (SGC, CRP), Section of Nephrology, and Division
of Pediatric Cardiac Surgery (RWK), Yale Cardiac Surgery, Yale University School
of Medicine, New Haven, CT; The Heart Institute (CDK) and Division of Nephrology
and Hypertension (PD), Cincinnati Children's Hospital Medical Center, University
of Cincinnati College of Medicine, Cincinnati, OH; Department of Pediatrics (MZ),
Division of Nephrology, McGill University Health Centre, Montreal Children's
Hospital, Montreal, Canada; and Department of Medicine (HT-P), Division of
Nephrology, University of Western Ontario, London, Ontario, Canada.
OBJECTIVE:: To determine the incidence, severity, and risk factors of acute
kidney injury in children undergoing cardiac surgery for congenital heart
defects. DESIGN:: Prospective observational multicenter cohort study. SETTING::
Three pediatric intensive care units at academic centers. PATIENTS:: Three
hundred eleven children between the ages of 1 month and 18 yrs undergoing
pediatric cardiac surgery. INTERVENTIONS:: None. MEASUREMENTS AND MAIN RESULTS::
Acute kidney injury was defined as a =50% increase in serum creatinine from the
preoperative value. Secondary outcomes were length of mechanical ventilation,
length of intensive care unit and hospital stays, acute dialysis, and in-hospital
mortality. The cohort had an average age of 3.8 yrs and was 45% women and mostly
white (82%). One-third had prior cardiothoracic surgery, 91% of the surgeries
were elective, and almost all patients required cardiopulmonary bypass. Acute
kidney injury occurred in 42% (130 patients) within 3 days after surgery.
Children =2 yrs old and <13 yrs old had a 72% lower likelihood of acute kidney
injury (adjusted odds ratio: 0.28, 95% confidence interval: 0.16, 0.48), and
patients 13 yrs and older had 70% lower likelihood of acute kidney injury
(adjusted odds ratio: 0.30, 95% confidence interval: 0.10, 0.88) compared to
patients <2 yrs old. Longer cardiopulmonary bypass time was linearly and
independently associated with acute kidney injury. The development of acute
kidney injury was independently associated with prolonged ventilation and with
increased length of hospital stay. CONCLUSIONS:: Acute kidney injury is common
after pediatric cardiac surgery and is associated with prolonged mechanical
ventilation and increased hospital stay. Cardiopulmonary bypass time and age were
independently associated with acute kidney injury risk. Cardiopulmonary bypass
time may be a marker for case complexity.
Crit Care Med. 2011 Feb 10. [Epub ahead of print]
Efficacy of portable and percutaneous cardiopulmonary bypass rewarming versus
that of conventional internal rewarming for patients with accidental deep
hypothermia.
Morita S, Inokuchi S, Yamagiwa T, Iizuka S, Yamamoto R, Aoki H, Okada M.
From the Department of Emergency and Critical Care Medicine, Tokai University
School of Medicine, Shimokasuya Isehara-City, Kanagawa, Japan.
OBJECTIVE:: Since 2001, at our institution, a portable and percutaneous
cardiopulmonary bypass system has been used for rewarming of patients with
accidental deep hypothermia. Before 2001, a conventional internal rewarming
technique was used. The aim of this research is to examine the efficacy of
portable and percutaneous cardiopulmonary bypass for rewarming of patients with
accidental severe hypothermia and compare it with that of conventional rewarming
methods. DESIGN:: Historical study. SETTING:: •••. PATIENTS:: From April 1992 to
March 2009, 70 patients with accidental deep hypothermia (core temperature <28°C)
were transferred to our hospital. Two patients presented with intracranial
hemorrhage on initial head computed tomography scans. These two patients were
excluded because each required an emergency operation. Therefore, 68 patients
were included in this study. We compared patients' clinical characteristics and
outcomes. The parameters included the following: sex, age, vital signs on arrival
to our hospital (Glasgow coma Scale scores, systolic blood pressure, heart rate,
respiratory rate, core temperature), electrocardiogram on arrival to our
hospital, rewarming speed, time of rewarming until 34°C was reached, ventricular
fibrillation occurrence rate during rewarming, cause of cold environmental
exposure, Glasgow Outcome Scale scores, and mortality. In addition, we divided
the conventional and portable and percutaneous cardiopulmonary bypass rewarming
groups into two categories depending on whether cardiopulmonary arrest occurred
on arrival to our hospital. We also compared the survival rate and average
Glasgow Outcome Scale scores for each group. INTERVENTIONS:: None. MEASUREMENTS
AND MAIN RESULTS:: Patients' clinical backgrounds did not differ significantly
between the conventional and portable and percutaneous cardiopulmonary bypass
rewarming groups. Glasgow Outcome Scale scores and survival rates of the portable
and percutaneous cardiopulmonary bypass rewarming group patients, irrespective of
whether cardiopulmonary arrest was experienced on arrival to our hospital, were
significantly higher than those of the conventional rewarming group.
CONCLUSIONS:: Portable and percutaneous cardiopulmonary bypass rewarming can
improve the mortality rates and Glasgow Outcome Scale scores of accidental deep
hypothermia patients.
Interact Cardiovasc Thorac Surg. 2011 Feb 5. [Epub ahead of print]
Should double lung transplant be performed with or without cardiopulmonary
bypass?
Nagendran M, Maruthappu M, Sugand K.
Green Templeton College, University of Oxford, Woodstock Road, Oxford, UK.
A best evidence topic in cardiothoracic surgery was written according to a
structured protocol. The question addressed was whether double lung
transplantation should be performed with or without cardiopulmonary bypass (CPB)
in order to improve postoperative clinical outcomes. Altogether 386 papers were
found using the reported search, of which 14 represented the best evidence to
answer the clinical question. The authors, journal, date and country of
publication, patient group studied, study type, relevant outcomes and results of
these papers are tabulated. All 14 papers assessed a range of postoperative
outcomes and broadly speaking, six papers found significantly worse outcomes with
CPB use, six found no difference and two found a mixture of both depending on the
specific outcomes assessed. Dalibon et al. [J Cardiothorac Vasc Anesth
2006;20:668-672] found that mortality was significantly worse in the CPB group at
48 h, one month and one year [P=0.001, odds ratio (OR)=246.1; P=0.083, OR=2.6;
P=0.001, OR=5.3, respectively]. Other papers revealed poor outcomes in the CPB
group in a range of measures including diffuse alveolar damage (P=0.009), chest
radiograph infiltrate score (P=0.005), longer intubation time (P=0.002), longer
intensive care unit stay (P=0.05), and greater incidence of pulmonary
reimplantation response (P=0.03). However, Myles et al. [J Cardiothorac Vasc
Anesth 1997;11:177-183] found that only acute postoperative outcomes were
significantly worse in their CPB group (P<0.001); medium- and long-term survival
outcomes were not significantly different (P=0.055). de Boer et al.
[Transplantation 2002;73:1621-1627] even found that there was an improved
one-year survival rate with CPB use (OR=0.25, P=0.038) and that the number of
HLA-DR mismatches influenced this effect. Those papers suggesting no deleterious
effects of CPB generally measured similar postoperative outcomes to those
mentioned above, with one study also assessing incidence of primary graft
failure, which was not significantly different (P=0.37). We conclude that CPB
should continue to be used where clinically indicated for a specific reason (for
example, where there is pulmonary hypertension or a requirement for concomitant
cardiac repair). However, given that the evidence for using CPB for all elective
cases is relatively weak, and the fact that there are strong arguments in the
literature for both methods, either approach would be clinically acceptable.
Keywords: Cardiopulmonary bypass; Lung transplantation; Postoperative outcomes;
Thoracic surgery.
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