TOP TEN SELECTED PAPERS
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March 2011 |
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J Thorac Cardiovasc Surg. 2011 Mar 30. [Epub ahead of print]
Totally thoracoscopic repair of ventricular septal defect: A short-term clinical
observation on safety and feasibility.
Ma ZS, Dong MF, Yin QY, Feng ZY, Wang LX.
Department of Cardiac Surgery, Liaocheng People's Hospital and Liaocheng Clinical
School of Taishan Medical University, Liaocheng, China.
OBJECTIVES: We sought to investigate the feasibility and safety of totally
thoracoscopic repair of a ventricular septal defect. METHODS: Totally
thoracoscopic repair of a perimembranous ventricular septal defect was performed
in 36 patients (16 male patients; age, 5-19 years; average age, 10.2 ± 4.5
years). Patients with a pulmonary arterial systolic pressure of 60 mm Hg or
greater or with supracristal or muscular ventricular septal defects were
excluded. An additional 16 patients undergoing open-chest ventricular septal
defect repair were selected as a control group. Through 3 port incisions in the
right chest, pericardiotomy, bicaval occlusion, atriotomy, and ventricular septal
defect repair were performed by a surgeon by means of thoracoscopy. RESULTS: The
cardiopulmonary bypass and aortic crossclamp times were 66.2 ± 21.3 and 36.4 ±
8.2 minutes, respectively. The length of stay in the intensive care unit was 20.0
± 4.1 hours. There were no mortalities and no major complications.
Transesophageal echocardiographic analysis 5.2 ± 3.6 months after the operation
showed complete closure of the defect without residual shunt. The intensive care
unit (17 ± 2 vs 25 ± 5 hours, P = .01) or postoperative hospital (4.2 ± 1.1 vs
6.7 ± 2.1 days, P = .03) stays in the thoracoscopic group were shorter than in
the control group. The percentage of patients who required postoperative opioid
analgesics in the thoracoscopic group was lower than in the control group (37.5%
vs 87.5%, P = .001). CONCLUSIONS: Totally thoracoscopic repair of a
perimembranous ventricular septal defect is feasible and safe for older children.
This technique is associated with a reduced intensive care and hospital stay in
comparison with conventional ventricular septal defect repair.
J Extra Corpor Technol. 2011 Mar;43(1):P68-71.
Perfusion and aortic surgery: patient directed cardiopulmonary bypass and quality
improvement.
Poullis M.
Liverpool Cardiothoracic Centre, Liverpool Heart and Chest Hospital NHS
Foundation Trust, Thomas Drive, Liverpool, England. mike.poullis@lhch.nhs.uk
Aortic surgery frequently extends the boundaries of perfusion knowledge learned
from non aortic cardiac surgery.This is due to the extremes of temperature,
prolonged bypass times, hypothermic arrest, and selective organ(s) perfusion.
Suboptimal perfusion can potentially affect outcomes even after technically
successful aortic surgery. We present the concepts of patient directed bypass
with regard to blood pressure, flow-during cardiopulmonary bypass (CPB), oxygen
delivery, cooling, and carbon dioxide levels on bypass. Quality of perfusion
during aortic surgery is then addressed in the context of Perfusion Standards of
Reporting Trials (PERFSORT, www.perfsort.net). PERFSORT analyses these variables
during bypass: blood pressure, hematocrit, lactate, glucose, and temperature, all
of which are known to affect outcomes. PERFSORT can be applied to individual
cases or a series, and although primarily designed for research publications, is
equally useful in a purely clinical setting. A new concept from engineering
called Lissajous figures is then discussed to potentially retrospectively assess
the effects of ischemia during aortic surgery. This may help identify why some
patients despite flawless surgery, anesthesia, and perfusion, in the absence of
bleeding, stroke, and obvious causes of organ damage at the time of aortic
surgery develop multi organ dysfunction.
J Extra Corpor Technol. 2011 Mar;43(1):13-8.
Monitoring the conjunctiva for carbon dioxide and oxygen tensions and pH during
cardiopulmonary bypass.
Weiss IK, Isenberg SJ, McArthur DL, Del Signore M, McDonald JS.
Department of Pediatrics, David Geffen School of Medicine at UCLA, Mattel
Children's Hospital UCLA, Los Angeles, California 90095-1752, USA.
iweiss@mednet.ucla.edu
The purpose of this study was to measure, for the first time, multiple
physiologic parameters of perfusion (pH, PCO2, PO2, and temperature) from the
conjunctiva of adult patients during cardiopulmonary bypass while undergoing
cardiothoracic surgery. Ten patients who underwent either intracardiac valve
repair, atrial septal defect repair, or coronary artery bypass graft surgery had
placement of a sensor which directly measured pH, PCO2, PO2, and temperature from
the conjunctiva. Data were stratified into seven phases (0-5 minutes prior to
bypass; 0-5, 6-10, and 11-15 minutes after initiation of bypass; 0-5 minutes
prior to conclusion of bypass; and 0-5 and 6-10 minutes after bypass) and
analyzed using a mixed model analysis.The change in conjunctival pH over the
course of measurement was not statistically significant (p = .56). The PCO2 level
followed a quadratic pattern, decreasing from a mean pre-bypass level of 37.7
mmHg at baseline prior to the initiation of cardiopulmonary bypass to a nadir of
33.2 mmHg, then increasing to a high of 39.4 mmHg at 6-10 minutes post bypass (p
< .01). The PO2 declined from a mean pre-bypass level of 79.5 mmHg to 31.3 mmHg
by 6-10 minutes post bypass and even post-bypass, it never returned to baseline
values (p < .01). Temperature followed a pattern similar to PCO2 by returning to
baseline levels as the patient was re-warmed following bypass (p < .01). There
was no evidence of any eye injury or inflammation following the removal of the
sensor. In the subjects studied, the conjunctival sensor yielded reproducible
measurements during the various phases of cardiopulmonary bypass without ocular
injury. Further study is necessary to determine the role of conjunctival
measurements in critical settings.
Int Urol Nephrol. 2011 Mar 27. [Epub ahead of print]
Renal tumor with tumor thrombus in inferior vena cava and right atrium: the
report of five cases with long-term follow-up.
Radak D, Milojevic P, Babic S, Matic P, Tanaskovic S, Vukotic V, Pejcic T,
Hadzi-Djokic J.
Department of Vascular Surgery, Institute for Cardiovascular disease "Dedinje",
Belgrade, Serbia.
OBJECTIVE: To evaluate early and long-term results of radical surgical removal of
renal cell cancer (RCC) with tumor thrombus (TT) in the inferior vena cava (IVC)
and right atrium (RA). METHODS: The study included five patients with RCC with TT
in IVC and right atrium, operated from January 2004 to September 2009 in the
Institute for Cardiovascular disease "Dedinje", Belgrade, Serbia. All patients
underwent atrial and caval thrombectomy with the use of normothermic
cardiopulmonary bypass (CPB) and the radical nephrectomy, by a joint
cardiovascular and urological team. After the surgery, patients were evaluated
every 3 months for the first year, every 6 months for the next 2 years, and
yearly thereafter. The mean follow-up was 32.6 months (range: 7-67 months).
RESULTS: There were no per-operative embolism and no in-hospital deaths. Two
patients developed tumor recurrence during a mean time of 5 months and died
within 1 year after the surgery. The three remaining patients are alive (mean
follow-up: 48 months) and without the evidence of tumor recurrence or metastases.
No patients received adjuvant therapy. CONCLUSIONS: Patients with RCC and the
extension of TT in IVC and right atrium need a multidisciplinary surgical
strategy. Atrial and caval tumor thrombectomy can be performed safely and
effectively, with a low complication rate, using normothermic CPB. Long-term
results are promising; however, larger prospective multicentre studies are
necessary.
Minerva Anestesiol. 2011 Mar;77(3):268-74.
Stress doses of hydrocortisone reduce systemic inflammatory response in patients
undergoing cardiac surgery without cardiopulmonary bypass.
Kilger E, Heyn J, Beiras-Fernandez A, Luchting B, Weis F.
Department of Anesthesiology, Grosshadern, University Hospital Munich, Munich,
Germany - abeiras@med.uni-muenchen.de.
BACKGROUND: Systemic inflammatory response occurs after cardiac surgery (CS) and
leads to a worse outcome in many cases. Stress doses of hydrocortisone have been
successfully used to reduce SIRS and to improve outcome of patients after CS with
cardiopulmonary bypass grafting (on-pump CABG), but the effect of hydrocortisone
on patients undergoing CS without cardiopulmonary bypass grafting (off-pump CABG)
is unclear. Therefore, we evaluated the effect of stress doses of hydrocortisone
in this group of patients.
METHODS: A total of 305 patients undergoing off-pump CABG were enrolled in a
prospective randomized trial according to the study protocol. The patients either
received stress doses of hydrocortisone or placebo. We measured various
laboratory and clinical variables characterizing the patients' outcomes.
RESULTS: The two study groups did not differ with regard to demographic data.
Patients receiving hydrocortisone had an increased Higgins score and a decreased
ejection fraction. Furthermore, patients from the hydrocortisone group had
significantly lower levels of IL-6 (275 [162/677] pg/mL vs. 450 [320/660] pg/mL,
P=0.001) and a shorter stay in the ICU (1 [1/3] day vs. 2 [2/3] days, P=0.04).
Both groups did not differ in regard to catecholamine support, duration of
mechanical ventilation, incidence of postoperative atrial fibrillation, blood
loss, and mortality rate.
CONCLUSION: We conclude that intravenous stress doses of hydrocortisone lead to a
reduction of systemic inflammation and to a potential improvement in the early
outcome of patients undergoing off-pump CABG.
Thromb Res. 2011 Mar 21. [Epub ahead of print]
Fibrin formation is more impaired than thrombin generation and platelets
immediately following cardiac surgery.
Solomon C, Rahe-Meyer N, Sørensen B.
Department of Anaesthesiology and Intensive Care, Salzburger Landeskliniken SALK,
Salzburg, Austria; Department of Anaesthesiology and Intensive Care Medicine,
Hannover Medical School, Hannover, Germany.
INTRODUCTION: Cardiac surgery performed on cardio-pulmonary bypass (CPB) may be
complicated by coagulopathy and bleeding. This prospective observational study
investigated the CPB-induced changes in thrombin generation, fibrin formation,
and in the platelet component of the whole blood clot elasticity. The effects of
haemostatic therapy with fresh frozen plasma (FFP) and platelet concentrate on
these parameters were also evaluated. MATERIALS AND METHODS: In 90 cardiac
surgery patients, thrombin generation was measured using the calibrated automated
thrombogram, fibrin formation was assessed as the maximum clot elasticity of the
fibrin-based clot in the thromboelastometry FIBTEM test (MCE(FIBTEM)), and the
platelet component was defined as the difference in maximum elasticity between
the whole blood clot obtained through extrinsic activation and the fibrin-based
clot (MCE(EXTEM)-MCE(FIBTEM)). Blood samples were collected before surgery,
immediately after CPB, and after administration of FFP or FFP and platelet
concentrate. RESULTS: Following CPB, the endogenous thrombin potential decreased
to 93%, from median 1485 (interquartile range 1207, 1777) to 1382 (1190, 1533)
nM*min (P>0.05), MCE(FIBTEM) decreased to 62%, from 21 (19, 29) to 14 (12, 19)
(P<0.001), and the platelet component to 73%, from 139 (119, 174) to 101 (87,
121) (P<0.001). Administration of 11 (10, 13) ml per kg of bodyweight (ml/kgbw)
FFP (40 patients), or of 13 (10, 18) ml/kgbw FFP and 7 (5, 9) ml/kgbw platelet
concentrate (18 patients) brought no statistically significant changes in these
parameters. CONCLUSIONS: Fibrin formation is more impaired than thrombin
generation and the platelet component of the whole blood clot immediately after
cardiopulmonary bypass.
J Thorac Cardiovasc Surg. 2011 Mar 17. [Epub ahead of print]
The influence of bypass temperature on the systemic inflammatory response and
organ injury after pediatric open surgery: A randomized trial.
Stocker CF, Shekerdemian LS, Horton SB, Lee KJ, Eyres R, D'Udekem Y, Brizard CP.
The Australia New Zealand Children's Heart Research Center, Melbourne, Australia;
Department of Pediatric Intensive Care, The Royal Children's Hospital, Melbourne,
Australia.
OBJECTIVE: Systemic cooling for cardiopulmonary bypass is widely used to
attenuate the systemic inflammatory response syndrome and organ injury in
children after open surgery. We compared the effects of moderate (24°C) and mild
(34°C) hypothermia during bypass on markers of the systemic inflammatory response
syndrome and organ injury, and on clinical outcome after corrective surgery for
congenital heart disease. METHODS: Sixty-six children (mean age, 6.8 ± 5.7
months; mean weight, 6.2 ± 2.3 kg) were randomized to 24°C or 34°C bypass
temperature during cardiac surgery. Perfusion strategies were otherwise strictly
identical. Clinical data and blood samples were collected before bypass, 5
minutes after aortic crossclamp release, and 4, 24, and 48 hours after bypass.
Patients were followed up until discharge from the hospital. RESULTS: In the 54
children with outcome data, bypass temperature did not influence the duration of
mechanical ventilation between the 24°C group and the 34°C group (median
[interquartile range] 22 [13-40] hours vs 14 [8-40] hours, P = .14), intensive
care unit stay (43 [24-49] hours vs 29 [23-47] hours, P = .79), blood loss (29
[20-38] mL/kg vs 23 [13-38] mL/kg, P = .36), or incidence of postoperative
infection (9% vs 11%, P = 1.0). There was no evidence of an influence of bypass
temperature on the markers of acute inflammation, innate immune response, organ
injury, coagulation, or hemodynamics. CONCLUSIONS: There is no evidence that the
systemic inflammatory response syndrome and organ injury after pediatric open
surgery are influenced by bypass temperature. The routine use of hypothermic
bypass may not be warranted in the pediatric population.
J Cardiothorac Vasc Anesth. 2011 Mar 16. [Epub ahead of print]
Early Complications and Immediate Postoperative Outcomes of Paravalvular Leaks
After Valve Replacement Surgery.
Wasowicz M, Meineri M, Djaiani G, Mitsakakis N, Hegazi N, Xu W, Katznelson R,
Karski JM.
Department of Anesthesia and Pain Management, Toronto General Hospital/University
Health Network, Toronto, Ontario, Canada; Department of Anesthesia, University of
Toronto, Toronto, Ontario, Canada.
OBJECTIVES: To evaluate the incidence of perivalvular leaks (PVLs) after valve
replacement and assess its impact on immediate postoperative outcomes. DESIGN: A
retrospective review. SETTINGS: A tertiary care university hospital.
PARTICIPANTS: Four hundred forty-two consecutive patients undergoing aortic (AVR)
and/or mitral (MVR) valve replacement. MEASUREMENTS AND MAIN RESULTS: All
patients had comprehensive intraoperative transesophageal echocardiography.
Follow-up transthoracic echocardiography was performed at 5 to 7 days and 1 year
after surgery. PVLs were classified as trace, mild, moderate, and severe.
Perioperative variables including demographic data, surgical characteristics
including the degree of valve calcification, and postoperative outcomes were
compared between patients with and without PVLs. Multivariate logistic regression
analysis was used to identify the variables predictive of PVLs. PVLs were
identified in a total of 53 (12%) patients, 29 (13%) after MVR and 24 (11%) after
AVR. At the 1-year transthoracic echocardiographic follow-up, 2 (7%) of 27
patients had residual PVLs after MVR and none after AVR. The duration of
cardiopulmonary bypass (CPB) was predictive of PVLs. The presence of PVLs was
associated with postoperative sepsis. CONCLUSIONS: The incidence of PVLs was
similar after MVR and AVR. Bioprosthetic MVR and mechanical AVR were associated
with higher-incidence PVLs when compared with controls. Mitral annular
calcification was a potential risk factor for PVLs with bioprosthetic valves. The
prolonged CPB time was predictive of PVLs. After adjusting for covariates, the
overall presence of PVLs was associated with an increased risk of sepsis after
surgery.
BMC Anesthesiol. 2011 Mar 14;11:7.
Postoperative cognitive deficit after cardiopulmonary bypass with preserved
cerebral oxygenation: a prospective observational pilot study.
Fudickar A, Peters S, Stapelfeldt C, Serocki G, Leiendecker J, Meybohm P,
Steinfath M, Bein B.
Department of Anesthesiology and Intensive Care Medicine, University Hospital
Schleswig-Holstein, Campus Kiel, Schwanenweg 21, D-24105 Kiel, Germany.
fudickar@anaesthesie.uni-kiel.de.
ABSTRACT:BACKGROUND: Neurologic deficits after cardiac surgery are common
complications. Aim of this prospective observational pilot study was to
investigate the incidence of postoperative cognitive deficit (POCD) after cardiac
surgery, provided that relevant decrease of cerebral oxygen saturation (cSO2) is
avoided during cardiopulmonary bypass.
METHODS: cSO2 was measured by near infrared spectroscopy in 35 patients during
cardiopulmonary bypass. cSO2 was kept above 80% of baseline and above 55% during
anesthesia including cardiopulmonary bypass. POCD was tested by trail making
test, digit symbol substitution test, Ray's auditorial verbal learning test,
digit span test and verbal fluency test the day before and 5 days after surgery.
POCD was defined as a decline in test performance that exceeded - 20% from
baseline in two tests or more. Correlation of POCD with lowest cSO2 and cSO2 -
threshold were determined explorative.
RESULTS: POCD was observed in 43% of patients. Lowest cSO2 during cardiopulmonary
bypass was significantly correlated with POCD (p = 0.015, r2 = 0.44, without
Bonferroni correction). A threshold of 65% for cSO2 was able to predict POCD with
a sensitivity of 86.7% and a specificity of 65.0% (p = 0.03, without Bonferroni
correction).
CONCLUSIONS: Despite a relevant decrease of cerebral oxygen saturation was
avoided in our pilot study during cardiopulmonary bypass, incidence of POCD was
comparable to that reported in patients without monitoring. A higher threshold
for cSO2 may be needed to reduce the incidence of POCD.
Eur J Cardiothorac Surg. 2011 Mar 10. [Epub ahead of print]
Resuscitation after prolonged cardiac arrest: effects of cardiopulmonary bypass
and sodium-hydrogen exchange inhibition on myocardial and neurological recovery.
Liakopoulos OJ, Hristov N, Buckberg GD, Triana J, Trummer G, Allen BS.
Department of Surgery, Division of Cardiothoracic Surgery, David Geffen School of
Medicine at University of California Los Angeles, Los Angeles, CA, USA;
Department of Cardiothoracic Surgery, Heart Center, University of Cologne,
Cologne, Germany.
Objective: To determine if cardiopulmonary bypass (CPB), together with inhibition
of the sodium-hydrogen exchanger (NHE), limits myocardial and neurological injury
and improves recovery after prolonged (unwitnessed) cardiac arrest (CA), as NHE
inhibition improved recovery after deep hypothermic circulatory arrest. Methods:
Twenty-seven pigs (31-39kg) underwent 15min of prolonged (no-flow) CA followed by
10min of cardiopulmonary resuscitation-advanced life support (CPR-ALS). Subjects
with restoration of spontaneous circulation (ROSC) during CPR-ALS received either
no drug (n=6) or an inhibitor of the NHE (HOE-642; n=5). In the 16 unsuccessfully
resuscitated animals, peripheral normothermic CPB was instituted, and either no
drug (n=9) or similar HOE-642 (n=7) therapy started. Hemodynamic data, a
species-specific neurological deficit score (0=normal to 500=brain death), and
mortality were recorded at 24h, and biochemical variables of organ injury
measured. Results: CPR-ALS restored ROSC in 41% (11/27) of animals, but was
unsuccessful in 59% (16/27) that required CPB. Without CPB, HOE-642 increased
cardiac index and decreased vascular resistance; with CPB, HOE-642 caused higher
pump flows (3.4±0.6lmin(-1)m(-2) vs 2.5±0.7lmin(-1)m(-2); p<0.001) and higher
post-arrest cardiac index; but animals required more vasopressors (p=0.019) from
drug-induced vasodilation. No differences between biochemical markers of
oxidative and organ injury and overall 24-h mortality (20%) were found between
groups. Neurological score was improved at 24h compared with 4h only after
HOE-642 treatment with (150±34 vs 220±43; p=0.003) or without CPB (162±39 vs
238±48; p=0.001), but failed to reach statistical difference with respect to the
untreated group. Conclusions: CPB is an effective resuscitative tool to treat
prolonged CA but there is limited improvement of neurological function. NHE
inhibition augments cardiac and neurological function, but its effect was less
pronounced than in other studies.
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