TOP TEN SELECTED PAPERS
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June 2011 |
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Korean Circ J. 2011 Jun;41(6):299-303. Epub 2011 Jun 30.
Percutaneous cardiopulmonary support-supported percutaneous coronary
intervention: a single center experience.
Cho SS, Oh CM, Jang JY, Yu HT, Bang WD, Kim JS, Ko YG, Choi D, Hong MK, Shim WH,
Cho SY, Jang Y.
Division of Cardiology, Yonsei Cardiovascular Center, Yonsei University College
of Medicine, Seoul, Korea.
BACKGROUND AND OBJECTIVES: Percutaneous cardiopulmonary support (PCPS) has proven
to be a valuable technique in high-risk coronary patients undergoing percutaneous
coronary intervention (PCI). However, there have been few studies on PCI
associated with PCPS in Korea. We summarized our experience with PCPS-supported
PCI.
SUBJECTS AND METHODS: We retrospectively reviewed 19 patients with PCPS-supported
PCI between August 2005 and June 2009. PCPS was used as an elective procedure for
10 patients with at least two of the following conditions: left-ventricular
ejection fraction <35%, target vessel(s) supplying more than 50% of the viable
myocardium, high risk surgical patients, and patients who refused coronary bypass
surgery. In the remaining 9 patients PCPS was used as an emergency procedure, to
stabilize and even resuscitate patients with acute myocardial infarction and
cardiogenic shock, in order to attempt urgent PCI.
RESULTS: Among the 19 patients who were treated with PCPS-supported PCI, 11
(57.9%) survived and 8 (42.1%) patients did not. ST elevation myocardial
infarction with cardiogenic shock was more prevalent in the non-survivors than in
the survivors (75% vs. 27.3%, p=0.04). The elective PCPS-supported PCI was
practiced more frequently in the survivors than in the non-survivors (72.7% vs.
25%, p=0.04). In the analysis of the event-free survival curve between elective
and emergency procedures, there was a significant difference in the survival rate
(p=0.025). Among the survivors there were more patients with multi-vessel
disease, but a lower Thrombolysis in Myocardial Infarction grade in the culprit
lesions was detected in the non-survivors, before PCI. Although we studied
high-risk patients, there was no procedure-related mortality.
CONCLUSION: Our experience suggests that PCPS may be helpful in high risk
patients treated with PCI, especially in elective cases. More aggressive and
larger scale studies of PCPS should follow.
Acta Cardiol. 2011 Jun;66(3):323-31.
Role of insulin receptors in myocardial ischaemia-reperfusion injury during
cardiopulmonary bypass.
Liang GY, Wu HS, Li J, Ca QY, Gao ZY.
Affiliated Hospital of Zunyi Medical College, Department of Thoracic and
Cardiovascular Surgery, Zunyi, Guizhou, China.
BACKGROUND: Ischaemia-reperfusion injury after cardiac bypass causes cardiac
dysfunction and tissue damage. Insulin resistance during reperfusion contributes
to the dysfunction, but the role of changes in myocardial insulin receptors
during this period has not been determined yet.
METHODS: Twelve mongrel dogs underwent cardiac bypass, 6 for 30 min and 6 for 120
min. Blood samples were taken from the coronary artery and coronary sinus and
tissue samples from the apex of the left ventricle before bypass and 15, 45, and
75 min after termination of bypass surgery and initiation of reperfusion. Plasma
glucose and insulin, the Insulin Resistance Index, myocardial glycogen, insulin
receptor alpha and beta subunits, and total insulin mRNA were measured in these
samples.
RESULTS: Plasma glucose and insulin and the insulin resistance index all
increased significantly during the reperfusion period. A significant decrease in
myocardial glycogen occurred at the same time. The alpha subunits of the insulin
receptor were seen on the myocyte surface and the beta subunits mostly in the
cytoplasm.The expression of both subunits and total insulin mRNA decreased in a
similar manner after termination of bypass surgery. All parameters gradually
returned toward pre-bypass values as the post-bypass period progressed. And at
all post-bypass time points, the 120-min bypass group showed a significantly
greater effect from ischaemia than the 30-min bypass group.
CONCLUSION: A decrease in insulin receptor expression is a cause of post-bypass
insulin resistance, and this decrease is initiated at the mRNA level. Increased
insulin resistance leads to excessive reliance on myocardial glycogen as an
energy source and a deficit in energy substrates that contributes to cardiac
dysfunction.
Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2011 Jun;36(6):576-80.
[Evaluation of minimally invasive peratrial device closure of secundum atrial
septal defects in children].
[Article in Chinese]
Yin N, Zhao T, Yang Y, Xu X, Wang X, Wu Q, Gao L, Chen J.
Department of Cardiothoracic Surgery, Second Xiangya Hospital, Central South
University, Changsha 410011, China.
OBJECTIVE: To introduce peratrial device closure of secundum atrial septal
defects (ASD) under the guidance of transesophageal echocardiography (TEE)
without cardiopulmonary bypass (CPB) in children, and to summarize the clinical
experiences.
METHODS: A total of 115 children with secundum ASD (the occlusion group)
underwent peratrial device closure of atrial septal defects through a small
sternotomy under TEE guidance without cardiopulmonary bypass. Children were
followed up closely for 1-13 months. Another 59 children (the bypass group) had
closed atrial septal defects under cardiopulmonary bypass during the same period.
The differences in the operation duration, convalescence and complication between
the 2 groups were compared.
RESULTS: Except 1 patient was operated under the CPB, the rest 114 patients in
the occlusion group were successfully closed by the occluders. The duration of
the operation, mechanical ventilation, intensive care and hospitalization, and
the rate of blood-transfusion in the occlusion group were significantly lower
than those in the bypass group (P<0.01), with no difference in complications in
the 2 groups (P>0.05).
CONCLUSION: Minimally invasive peratrial device closure of ASD without CPB is a
relatively simple, safe and effective operation under the guidance of TEE for
children. The short and mid-term clinical outcomes are promising. Long-term
follow-up is indispensable.
Perfusion. 2011 Jun 30. [Epub ahead of print]
Active or passive bio-coating: does it matters in extra-corporeal circulation?
Jacobs S, De Somer F, Vandenplas G, Van Belleghem Y, Taeymans Y, Van Nooten G.
Department of Anaesthesia, University Hospital Gent, Gent, Belgium.
BACKGROUND: Two types of surface coating for cardiopulmonary bypass (CPB) are
used: bioactive (heparin, nitric oxide) and biopassive (albumin,
polyethyleneoxide (PEO), phosphorylcholine). When haemocompatible coatings are
combined with the separation of pleuro-pericardial aspiration, attenuation of
both the coagulation and complement cascades, as well as better platelet
preservation, has been demonstrated. This study wants to investigate if the
combination of a bioactive with a biopassive coating (unfractionated heparin
embedded in a phosphorylcholine matrix) combines the beneficial effects of both
approaches. Materials and methods: Thirty patients undergoing elective CABG were
prospectively randomized into two groups of 15 patients. The sole exclusion
criterion was an ejection fraction of less than 40%. In the control group (PC),
the whole CPB circuit was coated with phosphorylcholine (PC). In the study group
(XPC), unfractionated heparin was embedded in the PC matrix of the oxygenator and
arterial line filter. RESULTS: No differences were found for haemolytic index,
thrombin-anti-thrombin complex (TAT), IL-6, IL-10 and blood loss. PF4 plasma
concentration increased from 27.6±22.0 IU/mL to 165.7±43.9 IU/mL (p<0.001) at 15
minutes of CPB in the PC and from 16.0±9.7 IU/mL to 150.9 ± 61.3 IU/mL (p<0.001)
in the XPC group. Terminal complement complex (TCC) increased over time in both
groups until the end of CPB (Figure 2A). Within each group, TCC generation was
statistically significantly higher after the release of the aortic cross-clamp
(p<0.001) and at the end of CPB (p<0.001). Total TCC generation was statistically
significantly higher in the XPC group compared to the PC group (p=0.026). The
difference was statistically significant after the release of the aortic
cross-clamp (p=0.005) and at the end of CPB (p=0.001). CONCLUSIONS: Based on our
results, there is no additional benefit in combining phosphorylcholine with
unfractionated heparin in elective patients undergoing coronary artery bypass
grafting (CABG). Massive haemodilution leads to enhanced complement activation.
Crit Care. 2011 Jun 29;15(3):R160. [Epub ahead of print]
High-dose fenoldopam reduces postoperative neutrophil gelatinase-associated
lipocaline and cystatin C levels in pediatric cardiac surgery.
Ricci Z, Luciano R, Favia I, Garisto C, Muraca M, Morelli S, Di Chiara L, Cogo P,
Picardo S.
Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric
Cardiology and Cardiac Surgery, Bambino Gesł Children's Hospital, Piazza S,
Onofrio 4, 00165, Rome, Italy. z.ricci@libero.it.
ABSTRACT: INTRODUCTION: The aim of the study was to evaluate the effects of
high-dose fenoldopam, a selective dopamine-1 receptor, on renal function and
organ perfusion during cardiopulmonary bypass (CPB) in infants with congenital
heart disease (CHD). METHODS: A prospective single-center randomized double-blind
controlled trial was conducted in a pediatric cardiac surgery department. We
randomized infants younger than 1 year with CHD and biventricular anatomy (with
exclusion of isolated ventricular and atrial septal defect) to receive blindly a
continuous infusion of fenoldopam at 1 µg/kg/min or placebo during CPB.
Perioperative urinary and plasma levels of neutrophil gelatinase-associated
lipocaline (NGAL), cystatin C (CysC), and creatinine were measured to assess
renal injury after CPB. RESULTS: We enrolled 80 patients: 40 received fenoldopam
(group F) during CPB, and 40 received placebo (group P). A significant increase
of urinary NGAL and CysC levels from baseline to intensive care unit (ICU)
admission followed by restoration of normal values after 12 hours was observed in
both groups. However, urinary NGAL and CysC values were significantly reduced at
the end of surgery and 12 hours after ICU admission (uNGAL only) in group F
compared with group P (P = 0.025 and 0.039, respectively). Plasma NGAL and CysC
tended to increase from baseline to ICU admission in both groups, but they were
not significantly different between the two groups. No differences were observed
on urinary and plasma creatinine levels and on urine output between the two
groups. Acute kidney injury (AKI) incidence in the postoperative period, as
indicated by pRIFLE classification (pediatric score indicating Risk, Injury,
Failure, Loss of function, and End-stage kidney disease level of renal damage)
was 50% in group F and 72% in group P (P = 0.08; odds ratio (OR), 0.38; 95%
confidence interval (CI), 0.14 to 1.02). A significant reduction in diuretics
(furosemide) and vasodilators (phentolamine) administration was observed in group
F (P = 0.0085; OR, 0.22; 95% CI, 0.07 to 0.7). CONCLUSIONS: The treatment with
high-dose fenoldopam during CPB in pediatric patients undergoing cardiac surgery
for CHD with biventricular anatomy significantly decreased urinary levels of NGAL
and CysC and reduced the use of diuretics and vasodilators during CPB. TRIAL
REGISTRATION: Clinical Trial.Gov NCT00982527.
J Vasc Surg. 2011 Jun 23. [Epub ahead of print]
Short-term results of a randomized trial examining timing of carotid
endarterectomy in patients with severe asymptomatic unilateral carotid stenosis
undergoing coronary artery bypass grafting.
Illuminati G, Ricco JB, Caliņ F, Pacilč MA, Miraldi F, Frati G, Macrina F,
Toscano M.
"Francesco Durante" Department of Surgery, University of Rome "La Sapienza,"
Rome, Italy.
OBJECTIVE: This study evaluated the timing of carotid endarterectomy (CEA) in the
prevention of stroke in patients with asymptomatic carotid stenosis >70%
receiving a coronary artery bypass graft (CABG). METHODS: From January 2004 to
December 2009, 185 patients with unilateral asymptomatic carotid artery stenosis
>70%, candidates for CABG, were randomized into two groups. In group A, 94
patients received a CABG with previous or simultaneous CEA. In group B, 91
patients underwent CABG, followed by CEA. All patients underwent preoperative
helical computed tomography scans, excluding significant atheroma of the
ascending aorta or aortic arch. Baseline characteristics of the patients, type of
coronary artery lesion, and preoperative myocardial function were comparable in
the two groups. In group A, all patients underwent CEA under general anesthesia
with the systematic use of a carotid shunt, and 79 patients had a combined
procedure and 15 underwent CEA a few days before CABG. In group B, all patients
underwent CEA, 1 to 3 months after CABG, also under general anesthesia and with
systematic carotid shunting. RESULTS: Two patients (one in each group) died of
cardiac failure in the postoperative period. Operative mortality was 1.0% in
group A and 1.1% in group B (P = .98). No strokes occurred in group A vs seven
ipsilateral ischemic strokes in group B, including three immediate postoperative
strokes and four late strokes, at 39, 50, 58, and 66 days, after CABG. These late
strokes occurred in patients for whom CEA was further delayed due to an
incomplete sternal wound healing or because of completion of a cardiac
rehabilitation program. The 90-day stroke and death rate was 1.0% (one of 94) in
group A and 8.8% (eight of 91) in group B (odds ratio [OR], 0.11; 95% confidence
interval [CI], 0.01-0.91; P = .02). Logistic regression analysis showed that only
delayed CEA (OR, 14.2; 95% CI, 1.32-152.0; P = .03) and duration of
cardiopulmonary bypass (OR, 1.06; 95% CI, 1.02-1.11; P = .004) reliably predicted
stroke or death at 90 days. CONCLUSIONS: This study suggests that previous or
simultaneous CEA in patients with unilateral severe asymptomatic carotid stenosis
undergoing CABG could prevent stroke better than delayed CEA, without increasing
the overall surgical risk.
BMC Med Inform Decis Mak. 2011 Jun 21;11:44.
A simple clinical model for planning transfusion quantities in heart surgery.
Simeone F, Franchi F, Cevenini G, Marullo A, Fossombroni V, Scolletta S, Biagioli
B, Giomarelli P, Barbini P.
Department of Surgery and Bioengineering, Universitą di Siena, Siena, Italy.
paolo.barbini@unisi.it.
ABSTRACT:BACKGROUND: Patients undergoing heart surgery continue to be the largest
demand on blood transfusions. The need for transfusion is based on the risk of
complications due to poor cell oxygenation, however large transfusions are
associated with increased morbidity and risk of mortality in heart surgery
patients. The aim of this study was to identify preoperative and intraoperative
risk factors for transfusion and create a reliable model for planning transfusion
quantities in heart surgery procedures.
METHODS: We performed an observational study on 3315 consecutive patients who
underwent cardiac surgery between January 2000 and December 2007. To estimate the
number of packs of red blood cells (PRBC) transfused during heart surgery, we
developed a multivariate regression model with discrete coefficients by selecting
dummy variables as regressors in a stepwise manner. Model performance was
assessed statistically by splitting cases into training and testing sets of the
same size, and clinically by investigating the clinical course details of about
one quarter of the patients in whom the difference between model estimates and
actual number of PRBC transfused was higher than the root mean squared error.
RESULTS: Ten preoperative and intraoperative dichotomous variables were entered
in the model. Approximating the regression coefficients to the nearest half unit,
each dummy regressor equal to one gave a number of half PRBC. The model assigned
4 units for kidney failure requiring preoperative dialysis, 2.5 units for
cardiogenic shock, 2 units for minimum hematocrit at cardiopulmonary bypass less
than or equal to 20%, 1.5 units for emergency operation, 1 unit for preoperative
hematocrit less than or equal to 40%, cardiopulmonary bypass time greater than
130 minutes and type of surgery different from isolated artery bypass grafting,
and 0.5 units for urgent operation, age over 70 years and systemic arterial
hypertension.
CONCLUSIONS: The regression model proved reliable for quantitative planning of
number of PRBC in patients undergoing heart surgery. Besides enabling more
rational resource allocation of costly blood-conservation strategies and blood
bank resources, the results indicated a strong association between some essential
postoperative variables and differences between the model estimate and the actual
number of packs transfused.
Eur J Cardiothorac Surg. 2011 Jun 16. [Epub ahead of print]
Intra-operative conversion is a cause of masked mortality in off-pump coronary
artery bypass: a meta-analysis.
Mukherjee D, Ashrafian H, Kourliouros A, Ahmed K, Darzi A, Athanasiou T.
Department of Surgery and Cancer, Imperial College London and Department of
Cardiothoracic Surgery, Imperial College Healthcare NHS Trust, 10th Floor, Queen
Elizabeth The Queen Mother (QEQM) Building, St. Mary's Hospital Campus, Praed
Street, London W2 1NY, UK.
Coronary artery bypass surgery can offer excellent results when performed with
cardiopulmonary bypass (on pump) or without cardiopulmonary bypass (off pump).
The debate as to which technique is superior remains unanswered. Intra-operative
conversion from off- to on-pump coronary surgery is a relatively unexplored
phenomenon, which cannot be assessed within randomised controlled trial design.
We aimed to assess the effect of off-pump conversion on patient mortality.
Medline, Embase, Cochrane and Google Scholar databases were systematically
reviewed for studies published between 1980 and 2010 that compared the incidence
of mortality between converted and non-converted off-pump patients. Publication
bias and heterogeneity were assessed and data were extracted independently by
multiple observers. We undertook a meta-analysis of these studies using random
effects modelling. A total of 17 studies fulfilled our inclusion criteria,
containing data for 16,644 off-pump coronary artery bypass operations spanning a
decade (1998-2008), involving 915 cases of conversion. Overall, conversion
increased mortality by an odds ratio of 6.18 (95% confidence interval 4.65-8.20),
whereas emergency conversion further raised the odds ratio of mortality to 6.99
(95% confidence interval 5.18-9.45). The conversion from off- to on-pump cardiac
surgery may significantly increase the chance of an adverse outcome, whereas
emergency conversion confers a significant rise in mortality. The risk of
conversion should be discussed when obtaining the patient's informed consent and
its prevention warrants serious consideration by cardiac surgeons and cardiac
surgical training programmes.
J Anesth. 2011 Jun 17. [Epub ahead of print]
Association between cerebrovascular carbon dioxide reactivity and postoperative
short-term and long-term cognitive dysfunction in patients with diabetes
mellitus.
Kadoi Y, Kawauchi C, Kuroda M, Takahashi K, Saito S, Fujita N, Mizutani A.
Department of Anesthesiology, Graduate School of Medicine and Saitama Prefectural
Cardiovascular Center, Gunma University, 3-39-22 Showa-Machi, Maebashi, Gunma,
371-8511, Japan, kadoi@med.gunma-u.ac.jp.
PURPOSE: Our intent was to identify whether cerebrovascular CO(2) reactivity in
diabetic patients is a risk factor for postoperative cognitive dysfunction after
coronary artery bypass graft (CABG) surgery. METHODS: One hundred twenty-four
diabetic patients undergoing elective CABG were studied and analyzed. Diabetic
patients were divided into three groups: normal CO(2) reactivity group (above
5%/mmHg), medium CO(2) reactivity group (between 5 and 3%/mmHg), or impaired
CO(2) reactivity group (below 3%/mmHg). After the induction of anesthesia and
before the start of surgery, cerebrovascular CO(2) reactivity was measured for
all patients. Hemodynamic parameters (arterial and jugular venous blood gas
values) were measured during cardiopulmonary bypass. All patients underwent a
battery of neurological and neuropsychological tests the day before surgery,
7 days after surgery, and 6 months after surgery. RESULTS: At 7 days, the rate of
cognitive dysfunction in the impaired CO(2) group was higher than in the other
three groups (normal, 30%; medium, 25%; impaired, 57%; *P < 0.01 compared with
the other groups). In contrast, at 6 months postoperatively, no significant
difference in the rate of cognitive dysfunction was found among the three groups.
Age, hypertension, CO(2) reactivity, the duration for which jugular venous oxygen
saturation (SjvO(2)) was less than 50%, ascending aorta atherosclerosis, diabetic
retinopathy, and insulin therapy were independent predictors of short-term
cognitive dysfunction in diabetic patients, and HbA1c, diabetic retinopathy, and
insulin therapy were independent predictors of long-term cognitive dysfunction in
diabetic patients. CONCLUSIONS: We found that impaired cerebrovascular CO(2)
reactivity was associated with postoperative short-term cognitive dysfunction in
diabetic patients.
Eur J Cardiothorac Surg. 2011 Jun 9. [Epub ahead of print]
Evaluation of platelet count after isolated biological aortic valve replacement
with Freedom Solo bioprosthesis.
Miceli A, Gilmanov D, Murzi M, Parri MS, Cerillo AG, Bevilacqua S, Farneti PA,
Glauber M.
Department of Cardiothoracic Surgery, Fondazione G. Monasterio CNR-Regione
Toscana, Via Aurelia Sud, 54100 Massa, Italy.
Objective: The risk of thrombocytopenia in patients undergoing aortic valve
replacement (AVR) with the Freedom Solo (FS) bioprosthesis is controversial. The
aim of our study was to evaluate the postoperative evolution of platelet count
and function after AVR in patients undergoing isolated biological AVR with FS.
Methods: Between May 2005 and June 2010, 322 patients underwent isolated
biological AVR. Of these, 116 patients received FS and were compared with 206
patients who received biological valves. Platelet count, mean platelet volume
(MPV), and platelet distribution width (PDW) were evaluated at baseline (T0),
first (T1), second (T2), and fifth (T3) postoperative days, respectively.
Results: Overall in-hospital mortality was 1.5% with no difference between the
two groups. Thirty-seven (11.5%) patients developed thrombocytopenia. FS
implantation was associated with a higher incidence of thrombocytopenia compared
with the control group (24.1% vs 4.4%, p<0.0001). Patients in the FS group showed
a lower platelet count than the control group at T1 (99.4±38×10(3)µl(-1) vs
122.5±41.6×10(3)µl(-1), p<0.001), T2 (79.7±36.3×10(3)µl(-1) vs
122.5±43.3×10(3)µl(-1), p<0.001) and T3 (86.6±57.4×10(3)µl(-1) vs
158.4±55.8×10(3)µl(-1), p<0.001). Moreover, the FS group also had a higher MPV
(11.6±0.9fl vs 11±1fl, p<0.001) and higher PDW (15.1±2.3fl vs 13.9±2.1fl,
p<0.001) at T3. In a multivariable analysis, FS (p<0.0001), body surface area
(p<0.0001), cardiopulmonary bypass time (p=0.003), and lower preoperative
platelet counts (p=0.006) were independent predictors of thrombocytopenia.
Conclusions: The FS valve might increase the risk of thrombocytopenia and
platelet activation, in the absence of adverse clinical events. Prospective
randomized studies on platelet function need to confirm our data.
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