TOP TEN SELECTED PAPERS
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July 2011 |
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J Heart Valve Dis. 2011 Jul;20(4):401-6.
Thrombocytopenia following implantation of the stentless biological sorin freedom
SOLO valve.
Gersak B, Gartner U, Antonic M.
Department of Cardiovascular Surgery, University Medical Center, Ljubljana,
Slovenia.
BACKGROUND AND AIM OF THE STUDY: Stentless biological valves have proven
advantages in hemodynamic performance and left ventricular function compared to
stented biological valves. Following a marked postoperative fall in the platelet
count of patients after implantation of the Freedom SOLO valve, the study aim was
to confirm clinical observations that this effect was more severe in patients
receiving Freedom SOLO valves than in those receiving St. Jude Medical (SJM)
mechanical aortic valves.
METHODS: Preoperative and postoperative platelet counts were compared in two
groups of patients who underwent aortic valve replacement (AVR) without any
concomitant procedures between January and December 2007. Patients received
either a Freedom SOLO valve (n = 28) or a SJM mechanical valve (n = 41). Mean
values of platelet counts were compared using three multiple linear regression
models.
RESULTS: Platelet counts were significantly lower in the Freedom SOLO group than
in the SJM group from the first postoperative day (POD 1) up to POD 6 (p <0.001).
In three patients of the Freedom SOLO group the platelet count fell below
30x10(9)/l, while the lowest level in the SJM group was 75x10(9)/l. Based on
multiple linear regression models, the type of valve implanted had a
statistically significant influence on postoperative platelet counts on POD 1,
POD 3, and POD 5 (p <0.001).
CONCLUSION: Whilst the reason for this phenomenon is unknown, the use of
consistent monitoring should prevent severe falls in platelet count from becoming
dangerous for the patient. Further studies are required to investigate the
phenomenon since, despite a shorter cardiopulmonary bypass time, the fall in
platelet count was more profound in the Freedom SOLO group.
Transplant Proc. 2011 Jul-Aug;43(6):2249-50.
Changes of lactate levels during cardiopulmonary bypass in patients undergoing
cardiac transplantation: possible early marker of morbidity and mortality.
Noval-Padillo JA, Serra-Gomez C, Gomez-Sosa L, Hinojosa-Perez R, Huici-Moreno MJ,
Adsuar A, Herruzo-Avilés A, Lopez-Romero JL, León-Justel A, Guerrero-Montavez JM.
Department of Clinical Laboratory Sciences, Department of Anesthesiology, General
Hospital, Intensive Care and Emergency Department, Heart Unit, Virgen del Rocio
Hospital, Seville, Spain.
OBJECTIVES: High levels of lactate are associated with tissue hypoperfusion
during cardiac surgery resulting in postoperative morbidity and mortality among
patients undergoing cardiopulmonary bypass (CBP). Our goal was to evaluate the
change in lactate levels during CBP for their possible predictive value for
complications after heart transplant surgery.
MATERIALS AND METHODS: From January to December 2010 we studied lactate levels in
16 heart transplant patients. Arterial blood samples were collected before,
during, and after cardiopulmonary bypass on admission to the intensive care unit
(ICU). Lactate levels were measured using the cobas B221 (Roche Diagnostic). The
neurological, lung, and kidney complications were associated with mortality
within 30 days.
RESULTS: One patient displayed lactate levels > 2 mmol/L before bypass while 4
(25%) showed levels > 4 mmol/L during CPB. Lactate values higher than or equal to
4 mmol/L on ICU admission occurred in nine patients (56%). Postoperative
mortality was higher among the group with levels above below 4 mmol/L on ICU
admission (18.7% vs 6.2%). Neurological complications were observed in 22% of
patients with elevated levels as opposed to none of the patients with levels
below 4 mmol/L. Pulmonary complications were noted in 22% of patients with high
lactate values versus 0% among the other group.
CONCLUSION: Hyperlactemia above certain levels occurring during CPB serve as a
biomarker to identify early postoperative morbidity and mortality.
Arq Bras Cardiol. 2011 Jul 29. pii: S0066-782X2011005000079. [Epub ahead of
print]
Trimetazidine on ischemic injury and reperfusion in coronary artery bypass
grafting.
[Article in English, Portuguese]
Martins GF, Siqueira Filho AG, Santos JB, Assunção CR, Bottino F, Carvalho KG,
Valência A.
Instituto Estadual de Cardiologia Aloysio de Castro.
BACKGROUND: The ischemia and reperfusion ischemia is a common physiopathological
mechanisms, which has difficult control during Coronary Artery Bypass Grafting
(CABG) with cardiopulmonary bypass, the critical moment of which happening by the
end of surgery, when there is declamping of aorta and release of hyperoxic
radicals causing the injury. OBJECTIVE: Evaluate, in a randomized double-blind
prospective study, controlled with placebo, the effects of Trimetazidine (Tmz) on
ischemic injury and myocardial reperfusion, identifying the change in plasma
markers of a myocardial aggression (troponin T and CPK-MB), and echocardiographic
changes of ventricular function. METHODS: We studied 60 patients divided in two
groups (placebo and Tmz) with mild ventricular dysfunction at the most,
stratified by echocardiography and receiving medication/placebo at a dose of 20
mg/3x/day, starting from 12 to 15 days after pre-operative period up to 5 to 8
days after post-operative period. Troponin T and Cpk-Mb were measured
preoperatively without medication, 12 to 15 days of medication/placebo taken five
minutes after aortic declamping, and at subsequent 12, 24 and 48 hours. RESULTS:
Both Troponin T and Cpk-Mb reached highly significant values (p = 0.0001) in the
treated group compared to the control group at the four moments analyzed - 5 min,
12h, 24h and 48h. The echocardiographic variables did not show evolutive changes
in each group severally considered and when compared among themselves.
CONCLUSION: Trimetazidine was effective in reducing ischemic injury and
reperfusion, had no effect on left ventricular function, and no side effects were
observed.
Nephrol Dial Transplant. 2011 Jul 29. [Epub ahead of print]
Greater increase in urinary hepcidin predicts protection from acute kidney injury
after cardiopulmonary bypass.
Prowle JR, Ostland V, Calzavacca P, Licari E, Ligabo EV, Echeverri JE, Bagshaw
SM, Haase-Fielitz A, Haase M, Westerman M, Bellomo R.
1Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.
BACKGROUND: Acute kidney injury (AKI) is a common and serious complication of
cardiopulmonary bypass (CPB) surgery. Hepcidin, a peptide hormone that regulates
iron homeostasis, is a potential biomarker of AKI following CPB. METHODS: We
investigated the association between post-operative changes in serum and urinary
hepcidin and AKI in 93 patients undergoing CPB. RESULTS: Twenty-five patients
developed AKI based on the Risk, Injury, Failure, Loss, End-stage kidney disease
(RIFLE) criteria in the first 5 days. Serum hepcidin, urine hepcidin
concentration, the urinary hepcidin:creatinine ratio and fractional excretion of
hepcidin in urine rose significantly after surgery. However, urine hepcidin
concentration and urinary hepcidin:creatinine ratio were significantly lower at
24 h in patients with RIFLE-Risk, Injury or Failure compared to those without AKI
(P = 0.0009 and P < 0.0001, respectively). Receiver operator characteristic
analysis showed that lower 24-h urine hepcidin concentration and urinary
hepcidin:creatinine ratio were sensitive and specific predictors of AKI. The
urinary hepcidin:creatinine ratio had an area under the curve for the diagnosis
of RIFLE = risk at 24 h of 0.77 and of 0.84 for RIFLE = injury. Urinary hepcidin
had similar predictive accuracy. Such predictive ability remained when patients
with early creatinine increases were excluded. CONCLUSIONS: Urinary hepcidin and
hepcidin:creatinine ratio are biomarkers of AKI after CPB, with an inverse
association between its increase at 24 h and risk of AKI in the first five
post-operative days. Measuring hepcidin in the urine on the first day following
surgery may deliver earlier diagnosis and interventions.
Blood Coagul Fibrinolysis. 2011 Jul 27. [Epub ahead of print]
Peroperative effects of fresh frozen plasma and antithrombin III on heparin
sensitivity and coagulation during nitroglycerine infusion in coronary artery
bypass surgery.
Kanbak M, Oc B, Salman MA, Ocal T, Oc M.
aDepartment of Anesthesiology and Reanimation, Faculty of Medicine, Hacettepe
University, Ankara bDepartment of Anesthesiology and Reanimation, Selcuklu
Faculty of Medicine, Selcuk University, Konya cDepartment of Anesthesiology and
Reanimation, Ankara Guven Hospital, Ankara dDepartment of Cardiovascular Surgery,
Selcuklu Faculty of Medicine, Selcuk University, Konya, Turkey.
Nitroglycerin (NTG) reduces the anticoagulant effects of heparin and may lead to
heparin resistance. Fresh frozen plasma (FFP) and antithrombin III (ATIII) may be
used for the treatment of heparin resistance. We aimed to compare the effects of
FFP and ATIII on heparin requirement, coagulation parameters, and bleeding in
patients undergoing coronary artery bypass graft surgery (CABGS) with moderate
dose of intraoperative NTG infusion. Forty-eight patients undergoing CABGS with
NTG infusion were randomly allocated to three groups. Group C served as control,
whereas the patients in group P received FFP and those in group A received ATIII
after anesthesia induction. ATIII activity and coagulation parameters were
measured at five different times intraoperatively. Total heparin requirement,
heparin consumption, and heparin sensitivity were calculated. ATIII activity and
ACT were significantly higher and activated partial thromboplastin time and
fibrinogen level were significantly lower during cardiopulmonary bypass in group
A than in groups P and C. Heparin sensitivity was significantly higher and total
heparin requirement and consumption were significantly lower in ATIII group than
in other groups. ATIII administration increases heparin sensitivity and decreases
heparin requirements compared with FFP in patients undergoing CABGS with
peroperative NTG infusion. ATIII may be preferred to FFP in patients with heparin
resistance due to NTG infusion undergoing CABGS.
J Cardiothorac Vasc Anesth. 2011 Jul 27. [Epub ahead of print]
Multimodal Brain Monitoring Reduces Major Neurologic Complications in Cardiac
Surgery.
Zanatta P, Benvenuti SM, Bosco E, Baldanzi F, Palomba D, Valfrè C.
Anaesthesia and Intensive Care Department, Treviso Regional Hospital, Treviso,
Italy.
OBJECTIVE: Although adverse neurologic outcomes are common complications of
cardiac surgery, intraoperative brain monitoring has not received adequate
attention. The aim of the present study was to evaluate the effectiveness of
multimodal brain monitoring in the prevention of major brain injury and reducing
the duration of mechanical ventilation, intensive care unit, and postoperative
hospital stays after cardiac surgery. DESIGN: A retrospective, observational,
controlled study. SETTING: A single-center regional hospital. PARTICIPANTS: One
thousand seven hundred twenty-one patients who had undergone cardiac surgery with
cardiopulmonary bypass from July 2007 to July 2010. One hundred sixty-six
patients with multimodal brain monitoring and a control group without brain
monitoring (N = 1,555) were compared retrospectively. INTERVENTIONS: Multimodal
brain monitoring was performed for 166 patients, consisting of intraoperative
recordings of somatosensory-evoked potentials, electroencephalography, and
transcranial Doppler. MEASUREMENTS AND MAIN RESULTS: The incidence of major
neurologic complications and the duration of mechanical ventilation, intensive
care unit, and postoperative hospital stays were considered. Patients with brain
monitoring had a significantly lower incidence of perioperative major neurologic
complications (0%) than those without monitoring (4.06%, p = 0.01) and required
significantly shorter periods of mechanical ventilation (p = 0.001) and intensive
care unit stays (p = 0.01) than controls. The length of postoperative hospital
stays did not differ significantly between the 2 groups (p = 0.57). CONCLUSIONS:
This preliminary study suggests that multimodal brain monitoring can reduce the
incidence of neurologic complications as well as hospital costs associated with
post-cardiac surgery patient care. Furthermore, intraoperative brain monitoring
provides useful information about brain functioning, blood flow velocity, and
metabolism, which may guide the anesthesiologist during surgery.
Eur J Cardiothorac Surg. 2011 Jul 27. [Epub ahead of print]
Lung transplantation for cystic fibrosis: a single center experience of 100
consecutive cases.
Inci I, Stanimirov O, Benden C, Kestenholz P, Hofer M, Boehler A, Weder W.
Division of Thoracic Surgery, University Hospital Zurich, Raemistr 100, CH-8091
Zurich, Switzerland.
Objective: Lung transplantation is the ultimate treatment option for patients
with end-stage cystic fibrosis (CF) lung disease. Despite poorer reports on
survival benefit for CF patients undergoing lung transplantation, several
centers, including ours were able to show a survival benefit. This study compares
our center's experience with 100 consecutive recipients in two different eras.
Methods: All CF patients who underwent lung transplantation at our center were
included (1992-2009). Survival rates were calculated and compared between the
earlier era (before 2000) and later era (since 2000). Results: CF patients
constituted 35% of all transplantations performed at our institution. Mean age at
transplantation was 27 years (range 12-52). Fifty-one percent of the patients
were female. Waiting list time was lower in the earlier era compared to the later
era (p=0.04). Lobar transplantation was performed in 10 cases. Thirty-four
percent of the cases required downsizing of the graft. In 33% of the cases,
transplantations were done on cardiopulmonary bypass. There were no anastomotic
complications. Total intensive care unit stay was significantly lower in the
later era compared to earlier era (p=0.001). The other parameters such as
C-reactive protein at the time of transplantation, total cold ischemic time, and
total operation time were comparable between the two eras. Overall 30-day
mortality was 5%. The 30-day mortality was significantly lower in the second
period (p=0.006). In the earlier era, 3-month, 1-year, and 5-year survival were
85±6%, 77±8%, and 60±9%, respectively, and in the later era improved to 96±2%,
92±3%, and 78±5% (p=0.03). Conclusion: Improved results obtained in the early
postoperative period since 2000 is most likely due to change in surgical
management approach. Improved surgical outcome for CF patients can be obtained,
especially in experienced transplant centers.
J Card Surg. 2011 Jul;26(4):429-34. doi: 10.1111/j.1540-8191.2011.01270.x.
Surgical closure of sinus venosus atrial septal defect using a single
patch-transcaval repair technique.
Gajjar TP, Hiremath CS, Desai NB.
Department of Cardiothoracic and Vascular Surgery, Sri Sathya Sai Institute of
Higher Medical Sciences, Prasanthigram-515134, District Anantapur, Andhra
Pradesh, India.
Abstract Objective: We would like to share our experience of surgical repair of
sinus venosus atrial septal defect (ASD) using a simple "transcaval repair
technique." Method: Between January 2007 and October 2010, 48 consecutive
patients of sinus venosus ASD underwent surgical repair using transcaval repair
technique at our institute. Their ages ranged from 5 to 15 years and male to
female ratio was 1.6:1. The principles of the technique were longitudinal
incision over the lateral aspect of superior vena cava (SVC) at the entry point
of anomalous right pulmonary veins, use of a single autologous untreated
pericardial patch, and finally closure of the caval incision in such a way that
the patch gets sandwiched between two caval lips. Results: All 48 patients came
off cardiopulmonary bypass in sinus rhythm. The average pressure gradient across
the patch was 3 mmHg. Immediate postoperative electrocardiograms and
echocardiograms showed all patients were in sinus rhythm with no residual shunt
and no pulmonary or systemic venous obstruction respectively, except in one
patient who required SVC augmentation. The follow-up was done at three months
(100%), one year, and two years. All patients were asymptomatic and their
electrocardiograms and transthoracic echocardiograms revealed sinus rhythm, no
residual shunt, and no obstruction to systemic or pulmonary venous drainage,
respectively. There was no early or late mortality. Conclusion: We conclude that
this technique is safe and simple for the repair of selected cases of sinus
venosus atrial septal defect with partial anomalous pulmonary venous connection
and it preserves the sinoatrial node function after surgery. (J Card Surg
2011;26:429-434).
Interact Cardiovasc Thorac Surg. 2011 Jul 26. [Epub ahead of print]
Does prophylactic inhaled nitric oxide reduce morbidity and mortality after lung
transplantation?
Tavare AN, Tsakok T.
Department of Acute Medicine, Hammersmith Hospital, London W12 0HS, UK.
A best evidence topic in thoracic surgery was written according to a structured
protocol. The question addressed was does prophylactic inhaled nitric oxide (NO)
reduce morbidity and mortality after lung transplantation? Altogether 230 papers
were found using the reported search, of which six 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 were tabulated. Primary graft dysfunction and failure are serious
complications in the first few days following lung transplantation. These
phenomena are characterised by bilateral infiltrates on chest radiographs,
reduced lung compliance and increased FiO2 requirements and alveolar-arterial
gradients; thus necessitating prolonged mechanical ventilation and often leading
to significant mortality. The process known as ischaemic-reperfusion injury is
thought to underlie primary graft failure. The studies conducted examining the
role of inhaled NO in preventing morbidity and mortality after orthotropic lung
transplant tend to focus on potential reductions in the incidence of
ischaemic-reperfusion injury as the determinant of clinical outcomes. The
majority of these are unfortunately non-randomised and/or uncontrolled studies.
All the studies discussed, including the two prospective randomised controlled
trials, suffer from small sample sizes. Nonetheless, despite their limitations,
there are currently, no randomised controlled studies that demonstrate a
reduction in morbidity [time to extubation, length of intensive care unit (ICU)
or hospital stay] or mortality. As such it is difficult to currently, recommend
the routine use of prophylactic inhaled NO in lung transplant surgery. Further
studies may outline a benefit in certain types of surgeries, e.g. single-lung
transplants or double-lung requiring cardiopulmonary bypass. Keywords: Nitric
oxide; Lung transplantation; Mechanical ventilation; Intensive care.
Transfusion. 2011 Jul 25. doi: 10.1111/j.1537-2995.2011.03236.x. [Epub ahead of
print]
A randomized controlled pilot study of adherence to transfusion strategies in
cardiac surgery.
Shehata N, Burns LA, Nathan H, Hebert P, Hare GM, Fergusson D, Mazer CD.
From the Departments of Medicine, Anesthesia and Physiology, University of
Toronto, Li Ka Shing Knowledge Institute, Division of Hematology St. Michael's
Hospital; Central Ontario Region, Canadian Blood Services, Toronto, Ontario; the
Department of Anesthesia, St Michael's Hospital, University of Toronto, Toronto,
Ontario; the Department of Anesthesia, University of Ottawa, Ottawa, Ontario; and
the Department of Critical Care, General Campus, and Clinical Epidemiology,
Ottawa Hospital Research Institute, CMAJ, Ottawa, Ontario, Canada.
BACKGROUND: It is important to determine the optimal hemoglobin (Hb)
concentration for red blood cell (RBC) transfusion for patients undergoing
cardiac surgery because increased mortality has been associated with the severity
of anemia and exposure to RBCs. Because a definitive trial will require thousands
of patients, and because there is variability in transfusion practices, a pilot
study was undertaken to determine adherence to proposed strategies. STUDY DESIGN
AND METHODS: A single-center parallel randomized controlled pilot trial was
conducted in high-risk cardiac patients to assess adherence to two transfusion
strategies. Fifty patients were randomly assigned either to a "restrictive"
transfusion strategy (RBCs if their Hb concentration was 70 g/L or less
intraoperatively during cardiopulmonary bypass [CPB] and 75 g/L or less
postoperatively) or a "liberal" transfusion strategy (RBCs if their Hb
concentration was 95 g/L or less during CPB and less than 100 g/L
postoperatively). RESULTS: The percentage of adherence overall was 84% in the
restrictive arm and 41% in the liberal arm. Twenty-two (88%) patients were
transfused 99 units of RBCs in the liberal group compared to 13 patients who were
transfused 50 units in the restrictive group (p < 0.01). There were no
significant differences in individual adverse outcomes; however, more adverse
events occurred in the restrictive group (38 vs. 15, p < 0.01). CONCLUSION:
Adherence to the evaluated interventions is vital to all randomized controlled
trials as it has the potential to affect outcomes. Further pilot studies are
required to optimize enrollment and transfusion adherence before a definitive
study is conducted.
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