TOP TEN SELECTED PAPERS
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August 2011 |
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Heart Lung Circ. 2011 Aug 30. [Epub ahead of print]
Impact of Warden's Procedure on the Sinus Rhythm: Our Experience.
Agarwal V, Okonta KE, Abubakar U, Gichuhi S.
Department of Cardiac Surgery, Institute of Cardiovascular Diseases, Madras
Medical Mission, Chennai, India.
OBJECTIVES: Our experience with the use of Warden's procedure for the repair of
sinus venosus ASD with anomalous right upper pulmonary venous connection. METHOD:
Fifty-eight patients had Warden's procedure from September 2008 to May 2011. The
demographic data, preoperative and postoperative ECG, aortic cross-clamp time,
cardiopulmonary bypass time, Holter monitoring, complications length of ICU and
hospital stay were analysed. RESULT: The male to female ratio was 1:1. The median
age was 10.9 years (range 2-48 years). Preoperatively all patients were in sinus
rhythm. Twenty-six patients had associated left superior vena cava and two
patients had also Tuckers procedure at the same time. The mean follow up was 1.2
years (range 1 months-2.8 years). Postoperative Holter monitoring showed sinus
rhythm in all the patients. The mean CPB time was 83.6min (range 54-163min), mean
aortic cross-clamp time was 48.0min (range 22-112min), mean ICU stay was 1.26
days (range 1-4 days) and length of hospital was 8.3 days (range 5-13 days)
Postoperative echocardiography showed less than 1mmHg gradient across the SVC-RA
appendage anastomotic site in all the patients. No mortality was recorded.
CONCLUSION: This is the largest reported series of Warden's procedure in the
literature till date. It is known from other studies that sinus node dysfunction
and conversion to junctional nodal rhythm were quite a concern with the
conventional techniques and Warden's procedure specifically avoids these
problems.
J Thorac Cardiovasc Surg. 2011 Aug 30. [Epub ahead of print]
Avoiding sternotomy in repeat coronary artery bypass grafting: Feasibility,
safety, and mid-term outcome of the transabdominal off-pump technique using the
right gastroepiploic artery.
Tavilla G, Bruggemans EF.
Department of Cardiothoracic Surgery, Leiden University Medical Center, Leiden,
The Netherlands; Department of Cardiothoracic Surgery, University Medical Center
St. Radboud, Nijmegen, The Netherlands.
OBJECTIVES: Repeat sternotomy is associated with a substantial risk of
cardiovascular injury. We evaluated the feasibility and clinical outcome of a
transabdominal approach without sternotomy and without cardiopulmonary bypass in
repeat coronary artery bypass grafting, using the right gastroepiploic artery to
graft vessels of the inferior wall of the heart. METHODS: From July 1999 to
October 2010, 22 patients presenting with only right coronary artery disease
underwent reoperation using the transabdominal approach and a skeletonized
gastroepiploic artery graft. In all patients but 1, a patent graft to the
anterior wall was present. The mean EuroSCORE was 6.4 ± 2.5. RESULTS: All
patients had adequate surgical exposure, and no conversion to sternotomy or the
use of cardiopulmonary bypass was required. There was no in-hospital mortality.
Hospital morbidity included pneumothorax in 1 patient and atrial fibrillation in
2 patients. The median hospital stay was 5 days. Follow-up was complete, and the
median follow-up time was 6 years. There were 2 late deaths. Four patients
experienced recurrence of angina, of whom three required percutaneous coronary
intervention. The estimated freedom from major cardiovascular and cerebrovascular
events rate was 70.2% at 6 years. Fourteen patients underwent an exercise stress
test at a median interval of 2 years, with all showing no signs of myocardial
ischemia. CONCLUSIONS: Transabdominal off-pump coronary artery bypass grafting
using the right gastroepiploic artery is a safe and effective procedure with low
in-hospital mortality and morbidity and favorable mid-term outcome. In redo
operations, this technique excludes the risk of cardiovascular injury.
Anaesthesia. 2011 Aug 24. doi: 10.1111/j.1365-2044.2011.06862.x. [Epub ahead of
print]
A quality assurance programme for cell salvage in cardiac surgery.
Kelleher A, Davidson S, Gohil M, Machin M, Kimberley P, Hall J, Banya W.
Consultant, Department of Anaesthesia Clinical Scientist, Department of
Haematology Perfusionist Chief of Perfusion, Department of Perfusion Clinical
Information Development Manager, Department of Clinical Audit Trust
Statistician, Department of Research and Development, Royal Brompton Hospital,
London, UK.
At the same time as cell salvage was introduced into our institution for all
patients undergoing cardiac surgery with cardiopulmonary bypass, we established a
supporting programme of quality assurance to reassure clinicians regarding safety
and efficacy. Data collected in patients operated on between 2001 and 2007
included pre- and post-wash heparin concentration, haemoglobin concentration and
free haemoglobin concentration. Cell salvage was used in 6826 out of a total of
7243 patients (94%). Post-wash heparin concentration was consistently low (always
< 0.4 IU.ml(-1) ). There was a significant decrease in post-wash haemoglobin
concentration in 2003 compared to 2001, from a median (IQR [range]) of 19.6
(16.7-22.2 [12.9-25.5]) g.dl(-1) to 17.5 (13.6-20.8 [12.6-23.7]) g.dl(-1)
(p < 0.015). In addition, there was a significant increase in free plasma
haemoglobin in 2006 compared to 2001, from 0.5 (0.3-0.8 [0.1-2.6]) g.l(-1) to 0.8
(0.3-1.4 [0.3-5.2]) g.l(-1) (p < 0.001). This programme led to the detection of a
change in operator behaviour in 2003 and progressive machine deterioration
resulting in appropriate fleet replacement in 2006. You can respond to this
article at http://www.anaesthesiacorrespondence.com.
J Thorac Cardiovasc Surg. 2011 Aug 25. [Epub ahead of print]
Effect of normothermic cardiopulmonary bypass on renal injury in pediatric
cardiac surgery: A randomized controlled trial.
Caputo M, Patel N, Angelini GD, de Siena P, Stoica S, Parry AJ, Rogers CA.
Bristol Royal Hospital for Children, University of Bristol, Bristol, United
Kingdom; Bristol Heart Institute, University of Bristol, Bristol, United Kingdom.
OBJECTIVE: Hypothermic cardiopulmonary bypass (CPB), although associated with a
reduction in oxygen requirement, has a number of disadvantages including
detrimental effects on enzymatic function, energy generation, and cellular
integrity. Normothermic perfusion is potentially a more physiologic method to
maintain the functional integrity of major organ systems. One of the aims of this
trial was to compare the effect of normothermic and hypothermic CPB on renal
injury in pediatric patients undergoing cardiac surgery. METHODS: Fifty-nine
children (median age, 78 months; interquartile range, 39-130) undergoing
corrective cardiac surgery were randomized to either hypothermic (28°C) or
normothermic (35°C-37°C) CPB. Urinary albumin, retinal binding protein (RBP) and
N-acetyl-ß-glucosaminidase (NAG) were measured preoperatively, end of CPB, 4, and
24 hours postoperatively and were expressed as a ratio of urinary creatinine.
Serum creatinine was measured preoperatively, end of CPB, and 24 and 48 hours
postoperatively. Results are expressed as a difference in means (normotheric -
hypothermic) or as a ratio of geometric means (normothermic/hypothermic).
RESULTS: Baseline characteristics were similar in both groups. For these
biochemical markers no significant interactions between treatment and
postintervention time were found. Serum creatinine (-2.10; 95% confidence
interval [CI], -6.51-2.31), RBP (ratio, 0.96; 95% CI, 0.65-1.41), and NAG (ratio,
0.86; 95% CI, 0.56-1.36) were similar in the 2 groups (P = .34), but the urinary
albumin was significantly lower in the normothermic group (ratio, 0.63; 95% CI,
0.42-0.95, P = .03). CONCLUSIONS: Normothermic CPB is associated with similar
renal impairment to hypothermic CPB in children undergoing heart surgery.
Am J Respir Crit Care Med. 2011 Aug 25. [Epub ahead of print]
Intestinal Injury and Endotoxemia in Children Undergoing Surgery for Congenital
Heart Disease.
Pathan N, Burmester M, Adamovic T, Berk M, Ng KW, Betts H, Macrae D, Waddell S,
Paul-Clark M, Nuamah R, Mein C, Levin M, Montana G, Mitchell J.
Pediatric Critical Care, Royal Brompton Hospital, London, United Kingdom.
RATIONALE: Children with congenital heart disease are at risk of gut barrier
dysfunction and translocation of gut bacterial antigens into the bloodstream.
This may be due to suboptimal perfusion of intestinal mucosa in the abnormal
anatomical state pre-operatively, as well as the effects of cardiopulmonary
bypass and surgery, and may contribute to inflammatory activation and organ
dysfunction post-operatively. OBJECTIVES: To investigate the role of intestinal
injury and endotoxaemia in the pathogenesis of organ dysfunction following
surgery for congenital heart disease. METHODS: We analysed blood levels of
Intestinal fatty acid binding protein (IFABP) and endotoxin (Endotoxin Activity
Assay) alongside global transcriptomic profiling and assays of monocyte endotoxin
receptor expression in children undergoing surgery for congenital heart disease.
MEASUREMENTS AND MAIN RESULTS: Levels of IFABP and endotoxin were greater in
children with duct-dependent cardiac lesions. Endotoxemia was associated with
severity of vital organ dysfunction and intensive care stay. We identified
activation of pathogen sensing, antigen processing and immune suppressing
pathways at genomic level in the early postoperative period and downregulation of
pathogen sensing receptors on circulating immune cells post-operatively compared
to pre-operative levels. CONCLUSIONS: Children undergoing surgery for congenital
heart disease are at increased risk of intestinal mucosal injury and
endotoxaemia. This is likely to aggravate post-operative inflammatory
dysfunction. Endotoxin activity is a good marker of outcome in this population
and may be used to guide the use of gut protective strategies.
J Cardiothorac Vasc Anesth. 2011 Aug 23. [Epub ahead of print]
Feasibility of Measuring Renal Blood Flow Using Transesophageal Echocardiography
in Pediatric Patients Undergoing Cardiac Surgery.
Zhu D, Yu H, Zhou Y, Li Q, Zhao L, Peng LQ, Liu B.
Department of Anesthesiology, West China Hospital of Sichuan University, Sichuan,
China.
OBJECTIVE: To evaluate the feasibility of measuring renal blood flow (RBF) using
transesophageal echocardiography (TEE) in pediatric patients undergoing cardiac
surgery. DESIGN: A prospective noninterventional study. SETTING: A university
hospital. PARTICIPANTS: Twenty-three pediatric patients who underwent surgical
repair for complex congenital heart defects were included in this study.
INTERVENTION: None. MEASUREMENTS AND MAIN RESULTS: The authors evaluated the
accuracy of using TEE to visualize the left renal artery by comparing TEE images
with preoperative computed tomography angiographic images. RBF was measured
during the cardiopulmonary bypass (CPB) period. TEE images and Doppler studies
from all subjects were interpreted by 2 blinded independent assessors. Inter- and
intraobserver reproducibility was quantified by calculating the variability and
intraclass correlation coefficients. Linear regression models were used to
further investigate the relationship between volumetric RBF and CPB perfusion
rate. The left renal artery was indentified successfully in 96% of the study
population, with a mean Doppler angle of 19.5° ± 6.7° (all of them <30°). Both
inter- and intraobserver variability was <10%. Inter- and intraobserver
reproducibility in the RBF measurements were excellent. The volumetric RBF showed
a linear relationship with the CPB perfusion rate (r = 0.881, p < 0.001) and the
mean artery pressure (r = 0.457, p = 0.032). CONCLUSION: For 96% of pediatric
patients undergoing cardiac surgery, it is feasible to measure RBF using
intraoperative TEE during CPB. Volumetric RBF was related to the perfusion rate
and the mean artery pressure during CPB.
J Thorac Cardiovasc Surg. 2011 Aug 22. [Epub ahead of print]
Long-term survival after lung resection for non-small cell lung cancer with
circulatory bypass: A systematic review.
Muralidaran A, Detterbeck FC, Boffa DJ, Wang Z, Kim AW.
Section of Thoracic Surgery, School of Medicine, Yale University, New Haven,
Conn.
OBJECTIVE: Resection of locally advanced non-small cell lung cancer using
circulatory bypass is not frequently performed. The objective of this study was
to systematically review the long-term survival associated with the published
studies dealing with the performance of lung resections for non-small cell lung
cancer using circulatory bypass. METHODS: A systematic review of publications
dealing with lung resections for non-small cell lung cancer under circulatory
bypass spanning from January 1, 1990, to December, 31 2010, was performed using a
PubMed search with specific inclusion and exclusion criteria. The primary end
point collected was survival. Several other clinical variables were also
collected and analyzed. Survival curves were calculated using the Kaplan-Meier
method. Univariate comparisons of survival were performed using a Cox
proportional hazard model. Multivariate analysis was carried out using a Cox
regression model. RESULTS: The search algorithm yielded 20 articles for the
analysis. The overall 5-year survival was 37% (median, 36 ± 6 months). Survival
was significantly higher when placement on bypass was planned (54%, median: 67±
19 months) as opposed to unplanned or emergency placement (11%; median, 19 ± 6
months; P = .006). Multivariate analysis demonstrated that the use of unplanned
bypass was prognostic for a worse long-term survival (hazard ratio = 0.28; 95%
confidence interval, 0.09-0.90; P = .033). The 30-day and 90-day perioperative
mortalities were 0% and 1%, respectively. CONCLUSIONS: The literature over the
past 2 decades demonstrates that favorable long-term survival for extended
resections of locally advanced non-small cell lung cancer using circulatory
bypass can be achieved. The use of unplanned cardiopulmonary bypass, though,
seems to be prognostic of unfavorable long-term survival.
Ann Thorac Surg. 2011 Aug 17. [Epub ahead of print]
Induced Interleukin-19 Contributes to Cell-Mediated Immunosuppression in Patients
Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass.
Yeh CH, Cheng BC, Hsu CC, Chen HW, Wang JJ, Chang MS, Hsing CH.
Institute of Medical Science, College of Health Science, Chang Jung Christian
University, Tainan, Taiwan.
BACKGROUND: Coronary artery bypass graft (CABG) surgery with cardiopulmonary
bypass (CPB) promotes immunosuppression, which predisposes patients to infectious
complications. We investigated the role of interleukin (IL)-19 in the functions
of CD4+ T cells in patients undergoing CABG with CPB. METHODS: Blood samples were
withdrawn from 42 patients undergoing elective CABG with CPB. Serum levels of
IL-19 were analyzed by enzyme-linked immunosorbent assay (ELISA). The CD4+/CD25+
T-cell population was determined with flow cytometry. Isolated CD4+ T cells were
cultured and assayed for proliferation and cytokine production under phorbol
myristate acetate/ionomycin stimulation. Cytokine production and Foxp3 mRNA
expression in CD4+ T cells from healthy volunteers with or without IL-19
treatment were determined with ELISA and real-time polymerase chain reaction,
respectively. RESULTS: Proliferation percentages were 162%, 48%, 34%, and 39%,
and interferon (IFN)-? production was 1.22 ng/mL, 0.56 ng/mL, 0.33 ng/mL, and
0.35 ng/mL in the CD4+ T cells of patients before CPB and at 24 hours, 48 hours,
and 96 hours, respectively, after CPB. Serum levels of IL-19 were higher but
negatively correlated with CD4+ T-cell proliferation and IFN-? production. The
populations of CD4+/CD25+ T cells and expression of Foxp3 mRNA in T cells were
higher and were positively correlated with IL-19 levels after CPB. Treatment with
IL-19 reduced T-cell proliferation and IFN-? production, increased Foxp3 mRNA
expression, and induced the regulatory activity of CD4+ T cells. CONCLUSIONS:
Interleukin-19 reduces T-cell responses and promotes the regulatory activity of
CD4+ T cells. Induced IL-19 in patients undergoing CABG with CPB contributes to
cell-mediated immunosuppression.
Heart Surg Forum. 2011 Aug 1;14(4):E232-6.
Minimally invasive transaortic repair of the mitral valve.
Santana O, Lamelas J.
Columbia University Division of Cardiology, Mount Sinai Heart Institute, Miami
Beach, Florida.
Objective: We retrospectively evaluated the results of an edge-to-edge repair
(Alfieri stitch) of the mitral valve performed via a transaortic approach in
patients who were undergoing minimally invasive aortic valve replacement.Methods:
From January 2010 to September 2010, 6 patients underwent minimally invasive
edge-to-edge repair of the mitral valve via a transaortic approach with
concomitant aortic valve replacement. The patients were considered to be
candidates for this procedure if they were deemed by the surgeon to be high-risk
for a double valve procedure and if on preoperative transesophageal
echocardiogram the mitral regurgitation jet originated from the middle portion
(A2/P2 segments) of the mitral valve.Results: There was no operative mortality.
Mean cardiopulmonary bypass time was 137 minutes, and mean cross-clamp time was
111 minutes. There was a significant improvement in the mean mitral regurgitation
grade, with a mean of 3.8 preoperatively and 0.8 postoperatively. The ejection
fraction remained stable, with mean preoperative and postoperative ejection
fractions of 43.3% and 47.5%, respectively. Follow-up transthoracic
echocardiograms obtained at a mean of 33 days postoperatively (range, 8-108 days)
showed no significant worsening of mitral regurgitation.Conclusion: Transaortic
repair of the mitral valve is feasible in patients undergoing minimally invasive
aortic valve replacement.
Perfusion. 2011 Aug 22. [Epub ahead of print]
Are minimized perfusion circuits the better heart lung machines? final results of
a prospective randomized multicentre study.
El-Essawi A, Hajek T, Skorpil J, Böning A, Sabol F, Ostrovsky Y, Hausmann H,
Harringer W.
Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig,
Braunschweig, Germany.
INTRODUCTION: Minimized perfusion circuits (MPCs), although aiming at minimizing
the adverse effects of cardiopulmonary bypass, have not yet gained popularity.
This can be attributed to concerns regarding their safety, as well as lack of
sufficient evidence of their benefit. METHODS: Described is a randomized,
multicentre study comparing the MPC - ROCsafeRX to standard cardiopulmonary
bypass in patients undergoing elective coronary artery bypass grafting and/ or
aortic valve replacement. RESULTS: Five hundred patients were included in the
study (252 randomized to the ROCsafeRX group and 248 to standard cardiopulmonary
bypass). Both groups were well matched for demographic characteristics and type
of surgery. No operative mortality and no device-related complications were
encountered. Transfusion requirement (333 ± 603 vs. 587 ± 1010 ml; p=0.001),
incidence of atrial fibrillation (16.3% vs. 24.2%; p=0.03) and the incidence of
major adverse events (9.1% vs. 16.5%; p=0.02) were all in favour of the MPC
group. CONCLUSION: These results confirm both the safety and efficacy of the
ROCsafeRX MPC for a large variety of cardiac patients. Minimized perfusion
circuits should, therefore, play a greater role in daily practice so that as many
patients as possible can benefit from their advantages.
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