TOP TEN SELECTED PAPERS
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September 2011 |
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Crit Care. 2011 Oct 25;15(5):R255. [Epub ahead of print]
Post cardiac surgery vasoplegia is associated with high preoperative copeptin
plasma concentration.
Colson PH, Bernard C, Struck J, Morgenthaler NG, Albat B, Guillon G.
ABSTRACT: INTRODUCTION: Post cardiac surgery vasodilatation is possibly related
to a vasopressin deficiency that could be related to a chronic stimulation of the
adeno-hypophysis. To assess vasopressin system activation, perioperative course
of copeptin and vasopressin plasma concentrations have been studied in
consecutive patients operated on cardiac surgery. METHODS: 64 consecutive
patients scheduled for elective cardiac surgery with cardiopulmonary bypass were
studied. Haemodynamic, laboratory and clinical data were recorded before and
during cardiopulmonary bypass, and at the 8th post-operative hour (H8). At the
same time, point's blood was withdrawn to determine plasma concentrations of
arginine-vasopressin (AVP, radioimmunoassay) and copeptin (immunoluminometric
assay). Post cardiac surgery vasodilation (PCSV) was defined as a mean arterial
blood pressure less than 60 mmHg with a cardiac index [equal to or greater than]
2.2 L * min^-1 * m^-2, and was treated with norepinephrine (NE) in order to
restore a mean blood pressure > 60 mmHg. Patients with PCSV were compared to the
other patients (controls). Student's t, Fisher's exact test, or non parametric
tests (Mann Whitney, Wilkoxon) were used when appropriate. A correlation between
AVP and copeptin has been evaluated and a receiver-operator characteristic (ROC)
analysis was calculated to assess the utility of preoperative copeptin to
distinguish between controls and PCSV patients. RESULTS: Patients who experienced
a PCSV have significantly higher copeptin plasma concentration before
cardiopulmonary bypass (P <0.001) but lower AVP concentrations at H8 (P <0.01)
than controls. PCSV patients had preoperative hyponatremia and decreased left
ventricle ejection fraction, and experienced more complex surgery (redo). The
area under the ROC curve of preoperative copeptin concentration was
0.86[plus/minus]0.04 [95%CI: 0.78-0.94] (P <0.001). The best predictive value for
preoperative copeptin plasma concentration was 9.43 pmol/L with a sensitivity of
90% and a specificity of 77%. CONCLUSIONS: High preoperative copeptin plasma
concentration is predictive of PSCV and suggests an activation of the AVP system
before surgery that may facilitate depletion of endogenous AVP stores and a
relative AVP deficit after surgery.
Korean J Anesthesiol. 2011 Sep;61(3):210-5. Epub 2011 Sep 23.
The effects of magnesium on the course of atrial fibrillation and coagulation in
patients with atrial fibrillation undergoing mitral valve annuloplasty.
Kang WS, Yun HJ, Han SJ, Kim HY, Kim DK, Lim JA, Woo NS, Kim SH.
Department of Anaesthesiology and Pain Medicine, Konkuk University School of
Medicine, Seoul, Korea.
BACKGROUND: Atrial fibrillation (AF) is the most common cardiac arrhythmia.
Magnesium has been reported to be effective in reducing the incidence or
prophylaxis of AF. Magnesium is also an essential constituent of many enzyme
systems and plays a physiological role in coagulation regulation. The aim of the
present study was to examine the effects of magnesium, whether magnesium infusion
might decrease the incidence of AF and induce hypocoagulable state in patients
with AF, who were undergoing mitral valve annuloplasty.
METHODS: This prospective laboratory study was performed using blood from
patients with AF undergoing mitral valve annuloplasty. The radial artery was
punctured with a 20 gauge catheter and used for monitoring continuous arterial
pressure and blood sampling. After anesthesia induction, 4 g of magnesium was
mixed with 100 ml normal saline and infused for 5 minutes. Magnesium, calcium,
activated clotting time (ACT) and thromboelastographic parameters were checked
before and 60 minutes after the magnesium infusion. The electrocardiography
changes after magnesium infusion were also checked before commencing
cardiopulmonary bypass.
RESULTS: After magnesium infusion, the serum level of magnesium increased
significantly but serum calcium did not change significantly. ACT did not change
significantly before or after magnesium infusion. The thromboelastographic
parameters showed no significant changes before or after magnesium infusion. None
of the patients converted to sinus rhythm from AF after the magnesium infusion.
CONCLUSIONS: A magnesium infusion did not influence the course of AF and
coagulation in patients during prebypass period with AF undergoing mitral valve
annuloplasty.
Shock. 2011 Sep 27. [Epub ahead of print]
SELDI-Based Protein Patterns in the Diagnosis of SEPSIS/SIRS.
Kiehntopf M, Schmerler D, Brunkhorst FM, Winkler R, Ludewig K, Osterloh D, Bloos
F, Reinhart K, Deufel T.
1Institute for Clinical Chemistry and Laboratory Medicine, Medical Faculty,
Friedrich-Schiller-University Jena, Jena, Germany; 2SIRS-Lab GmbH, Jena, Germany;
3Dept of Anaesthesiology and Intensive Care Medicine,
Friedrich-Schiller-University Jena, Germany; 4Leibniz Institute for Natural
Product Research and Infection Biology, Hans-Knöll-Institute, Jena, Germany
Current affiliation: CINVESTAV Unidad Irapuato, Km. 9.6 Libramiento Norte Carr.
Irapuato-León, 36821 Irapuato Gto., México ; 5Paul-Martini Clinical Sepsis
Research Group, Friedrich-Schiller-University Jena, 6Center for Sepsis Control
and Care (CSCC), Friedrich-Schiller-University Jena.
Early differential diagnosis of systemic inflammatory reactions in critically ill
patients is essential for timely implementation of life-saving therapies. Despite
many efforts made, reliable biomarkers to discriminate between infectious and
non-infectious causes of systemic inflammatory response syndromes (SIRS) are
currently not available. Recent advances in mass spectrometry based methods have
raised hopes that identification of spectral patterns from serum/plasma samples
can be instrumental in this context. We compared protein expression patterns from
patients with SIRS of infectious and noninfectious origin. Plasma samples from
166 patients obtained under rigorously standardized preanalytical conditions were
applied to Q10 and CM10 ProteinChips. Protein profiles were used to train and
develop decision tree classification algorithms. Discriminatory peaks were
isolated and identified. Classification trees distinguished patients with
non-infectious SIRS with organ dysfunction following open heart surgery employing
cardiopulmonary bypass (CPB) from those with severe sepsis or septic shock with
distinct sensitivities and specificities. Results were validated in a blinded
test set in two independent experiments and in a second independently collected
test set. Discriminatory peaks at 13.8 kDa and 55.7 kDa were identified as
transthyretin and alpha-1-antitrypsin; the third protein at m/z 4798 was assigned
to a proteolytic fragment of alpha-1-antitrypsin. Taken together, our data
demonstrate that plasma protein profiling allows reproducible discrimination
between patients with infectious and non-infectious SIRS with high sensitivity
and specificity. However, rigorous standardization as well as considering drug
related interferences are essential when interpreting protein profiling studies.
Identification of discriminatory proteins suggests a direct link between
infectious-related protease activity and a sepsis-specific diagnostic pattern for
discrimination of patients with SIRS.
Arq Bras Cardiol. 2011 Sep 30. pii: S0066-782X2011005000092. [Epub ahead of
print]
Preoperative C-reactive protein predicts respiratory infection after coronary
artery bypass graft surgery.
[Article in English, Portuguese]
Mezzomo A, Bodin Jr OL, Lucia V.
Instituto de Cardiologia do Rio Grande do Sul, Fundação Universitária de
Cardiologia, Porto Alegre, RS, Brasil.
BACKGROUND: Increased levels of high-sensitive C-reactive protein (hsCRP) in the
preoperative evaluation for coronary artery bypass graft surgery (CABG) have been
associated to poor outcomes in the postoperative period. OBJECTIVE: To evaluate
the association of high levels of hsCRP with short-term outcomes after cardiac
surgery. METHODS: Prospective cohort with 331 patients who underwent CABG surgery
with cardiopulmonary bypass (CPB) at our Institution. Patients were assigned to
two groups according to hsCRP levels, measured before surgery: normal (N group)
with <3 mg/l hsCRP; and increased (A group) with >3 mg/l hsCRP. This cutoff of 3
mg/l had a sensitivity and specificity of 60% for predicting respiratory
infection, with a power of 90%. The patients were followed-up during the
in-hospital period. RESULTS: The mean age was 60 years, and 71.6% of the patients
were male. HsCRP was increased (group A) in 144 patients (43.5%). In-hospital
mortality was 4.8% and the most frequent complications in both groups were:
overall infections (18%), respiratory infections (16%), atrial fibrillation (15%)
and acute myocardial infarction (7.6%). The incidence of postoperative overall
infections was 14.4% in the N group and 23.6% in the A group (P=0.046).
Respiratory infections were also more frequent in the A group (21.5% vs. 11.8%; p
= 0.024). Multivariate analyses showed that hsCRP level represented an
independent predictor of postoperative respiratory infection (OR=2.08, 95% IC =
1.14-3.79). CONCLUSION: High preoperative hsCRP level is an independent predictor
of respiratory infections in the mid-term postoperative period of elective
coronary artery bypass graft surgery.
J Am Soc Echocardiogr. 2011 Nov;24(11):1226-32. Epub 2011 Sep 29.
Changes of Right Ventricular Function and Longitudinal Deformation in Children
with Hypoplastic Left Heart Syndrome before and after the Norwood Operation.
Petko C, Uebing A, Furck A, Rickers C, Scheewe J, Kramer HH.
Department of Congenital Heart Disease and Pediatric Cardiology, University
Hospital of Schleswig-Holstein, Campus Kiel, Kiel, Germany.
BACKGROUND: The purpose of this study was to investigate changes in right
ventricular (RV) function and deformation parameters before and at steady state
after the Norwood operation in neonates with hypoplastic left heart syndrome. A
further aim was to delineate factors that affected these changes.
METHODS: On echocardiograms before and 21 days (range, 10-35 days) after the
Norwood operation, the two-dimensional speckle-tracking parameters global and
regional peak systolic longitudinal strain and strain rate were retrospectively
compared in 33 patients with hypoplastic left heart syndrome. In addition, RV
functional assessment included RV fractional area change and tricuspid annular
plane systolic excursion. The associations between postoperative
echocardiographic findings and preoperative or postoperative complications,
prenatal diagnosis, postoperative heart rate, oxygen saturation, and medication
use as well as cardiopulmonary bypass and aortic cross-clamp times were tested.
RESULTS: Global strain (-18.3 ± 3.6% vs -16.8 ± 3.8%, P = .02) and global strain
rate (-1.6 ± 0.3 vs -1.2 ± 0.3 sec(-1), P < .0001) decreased significantly.
Regional strain decreased significantly in the apical and mid lateral segments,
while regional strain rate decreased significantly in all but the basal septal
segments. Tricuspid annular plane systolic excursion of the lateral annulus
decreased significantly, while RV fractional area change remained the same. No
significant associations were found between postoperative RV function and
potential impact factors.
CONCLUSIONS: Two-dimensional global and regional longitudinal strain and strain
rate as well as tricuspid annular plane systolic excursion were reduced in
patients with hypoplastic left heart syndrome after the Norwood operation. None
of the examined preoperative and postoperative patient or surgical factors was
found to explain this decrease.
J Cardiothorac Surg. 2011 Sep 29;6:123.
Intraoperative device closure of atrial septal defects in the Older Population.
Zhang H, Chen Q, Chen LW, Cao H, Zhang GC, Chen DZ.
Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University,
Fuzhou, 350001,P, R, China. scottie98345@sohu.com.
ABSTRACT:OBJECTIVE: This study sought to prove the safety and feasibility of
intraoperative device closure of atrial septal defect (ASD) with transthoracic
minimal invasion in the older patients.
METHODS: From January 2006 to December 2009, 47 patients aged 50 years or more
and suffered from atrial septal defect were enrolled in our institution. Patients
were divided into two groups, 27 of which in group I with intraoperative device
closure and the other 20 in group II with surgical closure. In group I, the
method involved a minimal intercostal incision, which was performed after full
evaluation of the atrial septal defect by transthoracic echocardiography, and the
insertion of the device through the delivery sheath to occlude the atrial septal
defect.
RESULTS: In group I, implantation was ultimately successful in all patients. The
complete closure rate at 24 hours and 1 year were 81.5% and 100% respectively. In
6 of 27 patients, minor complications occurred: transient arrhythmia (n = 5) and
blood transfusion (n = 3). In group II, all patients were closured successfully;
almost all of them needed blood transfusion and suffered from various minor
complications though. During a follow-up period of 1 to 5 years, no residual
shunt, noticeable mitral regurgitation, significant arrhythmias, thrombosis, or
device failure were found. In our comparative studies, group II had significantly
longer ICU stay and hospital stay than group I (p < 0.05). The cost of group I
was less than that of group II(p < 0.05).
CONCLUSIONS: Minimally invasive transthoracic device closure of the atrial septal
defect at advanced age with a domestically made device without cardiopulmonary
bypass is safe and feasible under transthoracic echocardiographic guidance. It
was cost-savings, yielding better cosmetic results and leaving fewer traumas than
surgical closure. Early and mid-term results are encouraging. However, it is
necessary to evaluate the long-term results.
Thromb Haemost. 2011 Sep 22;106(5). [Epub ahead of print]
Evaluating the role for the optical density in the diagnosis of heparin-induced
thrombocytopenia following cardiac surgery.
Chan CM, Corso PJ, Sun X, Hill PC, Shorr AF.
Dr. Andrew F. Shorr, MD, MPH, Pulmonary and Critical Care Medicine, Room 2A-68D,
Washington Hospital Center, 110 Irving St. NW, Washington, DC 20010, USA, Tel.:
+1 202 877 7856, Fax: +1 202 291 0386, E-mail: afshorr@dnamail.com.
The poor accuracy of the enzyme immune assay (EIA) contributes to the diagnostic
challenge of heparin-induced thrombocytopenia (HIT) following cardiac surgery. We
sought to determine if adjusting the threshold optical density (OD) defining a
positive EIA improves the test's accuracy in subjects with an OD>0.40. We
retrospectively analysed the results from both EIA and confirmatory serotonin
release assays (SRAs) in cardiac surgery patients with EIA OD of >0.4. Employing
the SRA as the standard, we compared the area under the receiver-operating
characteristic (AUROC) curves of various OD measurements for identifying HIT. We
examined baseline clinical variables associated with a positive SRA in the
setting of a positive HIT EIA (OD >0.4). We then used logistic regression to
identify baseline clinical variables independently associated with a positive SRA
given a positive EIA. The cohort included 99 subjects with positive EIAs and 35%
had positive SRAs. An OD>0.40 had moderate utility as a screening test for a
positive SRA (AUROC: 0.68; 95% CI: 0.55-0.80). Increasing the OD threshold did
not improve the HIT EIA's screening utility. Clinical variables independently
associated with a positive SRA if the EIA were positive included female gender,
absence of diabetes, and use of cardiopulmonary bypass. A relatively modest
elevation in the OD measurement, when it is already known to be greater than 0.4,
does not reliably exclude the potential for a positive SRA in this setting.
Br J Anaesth. 2011 Sep 22. [Epub ahead of print]
Early detection of postoperative acute kidney injury by Doppler renal resistive
index in cardiac surgery with cardiopulmonary bypass.
Bossard G, Bourgoin P, Corbeau JJ, Huntzinger J, Beydon L.
Pôle d'Anesthésie Réanimation, CHU d'Angers, Rue Larrey, 49933 Angers Cedex 9,
France.
BACKGROUND: /st>Acute kidney injury (AKI) is common after cardiac surgery,
affecting outcome. Early detection of an AKI marker is likely to speed diagnosis
and implementation of measures to preserve renal function. In septic shock and
unselected ventilated subjects, an increased Doppler renal resistive index (RRI)
is a predictor of AKI. This study aims to determine whether RRI would act
similarly in the postoperative setting of cardiac surgery. METHODS: /st>This
study included 65 subjects aged more than 60 yr undergoing elective heart surgery
with cardiopulmonary bypass (CPB) and at risk of AKI. All presented at least one
AKI risk factor [arteritis, diabetes, or serum creatinine (sCr) clearance of
30-60 ml min(-1)] and were haemodynamically stable without arrhythmia. Doppler
RRI was measured in the immediate postoperative period (POP) while subjects were
ventilated and sedated. AKI was assessed when sCr increased 30% above the
preoperative baseline. RESULTS: /st>Eighteen subjects developed AKI between days
1 and 4, with six requiring dialysis. RRI in the POP was increased in AKI [RRI:
0.79 (0.08) with AKI vs 0.68 (0.06) without AKI, P<0.001], correlating to AKI
severity [0.68 (0.06) without AKI, 0.77 (0.08) with AKI but no dialysis, and 0.84
(0.03) with AKI and dialysis, P<0.001]. RRI was similar in subjects receiving
catecholamines. RRI >0.74 in the POP predicted delayed AKI with high sensitivity
and specificity (0.85 and 0.94, respectively). Multivariate analysis showed that
AKI was associated with increased RRI and transfusion. CONCLUSIONS: /st>RRI used
in the immediate POP after cardiac surgery with CPB enabled prediction of delayed
AKI and anticipation of its severity.
Ann Thorac Surg. 2011 Sep 19. [Epub ahead of print]
Off-Pump Coronary Artery Bypass in Patients With Left Ventricular Dysfunction: A
Meta-Analysis.
Jarral OA, Saso S, Athanasiou T.
Department of Surgery and Cancer, Imperial College London, London, United
Kingdom.
BACKGROUND: In symptomatic multivessel disease with left ventricular dysfunction,
coronary artery bypass surgery (CAB) is the conventional approach. This study
assesses outcomes in patients with left ventricular dysfunction undergoing
coronary artery bypass with (on-pump; ONCAB) and without cardiopulmonary bypass
(off-pump; OPCAB). METHODS: A systematic literature search was performed and data
were extracted for the following outcomes of interest: 30-day, midterm, and
late-term mortality, myocardial infarction, and completeness of
revascularization. Random effects meta-analysis was used to aggregate the data.
Sensitivity, heterogeneity, and publication bias were assessed. RESULTS.:
Analysis of 23 nonrandomized studies revealed 7,759 patients, of whom 2,822
received OPCAB and 4,937 underwent ONCAB. Early mortality was significantly lower
in the OPCAB group (odds ratio 0.64, 95% confidence interval 0.51 to 0.81) with
no significant heterogeneity between the studies. This finding was supported by
subgroup analysis that included assessment of studies only including patients
with poor left ventricular function. Based on 13 studies, there was no difference
in mortality at the midterm, and based on 4 studies there was no significant
difference when comparing late-term mortality. Analysis of four studies revealed
the OPCAB group was associated with significantly less complete
revascularization. CONCLUSIONS.: Off-pump CAB may be associated with lower
incidence of early mortality in patients with impaired left ventricular function,
although the method of handling the conversion-related mortality in each study is
uncertain and may challenge these results. Incomplete revascularization provided
by the OPCAB group occurred more often, although its impact was not reflected in
the clinical outcomes but may explain why the early advantage in mortality was
not continued to the late term.
Pediatr Crit Care Med. 2011 Sep 15. [Epub ahead of print]
Washing red blood cells and platelets transfused in cardiac surgery reduces
postoperative inflammation and number of transfusions: Results of a prospective,
randomized, controlled clinical trial.
Cholette JM, Henrichs KF, Alfieris GM, Powers KS, Phipps R, Spinelli SL, Swartz
M, Gensini F, Daugherty LE, Nazarian E, Rubenstein JS, Sweeney D, Eaton M, Lerner
NB, Blumberg N.
From the Departments of Pediatrics (JMC, KSP, ED, EN, JSR), Pathology and
Laboratory Medicine (KFH, SLS, NB), Cardiac Surgery (GMA, MS, FG), Environmental
Medicine (RP), and Anesthesiology (DS, ME); University of Rochester, Rochester,
NY; Department of Pediatrics (NBL), St. Christopher's Hospital for Children,
Philadelphia, PA.
OBJECTIVES:: Children undergoing cardiac surgery with cardiopulmonary bypass are
susceptible to additional inflammatory and immunogenic insults from blood
transfusions. We hypothesize that washing red blood cells and platelets
transfused to these patients will reduce postoperative transfusion-related immune
modulation and inflammation. DESIGN:: Prospective, randomized, controlled
clinical trial. SETTING:: University hospital pediatric cardiac intensive care
unit. PATIENTS:: Children from birth to 17 yrs undergoing cardiac surgery with
cardiopulmonary bypass. INTERVENTIONS:: Children were randomized to an unwashed
or washed red blood cells and platelet transfusion protocol for their surgery and
postoperative care. All blood was leuko-reduced, irradiated, and ABO identical.
Plasma was obtained for laboratory analysis preoperatively, immediately, and 6
and 12 hrs after cardiopulmonary bypass. Primary outcome was the 12-hr
postcardiopulmonary bypass interleukin-6-to-interleukin-10 ratio. Secondary
measures were interleukin levels, C-reactive protein, and clinical outcomes.
MEASUREMENTS AND MAIN RESULTS:: One hundred sixty-two subjects were studied, 81
per group. Thirty-four subjects (17 per group) did not receive any blood
transfusions. Storage duration of blood products was similar between groups.
Among transfused subjects, the 12-hr interleukin ratio was significantly lower in
the washed group (3.8 vs. 4.8; p = .04) secondary to lower interleukin-6 levels
(after cardiopulmonary bypass: 65 vs.100 pg/mL, p = .06; 6 hrs: 89 vs.152 pg/mL,
p = .02; 12 hrs: 84 vs.122 pg/mL, p = .09). Postoperative C-reactive protein was
lower in subjects receiving washed blood (38 vs. 43 mg/L; p = .03). There was a
numerical, but not statistically significant, decrease in total blood product
transfusions (203 vs. 260) and mortality (2 vs. 6 deaths) in the washed group
compared to the unwashed group. CONCLUSIONS:: Washed blood transfusions in
cardiac surgery reduced inflammatory biomarkers, number of transfusions, donor
exposures, and were associated with a nonsignificant trend toward reduced
mortality. A larger study powered to test for clinical outcomes is needed to
determine whether these laboratory findings are clinically significant.
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