TOP TEN SELECTED PAPERS
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October 2011 |
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J Thorac Cardiovasc Surg. 2011 Oct 27. [Epub ahead of print]
Prophylactic amiodarone reduces junctional ectopic tachycardia after tetralogy of
Fallot repair.
Imamura M, Dossey AM, Garcia X, Shinkawa T, Jaquiss RD.
University of Arkansas for Medical Sciences, Arkansas Children's Hospital,
Department of Surgery, Department of Pediatrics, Little Rock, Ark.
OBJECTIVE: Junctional ectopic tachycardia is common after pediatric heart
surgery. After tetralogy of Fallot repair, the incidence of junctional ectopic
tachycardia may be as high as 15% to 20%. We introduced prophylactic amiodarone
for tetralogy repair. This study was conducted to evaluate the effectiveness of
the prophylactic amiodarone. METHODS: A continuous infusion of amiodarone was
started in the operating room at the time of rewarming during cardiopulmonary
bypass at a rate of 2 mg/kg/d and continued for 48 hours. Between November 2005
and November 2009, 63 consecutive patients underwent primary repair of tetralogy,
of whom 20 had prophylactic amiodarone (amiodarone group) and 43 did not (control
group). Variables studied included demographic and bypass data, surgical
procedure details (transannular or nontransannular patch), preoperative and
postoperative echocardiography findings, and postoperative inotropic support.
Univariate and stepwise multivariate analyses were conducted to determine factors
associated with the occurrence of junctional ectopic tachycardia. RESULTS: The
incidence of junctional ectopic tachycardia was 37% in the control group and 10%
in the amiodarone group. The groups were similar in age, weight, bypass time,
rate of transannular patch usage, and preoperative and postoperative gradient
through the right ventricular outflow tract. Prophylactic amiodarone was
significantly negatively associated with junctional ectopic tachycardia by both
univariate (P = .039) and multivariate (P = .027) analyses. There were no adverse
events attributable to prophylactic amiodarone use. CONCLUSIONS: Prophylactic
amiodarone is well tolerated and significantly associated with a decreased
incidence of junctional ectopic tachycardia after tetralogy repair.
Copyright © 2011 The American Association for Thoracic Surgery. Published by
Mosby, Inc. All rights reserved.
Ann Thorac Surg. 2011 Oct 28. [Epub ahead of print]
Mechanisms of Pulmonary Hypertension Related to Ventricular Septal Defect in
Congenital Heart Disease.
Pan X, Zheng Z, Hu S, Li S, Wei Y, Zhang Y, Cheng X, Ma K.
State Key Laboratory of Translational Cardiovascular Medicine, Fuwai Hospital,
Chinese Academy of Medical Sciences, Peking Union Medical College, The People's
Republic of China; Department of Cardiovascular Surgery, Fuwai Hospital, Chinese
Academy of Medical Sciences, Peking Union Medical College, The People's Republic
of China.
BACKGROUND: The aim of this study was to investigate differences in molecular
mechanisms of pulmonary hypertension between patients with complete transposition
of the great arteries (TGA) combined with ventricular septal defect (VSD) and
those with VSD alone. METHODS: Twenty-four consecutive patients with pulmonary
hypertension (mean pulmonary artery pressure > 30 mm Hg) underwent surgical
correction of TGA + VSD (n = 10) or VSD alone (n = 14). Lung specimens were taken
from the right middle lobe before cardiopulmonary bypass (CPB). Extent of
pulmonary hypertension was graded according to the Heath-Edwards pathologic
classification. Enzyme-linked immunosorbent assay (ELISA) was used to determine
expression of endothelial nitric oxide synthase (eNOS), inducible nitric oxide
synthase (iNOS), endothelin-1 (ET-1), endothelin A and B receptors (ET-AR,
ET-BR), matrix metalloproteinases 2 and 9 (MMP-2, MMP-9), and tissue inhibitor of
metalloproteinase (TIMP). RESULTS: There were no statistically significant
differences in age, height, weight, VSD diameter, or preoperative pulmonary
artery pressure between groups. Hemoglobin level, pulmonary artery oxygen
saturation, and reduction in postoperative pulmonary artery pressure were
significantly higher in patients undergoing correction of TGA + VSD (p < 0.05).
All patients had grade 0 to II Heath-Edwards morphologic changes in lung biopsy
samples. Expression of eNOS and MMP-2 was significantly lower in the TGA + VSD
group than in the VSD-alone group (eNOS, 280.13 ± 101.92 ng/mg versus 488.41 ±
249.60 ng/mg; p < 0.05; MMP-2, 31.68 ± 15.36 ng/mg versus 69.28 ± 49.12 ng/mg; p
< 0.05). There were no statistically significant differences between groups in
expression of iNOS, ET-1, ET-AR, ET-BR, MMP-9, or TIMP. CONCLUSIONS: In patients
with TGA + VSD, high oxygenation in the pulmonary circulation decreases
expression of MMP-2 and eNOS, which may affect the progress and reversibility of
pulmonary hypertension.
Copyright © 2011 The Society of Thoracic Surgeons. Published by Elsevier Inc.
All rights reserved.
Ital J Pediatr. 2011 Oct 26;37(1):51. [Epub ahead of print]
Gaslini's Tracheal Team: preliminary experience after one year of paediatric
airway reconstructive surgery.
Torre M, Carlucci M, Avanzini S, Jasonni V, Monnier P, Tarantino V, D'Agostino R,
Vallarino R, Della Rocca M, Moscatelli A, Deho A, Zannini L, Stagnaro N, Sacco O,
Panigada S, Tuo P.
ABSTRACT: BACKGROUND: congenital and acquired airway anomalies represent a
relatively common albeit challenging problem in a national tertiary care
hospital. In the past, most of these patients were sent to foreign Centres
because of the lack of local experience in reconstructive surgery of the
paediatric airway. In 2009, a dedicated team was established at our Institute.
Gaslini's Tracheal Team includes different professionals, namely anaesthetists,
intensive care specialists, neonatologists, pulmonologists, radiologists, and
ENT, paediatric, and cardiovascular surgeons. The aim of this project was to
provide these multidisciplinary patients, at any time, with intensive care,
radiological investigations, diagnostic and operative endoscopy, reconstructive
surgery, ECMO or cardiopulmonary bypass. Aim of this study is to present the
results of the first year of airway reconstructive surgery activity of the
Tracheal Team. METHODS: between September 2009 and December 2010, 97 patients
were evaluated or treated by our Gaslini Tracheal Team. Most of them were
evaluated by both rigid and flexible endoscopy. In this study we included 8
patients who underwent reconstructive surgery of the airways. Four of them were
referred to our centre or previously treated surgically or endoscopically without
success in other Centres. RESULTS: Eight patients required 9 surgical procedures
on the airway: 4 cricotracheal resections, 2 laryngotracheoplasties, 1 tracheal
resection, 1 repair of laryngeal cleft and 1 foreign body removal with
cardiopulmonary bypass through anterior tracheal opening. Moreover, in 1 case
secondary aortopexy was performed. All patients achieved finally good results,
but two of them required two surgeries and most required endoscopic manoeuvres
after surgery. The most complex cases were the ones who had already been
previously treated. CONCLUSIONS: The treatment of paediatric airway anomalies
requires a dedicated multidisciplinary approach and a single tertiary care Centre
providing rapid access to endoscopic and surgical manoeuvres on upper and lower
airways and the possibility to start immediately cardiopulmonary bypass or ECMO.
The preliminary experience of the Tracheal Team shows that good results can be
obtained with this multidisciplinary approach in the treatment of complicated
cases. The centralization of all the cases in one or few national Centres should
be considered.
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.
J Thorac Cardiovasc Surg. 2011 Oct 17. [Epub ahead of print]
Levosimendan is superior to epinephrine in improving myocardial function after
cardiopulmonary bypass with deep hypothermic circulatory arrest in rats.
Rungatscher A, Linardi D, Tessari M, Menon T, Luciani GB, Mazzucco A, Faggian G.
Department of Surgery, Division of Cardiac Surgery, University of Verona, Verona,
Italy.
OBJECTIVE: To investigate effects of epinephrine and levosimendan on cardiac
function after rewarming from deep hypothermia. METHODS: Forty-five male Wistar
rats (400-500 g) underwent cardiopulmonary bypass and were cooled to a core
temperature of 13°C to 15°C within 30 minutes. After 15 minutes of deep
hypothermic circulatory arrest, they were randomly assigned to treatment with
levosimendan (12 µg/kg; infusion of 0.2 µg · kg(-1) · min(-1)) (n = 15) or
epinephrine (0.1 µg/kg; infusion of 0.1 µg · kg(-1) · min(-1)) (n = 15) or saline
as control (n = 10). The rewarming lasted 60 minutes. Systolic and diastolic
function was evaluated at different preloads with a conductance catheter,
including the slope of the end-systolic pressure-volume relation (ESPVR) and
end-diastolic pressure-volume relationship (EDPVR), preload recruitable stroke
work, first derivative of left ventricular pressure (+dP/dt), and its relation to
end-diastolic volume, as well as the time constant of left ventricular relaxation
(Tau) and maximal slope of the diastolic pressure decrement (-dP/dt). Plasma
lactate levels were collected. RESULTS: Stroke volume, ejection fraction and
+dP/dt were significantly higher in the levosimendan-treated group than in the
epinephrine group. The slope values of preload recruitable stroke work, ESPVR,
and the relation of +dP/dt to end-diastolic volume were significantly higher,
indicating a better contractility and increased systolic function. -dP/dt was
significantly higher in the levosimendan group (3468 ± 320 vs 1103 ± 101 mm Hg/s;
P < .01). Left ventricular stiffness expressed by EDPVR and relaxation (Tau) were
significantly improved in levosimendan-treated group. Plasma lactated
concentrations were lower in levosimendan group (2.03 ± 1.27 vs 4.64 ± 1.02;
P < .05). CONCLUSIONS: Levosimendan has better inotropic and lusitropic effects
than epinephrine during rewarming from deep hypothermic circulatory arrest with
cardiopulmonary bypass.
Eur J Cardiothorac Surg. 2011 Oct 18. [Epub ahead of print]
Transapical aortic 'valve-in-valve' procedure for degenerated stented
bioprosthesis.
Ferrari E.
Cardiovascular Surgery Department, Centre Hôpitalier Universitaire Vaudois
(CHUV), University Hospital of Lausanne, CH-1011 Lausanne, Switzerland.
Standard surgical aortic valve replacement with a biological prosthesis remains
the treatment of choice for low- and mid-risk elderly patients (traditionally >65
years of age) suffering from severe symptomatic aortic valve stenosis or
insufficiency, and for young patients with formal contraindications to
long-lasting anticoagulation. Unfortunately, despite the fact that several
technical improvements have noticeably improved the resistance of pericardial and
bovine bioprostheses to leaflet calcifications and ruptures, the risk of early
valve failure with rapid degeneration still exists, especially for patients under
haemodialysis and for patients <60 years of age at the time of surgery. Until
now, redo open heart surgery under cardiopulmonary bypass and on cardioplegic
arrest was the only available therapeutic option in case of bioprosthesis
degeneration, but it carried a higher surgical risk when elderly patients with
severe concomitant comorbidities were concerned. Since a few years, the advent of
new transcatheter aortic valve procedures has opened new horizons in cardiac
surgery and, in particular, the possibility of implanting stented valves within
the degenerated stented bioprosthesis, the so-called 'valve-in-valve' (VinV)
concept, has become a clinical practice in experienced cardiac centres. The VinV
procedure represents a minimally invasive approach dedicated to high-risk redo
patients, and published preliminary reports have shown a success rate of 100%
with absence of significant valvular leaks, acceptable transvalvular gradients
and low complication rate. However, this procedure is not riskless and the most
important concerns are about the size mismatch and the right positioning within
the degenerated bioprosthesis. In this article, we review the limited available
literature about VinV procedures, underline important technical details for the
positioning and provide guidelines to prevent valve-prosthesis mismatch comparing
the three sizes of the only commercially available transapical device, the
Edwards Sapien™, with the inner diameter of three of the most commonly used
stented bioprostheses.
Eur J Cardiothorac Surg. 2011 Oct 18. [Epub ahead of print]
Randomized comparison between mild and moderate hypothermic cardiopulmonary
bypass for neonatal arterial switch operation.
Ali Aydemir N, Harmandar B, Riza Karaci A, Erdem A, Yurtseven N, Sasmazel A,
Yekeler I.
Department of Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and
Cardiovascular Training and Research Hospital, Istanbul, Turkey.
OBJECTIVESTo compare neonates receiving arterial switch operation (ASO) either
with mild or moderate hypothermic cardiopulmonary bypass.METHODSForty neonates
undergoing ASO were randomized to receive either mild (Mi > 32°C, n = 20) or
moderate (Mo > 26°C, n = 20) hypothermic cardiopulmonary bypass (CPB) between
April 2007 and June 2010. All patients were diagnosed with simple transposition
of the great arteries. Mean age (Mi: 8.32 ± 4.5 days, Mo: 7.54 ± 5.0 days,
P = 0.21) and body weight were similar in both groups (Mi: 3.64 ± 0.91 kg, Mo:
3.73 ± 0.84 kg, P = 0.14). Follow-up was 3.1 ± 2.5 years for all
patients.RESULTSLowest perioperative rectal temperature was 33.5 ± 1.4°C (Mi)
versus 28.2 ± 2.1°C (Mo) (P < 0.001). All patients safely weaned from CPB
required lower doses of dopamine (Mi: 5.1 ± 2.4 µg/kg min, Mo: 6.5 ± 2.1 µ/kg
min, P = 0.04), dobutamine (Mi: 7.2 ± 2.5 µg/kg min, Mo: 8.6 ± 2.4 µ/kg min,
P = 0.04) and adrenalin (Mi: 0.02 ± 0.02 µg/kg min, Mo: 0.05 ± 0.03 µ/kg min,
P = 0.03) in mild hypothermia group. Intraoperative blood transfusion (Mi:
190 ± 58 ml, Mo: 230 ± 24 ml, P = 0.03) and postoperative lactate levels (Mi:
2.7 ± 0.9 mmol/l, Mo: 3.1 ± 2.2 mmol/l, P = 0.02) were lower under mild
hypothermia. Secondary chest closure was performed in 30% (Mi) versus 35% (Mo)
(P = 0.65). Duration of inotropic support (Mi: 7 (4-11) days, Mo: 11 (7-15) days,
P = 0.03), time to extubation (Mi: 108 (88-128) h, Mo: 128 (102-210) h,
P = 0.04), lengths of intensive care unit (ICU) stay (Mi: 9 (5-14) days, Mo: 12
(10-18) days, P = 0.04) and hospital stay (Mi: 19 (10-29) days, Mo: 23 (15-37)
days, P = 0.04) were significantly shorter under mild hypothermia. Two-year
freedom from reoperation was 100% for both the groups.CONCLUSIONSThe ASO under
mild hypothermia seemed to be beneficial for pulmonary recovery, need for
inotropic support and length of ICU and hospital stay. No worse early- or
intermediate-term effects of mild hypothermia were found.
J Cardiothorac Surg. 2011 Oct 19;6(1):142. [Epub ahead of print]
Off-pump or Minimized On-pump Coronary Surgery - Initial experience with
Circulating Endothelial Cells (CEC) as a supersensitive marker of tissue damage.
Wittwer T, Choi YH, Neef K, Schink M, Sabashnikov A, Wahlers T.
ABSTRACT: BACKGROUND: Off-pump-coronary-artery-bypass-grafting (OPCAB) and
minimized-extracorporeal-circulation (Mini-HLM) have been proposed to avoid
harmful effects of cardiopulmonary-bypass (CPB). Controversies exist whether
OPCAB is still superior in perioperative outcome. Circulating endothelial cells
(CEC) are sensitive markers of endothelial damage and are significantly elevated
in conventional-CPB-procedures as compared to Mini-HLM-revascularisation.
Therefore, CEC might be of specific value in evaluating effectiveness of Mini-HLM
and OPCAB as currently applied less-invasive coronary procedures. METHODS: 76
coronary patients were randomly assigned either to OPCAB (n=34) or to Mini-HLM
(ROCsafeTM, Terumo Inc., n=42) procedures. Perioperative data, clinical and
serological outcome and measurements of CEC-release and parameters of endothelial
function (v.Willebrand-Factor, soluble-thrombomodulin) perioperatively
(pre-operative-baseline, post-Mini-HLM/release of OPCAB-stabilizer, 6h, 12h, 24h
and 5 days postoperatively) were obtained and compared by ANOVA models including
repeated-measures-analysis. RESULTS: Mean graft-number was 3.06+/-0.72 in
Mini-HLM-patients and 1.89+/-0.74 in OPCAB-patients (p<0.001). However,
ventilation-, ICU- and total-hospital duration were comparable between groups as
well as chest-tube-drainage, transfusion requirements, hemodynamics and
catecholaminergic support (p>0.05). CEC-release did not differ between groups
(p=0.274) and was generally within normal limits, Troponin-T levels where not
significanty different (p=0.108). No myocardial infarctions, strokes or deaths
occurred, neuron specific enolase (NSE) did not show any differences between
groups (p=0.194). CONCLUSION: Conceptional advantages of minimized CPB systems
(ROCsafeTM) result in morbidity and mortality comparable with OPCAB procedures.
Mini-HLM therefore minimizes CPB-related systemic and organ injury as
demonstrated by low CEC-values which indicates intact endothelial integrity.
Furthermore, Mini-HLM combines OPCAB-benefits with low morbidity in high-risk
patients while facilitating more complete revascularization in complex patients.
J Anesth. 2011 Oct 19. [Epub ahead of print]
High mortality associated with intracardiac and intrapulmonary thromboses after
cardiopulmonary bypass.
Ogawa S, Richardson JE, Sakai T, Ide M, Tanaka KA.
Department of Anesthesiology, Emory University School of Medicine, Atlanta, GA,
USA.
PURPOSE: Intrapulmonary or intracardiac thrombosis is a rare but catastrophic
event following complex cardiothoracic surgery. Although there have been multiple
cases reported in the literature, the causes of these events are largely unknown.
In this retrospective review, we attempt to identify risk factors and propose
possible mechanisms of thromboses after cardiopulmonary bypass (CPB). METHODS: A
literature search was conducted using the MEDLINE and EMBASE with these keywords:
(intra)pulmonary thrombosis, pulmonary embolism, pulmonary infarction, lung
embolism, (intra)cardiac thrombosis, cardiac thrombi, in combination with CPB,
extracorporeal membrane oxygenation, deep hypothermic circulatory arrest, or
cardiac surgery. Putative risk factors were compiled from reported cases.
RESULTS: We identified 34 cases of massive intrapulmonary and/or intracardiac
thromboses. All but 2 cases (94.1%) were fatal. Clinical presentations were
systemic hypotension and/or pulmonary hypertension, right ventricular failure,
and cardiogenic shock in 32 (94.1%) cases. The timing was immediate (<10 min)
following hemostatic intervention in 16 cases (47.1%), within 45 min in 8 cases
(23.5%), and not reported in the rest. Putative risk factors included
antifibrinolytic use (88.2%), congestive heart failure (55.9%), prolonged CPB use
(>2 h) (41.1%), and low activated clotting time (<400 s) after initial
heparinization (20.6%). The administration of tissue plasminogen activator in 5
cases was ineffective. CONCLUSIONS: Massive thrombosis following cardiac surgery
is a highly lethal event with limited treatment options. Particular attention
should be paid to the status of thrombin regulatory proteins before protamine and
other hemostatic interventions in patients undergoing complex cardiac surgery
with antifibrinolytic agents.
Anesth Analg. 2011 Oct 14. [Epub ahead of print]
Activation of the Hemostatic System During Cardiopulmonary Bypass.
Sniecinski RM, Chandler WL.
From the *Department of Anesthesiology, Division of Cardiothoracic Anesthesia,
Emory University School of Medicine, Atlanta, Georgia; and.
Cardiopulmonary bypass (CPB) is a unique clinical scenario that results in
widespread activation of the hemostatic system. However, surgery also results in
normal increases in coagulation activation, platelet activation, and fibrinolysis
that are associated with normal wound hemostasis. Conventional CPB interferes
with normal hemostasis by diluting hemostatic cells and proteins, through
reinfusion of shed blood, and through activation on the bypass circuit surface of
multiple systems including platelets, the kallikrein-kinin system, and
fibrinolysis. CPB activation of the kallikrein-kinin system increases activated
factor XIIa, kallikrein, bradykinin, and tissue plasminogen activator levels, but
has little effect on thrombin generation. Increased tissue plasminogen activator
and circulating fibrin result in increased plasmin generation, which removes
hemostatic fibrin. The nonendothelial surface of the bypass circuit, along with
circulating thrombin and plasmin, lead to platelet activation, platelet receptor
loss, and reduced platelet response to wounds. In this review, we highlight the
major mechanisms responsible for CPB-induced activation of the hemostatic system
and examine some of the markers described in the literature. Additionally,
strategies used to reduce this activation are discussed, including limiting
cardiotomy suction, increasing circuit biocompatibility, antithrombin
supplementation, and antifibrinolytic use. Determining which patients will most
benefit from specific therapies will ultimately require investigation into
genetic phenotypes of coagulation protein expression. Until that time, however, a
combination of approaches to reduce the hemostatic activation from CPB seems
warranted.
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