TOP TEN SELECTED PAPERS
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December 2010 |
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An Pediatr (Barc). 2010 Dec 27. [Epub ahead of print]
[Prognostic evaluation of arterial switch in the transposition of great
arteries.]
[Article in Spanish]
García-Hernández JA, Montero-Valladares C, Martínez-López AI, Gil-Fournier M,
Praena-Fernández JM, Cano-Franco J, Loscertales-Abril M.
Unidad de Gestión Clínica de Cuidados Críticos y Urgencias, Hospital Infantil
Universitario Virgen del Rocío, Sevilla, España.
INTRODUCTION AND OBJECTIVES: The arterial switch is the procedure of choice for
transposition of great arteries, with or without ventricular septal defect. The
aim of this study was to identify risk factors for hospital mortality. METHODS:
The study included 121 children between January 1994 and June 2008. Of these, 80
(66%) were diagnosed with intact ventricular septum, and 41 (34%) with
ventricular septal defect. Variables were collected pre-operatively, during
surgery, and postoperatively. RESULTS: The mean age was 11 [8 to 16] days and a
mean weight of 3.5 [3.0 to 3.7] kg. A ventricular septal defect was closed in 11
children (9.1%). Atotal of 81.8% had a normal coronary pattern. There was delayed
closure of the chest in 38 patients (31.4%). The hospital mortality was 11.6%,
decreasing over the past 5 years to 2.1%. The weight, abnormal coronary pattern,
time of cardiopulmonary bypass, mean arterial pressure at admission, pulmonary
dead space, and delayed closure of the chest, were risk factors of mortality. The
model that best predicts the death, consists of the mean arterial pressure at
admission, and delayed closure of the chest. CONCLUSIONS: The reduction in
extracorporeal circulation time and the use of delayed closure of the chest, have
helped to reduce mortality. The abnormal coronary pattern remains a risk factor
for mortality. In children with delayed closure of the chest, a mean arterial
pressure at admission = 47.5 mmHg is a goal to achieve.
Interact Cardiovasc Thorac Surg. 2010 Dec 22. [Epub ahead of print]
Candidemia after cardiac surgery in the intensive care unit: an observational
study.
Pasero D, De Rosa FG, Rana NK, Fossati L, Davi A, Rinaldi M, Di Perri G, Ranieri
VM.
Anesthesia and Intensive Care Medicine, San Giovanni Battista Hospital, Turin,
Italy.
Candidemia is a well-recognized complication of hospital stay, especially in
critically ill patients. There is not a general consensus that predictors for
candidemia in cardiosurgical intensive care unit (cICU) are different from a
general ICU and it has been reported that cardiopulmonary bypass time is a
specific risk factor in the cICU. We performed a prospective study to evaluate
the main predictors for candidemia in patients admitted to the cICU. Included
patients were adults admitted between July 2005 and December 2007 with an
ICU-length of stay (ICU-LOS) =48 hours after cardiac surgery. Exclusion criteria
were solid organ or bone marrow transplants, previous diagnosis of candidemia or
other invasive infections and ICU stay before surgery. A multiple regression
analysis was performed to identify the risk factors. Among 1955 patients admitted
to the cICU, 345 were enrolled. Only 26 patients (1.3%) had candidemia after an
ICU-LOS of 20 days (inter-quartile range, IQR 8-49 days). Total parenteral
nutrition [odds ratio (OR)=9.56; confidence interval (CI)=1.741-52.534], severe
sepsis (OR=4.20; CI=1.292-13.667), simplified acute physiology score II (OR=1.16;
CI=1.052-1.278) and ICU-LOS >20 days (OR=6.38; CI=1.971-20.660) were independent
predictors of candidemia. Patients undergoing cardiac surgery developed
candidemia late after cICU admission and the independent predictors were similar
to the general ICU. Keywords: Invasive candidemia; Cardiac surgery;
Cardiopulmonary bypass.
Anesthesiology. 2011 Jan;114(1):58-69.
Preoperative Cerebral Oxygen Saturation and Clinical Outcomes in Cardiac Surgery.
Heringlake M, Garbers C, Käbler JH, Anderson I, Heinze H, Schön J, Berger KU,
Dibbelt L, Sievers HH, Hanke T.
* Professor, Deputy Director, Cardiac Anesthesia Unit, Department of
Anesthesiology, University of Lübeck, Lübeck, Germany, † Medical Student,
Department of Anesthesiology, University of Lübeck, ‡ Deputy Director, Department
of Anesthesiology, University of Lübeck, § Deputy Director, Department of
Clinical Chemistry, University of Lübeck, ? Professor, Director, Department of
Cardiac and Thoracic Vascular Surgery, University of Lübeck, # Deputy Director,
Department of Cardiac and Thoracic Vascular Surgery, University of Lübeck.
BACKGROUND:: The current study was designed to determine the relation between
preoperative cerebral oxygen saturation (Sco2), variables of cardiopulmonary
function, mortality, and morbidity in a heterogeneous cohort of cardiac surgery
patients. METHODS:: In this study, 1,178 consecutive patients scheduled for
on-pump surgery were prospectively studied. Preoperative Sco2, demographics,
N-terminal pro-B-type natriuretic peptide, high-sensitive troponin T, clinical
outcomes, and 30-day and 1-yr mortality were recorded. RESULTS:: Median additive
EuroSCORE was 5 (range: 0-19). Thirty-day and 1-yr mortality and major morbidity
(at least two major complications and/or a high-dependency unit stay of at least
10 days) were 3.5%, 7.7%, and 13.3%, respectively. Median minimal preoperative
oxygen supplemented Sco2 (Sco2min-ox) was 64% (range: 15-92%). Sco2min-ox was
correlated (all: P value <0.0001) with N-terminal pro-B-type natriuretic peptide
(?: -0.35), high-sensitive troponin T (?: -0.28), hematocrit (?: 0.34),
glomerular filtration rate (?: 0.19), EuroSCORE (t: 0.20), and left ventricular
ejection fraction class (t: 0.12). Thirty-day nonsurvivors had a lower Sco2min-ox
than survivors (median 58% [95% CI, 50.7-62%] vs. 64% [95% CI, 64-65%]; P <
0.0001). Receiver-operating curve analysis of Sco2min-ox and 30-day mortality
revealed an area-under-the-curve of 0.71 (95% CI, 0.68-0.73%; P < 0.0001) in the
total cohort and an area-under-the-curve of 0.77 (95% CI, 0.69-0.86%; P < 0.0001)
in patients with a EuroSCORE more than 10. Logistic regression based on different
EuroSCORE categories (0-2; 3-5, 6-10, >10), Sco2min-ox, and duration of
cardiopulmonary bypass showed that a Sco2min-ox equal or less than 50% is an
independent risk factor for 30-day and 1-yr mortality. CONCLUSIONS:: Preoperative
Sco2 levels are reflective of the severity of cardiopulmonary dysfunction,
associated with short- and long-term mortality and morbidity, and may add to
preoperative risk stratification in patients undergoing cardiac surgery.
Interact Cardiovasc Thorac Surg. 2010 Dec 21. [Epub ahead of print]
Beating heart versus conventional mitral valve surgery.
Babaroglu S, Yay K, Parlar AI, Ates C, Mungan U, Cicekcioglu F, Tutun U,
Katircioglu SF.
Department of Cardiovascular Surgery, Turkiye Yuksek Ihtisas Hospital, Ankara,
Turkey.
Objectives: The present study aimed to compare the results of beating heart
technique and conventional mitral valve surgery (MVS). Methods: Three hundred and
nineteen patients who underwent MVS between April 2005 and December 2006 were
enrolled in the study. While 125 patients underwent beating heart MVS (group 1),
the conventional approach was used for 194 patients (group 2). Of those patients
who underwent beating heart MVS, 75 underwent MVS without cross-clamping the
aorta. Coronary sinus retroperfusion was used during surgery in the remaining 50
patients. The right anterolateral thoracotomy was performed in nine out of the 29
patients requiring re-operation, while resternotomy was performed in 20. Results:
No significant differences were shown between the groups in the preoperative
period in terms of the Parsonnet mortality score, Ontario mortality score, and
length of intensive care stay. However, there were significant differences with
respect to EuroSCORE risk score, EuroSCORE mortality, and Parsonnet risk score,
and length of hospital stay according to Ontario risk scoring. It was established
that the patients in group 1 had a shorter length of hospital stay [group 1: six
days (range, 4-37 days); group 2: 10 days (range, 4-62 days)]. Group 1 was
observed to have shorter time periods when the groups were compared regarding
operative time [group 1: 130 min (range, 100-270 min); group 2: 240 min (range,
100-360 min)], cross-clamping (XCL) time [group 1: 27.5 min (range, 3-99 min);
group 2: 60.5 min (range, 30-163 min)], and cardiopulmonary bypass time [group 1:
57 min (range, 22-150 min); group 2: 90 min (range, 39-388 min)]. There were also
significant differences in favor of group 1 in terms of postoperative need for
inotropic support [group 1: 26 patients (16%); group 2: 68 patients (35%)].
Although there were no statistically significant differences in the groups in
terms of mortality rates according to the Parsonnet scoring system, with the
exception of the moderate risk group, it was noted that the mortality rates in
the beating heart group were lower. Conclusions: This study concluded that
beating heart MVS can be performed successfully, particularly for patients at
higher risk which will lead to increased morbidity and mortality in postoperative
period. Keywords: Beating heart; Mitral valve surgery; Myocardial protection.
Diabetes Technol Ther. 2011 Jan;13(1):79-84.
Glucose and insulin administration while maintaining normoglycemia during cardiac
surgery using a computer-assisted algorithm.
Sato T, Carvalho G, Sato H, Lattermann R, Schricker T.
Department of Anaesthesia, Royal Victoria Hospital, McGill University Health
Centre , Montreal, Quebec, Canada .
Abstract Background: Applying the principles of the
hyperinsulinemic-normoglycemic clamp technique we have introduced glucose and
insulin administration while maintaining normoglycemia (GIN therapy) to surgical
patients. The objective of this study was to evaluate a novel computer software
(GIN Computer Software [GINCS]) program using an algorithm based on the original
clamp equation and modified for its use during cardiac surgery. Methods:
Thirty-six patients without diabetes undergoing elective cardiac surgery were
randomly assigned to manually controlled or computer-guided GIN therapy. In both
groups insulin was administered at 5?mU/kg/min during surgery. Simultaneously,
20% dextrose was infused at a rate adjusted to maintain blood glucose (BG)
between 4.0 and 6.0?mmol/L. The adjustments were made either following an
algorithm based on our previous GIN experience or suggestions made by the
software program. The primary outcome was the achievement of target glycemia.
Results: Normoglycemia was achieved in both groups as reflected by mean BG
concentrations of 5.0?±?0.5?mmol/L and 5.1?±?0.2?mmol/L. Mean sampling intervals
were longer in the GINCS group than in the manual group (21.5?±?1.9 vs.
14.2?±?2.2?min, P?
Ann Thorac Surg. 2011 Jan;91(1):131-6.
Outcomes of off-pump aortic valve bypass surgery for the relief of aortic
stenosis in adults.
Thourani VH, Keeling WB, Guyton RA, Dara A, Hurst SD, Lattouf OM.
BACKGROUND: Elderly patients with aortic stenosis presenting for an aortic valve
replacement with a hostile ascending aorta remain a challenging patient cohort.
The purpose of this study was to assess outcomes after the use of an aortic valve
bypass performed without cardiopulmonary bypass.
METHODS: A retrospective review was performed on 21 high-risk patients who
underwent primary, isolated aortic valve bypass from September 2004 to June 2009
at Emory Healthcare Hospitals. Aortic valve bypass was used for a porcelain aorta
alone in 6 (28.6%) patients, previous coronary artery bypass grafting in 4
(19.0%), or both in 10 (47.6%). One patient (4.8%) was thought not to be a
candidate for cardiopulmonary bypass secondary to a severe cirrhosis.
RESULTS: Mean age was 73.9 ± 7.0 years (median, 75.0 years), and 15 patients
(71.4%) were male. Mean New York Heart Association classification was 3.0 ± 1.0
(median, 3.0), and preoperative ejection fraction was 0.460 ± 0.163 (median,
0.500). Preoperative comorbidities included peripheral vascular disease (n = 10;
47.6%), chronic lung disease (n = 16; 76.2%), diabetes mellitus (n = 10; 47.6%),
and dialysis-dependence (n = 2; 9.5%). Either an 18-mm (n = 11; 52.4%) or 20-mm
(n = 10; 47.6%) conduit was used, with an interposed Freestyle 21 porcine root in
all patients. All operations were performed without cardiopulmonary bypass. There
were no intraoperative mortalities. The mean intensive care unit stay was 133.7 ±
161.3 hours (median, 80.2 hours), and overall postoperative length of stay was
12.9 ± 10.8 days (median, 9.0 days). In-hospital mortality occurred in 3 patients
(14.3%). Mid-term follow-up shows an additional 4 patients died at a median
follow-up of 1.3 years.
CONCLUSIONS: Aortic valve bypass without cardiopulmonary bypass is a feasible
alternative for the treatment of severe aortic stenosis with acceptable
short-term morbidity and minimal mortality in this extremely high-risk surgical
population.
J Thorac Cardiovasc Surg. 2010 Dec 15. [Epub ahead of print]
Predictors of massive transfusion with thoracic aortic procedures involving deep
hypothermic circulatory arrest.
Williams JB, Phillips-Bute B, Bhattacharya SD, Shah AA, Andersen ND, Altintas B,
Lima B, Smith PK, Hughes GC, Welsby IJ.
Division of Cardiovascular and Thoracic Surgery, Department of Surgery, Duke
University Medical Center, Durham, NC.
OBJECTIVE: Massive perioperative blood product transfusion may be required with
thoracic aortic operations and is associated with poor outcomes. We analyzed
independent predictors of massive transfusion in thoracic aortic surgical
patients undergoing deep hypothermic circulatory arrest. METHODS: The study
consisted of 168 consecutive patients undergoing open thoracic aortic procedures
involving deep hypothermic circulatory arrest between July 2005 and August 2008.
We identified 26 preoperative and procedural variables as potentially related to
blood product use, tested for association with total blood products transfused by
multivariate linear regression model, and constructed logistic regression model
for massive transfusion (requiring =5 units of transfused packed red blood cells
between incision and 48 postoperative hours). RESULTS: Multivariate linear
regression determined that 6 significant variables accounted for 42% of variation
in total blood products transfused: age (P = .008), preoperative hemoglobin
(P = .04), weight (P = .02), cardiopulmonary bypass time (P < .0001), emergency
status (P < .0001), and resternotomy (P < .0001). Final predictive logistic
regression model included 1-g/dL increase in preoperative hemoglobin (odds ratio,
0.54; 95% confidence interval, 0.43-0.69; P < .0001), 10-minute increase in
cardiopulmonary bypass time (odds ratio, 1.15; 95% confidence interval,
1.05-1.26; P = .0026), and emergency status (odds ratio, 4.02; 95% confidence
interval, 1.53-10.55; P = .0047. CONCLUSIONS: Cardiopulmonary bypass time,
emergency status, and preoperative hemoglobin were independent predictors of
massive transfusion. These variables, along with weight, age, and resternotomy,
were associated with total blood product use in thoracic aortic operations
involving deep hypothermic circulatory arrest.
Pediatr Blood Cancer. 2010 Dec 15. [Epub ahead of print]
Point of care testing in children undergoing cardiopulmonary bypass.
Tirosh-Wagner T, Strauss T, Rubinshtein M, Tamarin I, Mishaly D, Paret G, Kenet
G.
Department of Pediatrics of the Edmond and Lily Safra Children's Hospital,
Affiliated to Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
BACKGROUND: Excessive hemorrhage is a major complication after cardiac surgery
requiring cardiopulmonary bypass (CPB). The aim of this study was to define the
potential role of the cone and platelet analyzer (CPA) and the rotating
thromboelastogram (ROTEM) point of care tests in children undergoing CPB.
PROCEDURE: We prospectively studied 15 pediatric patients aged 1 month to 10
years. Blood count, blood coagulation tests (prothrombin time [PT], activated
partial thromboplastin time, fibrinogen, thrombin time), CPA and ROTEM parameters
were measured before and after CPB. Demographic and surgical data were recorded
as were those on perioperative blood loss and blood product transfusion. RESULTS:
Low body weight, longer duration on CPB and lower core body temperature were
associated with an increased bleeding risk. The ROTEM test showed a significant
prolongation of clotting time and decreased maximal clot firmness (MCF)
postoperatively in children with increased bleeding. The coagulation parameters
associated with increased bleeding were: prolonged PT, lower fibrinogen levels,
prior to surgery, and lower MCF after surgery. CPA test findings were not
associated with postoperative bleeding in our patients. CONCLUSIONS: CPA did not
serve as a prognostic tool for predicting bleeding risk in children undergoing
CPB. The change in ROTEM's post-CPB results associated with bleeding tendency,
and they may predict for poorer clot formation and stability. Pediatr Blood
Cancer © 2010 Wiley-Liss, Inc.
Curr Opin Anaesthesiol. 2010 Dec 13. [Epub ahead of print]
Update on management strategies for separation from cardiopulmonary bypass.
Lombard FW, Grichnik KP.
Division of Cardiothoracic Anesthesia and Critical Care Medicine, Duke University
Medical Center, Durham, North Carolina, USA.
PURPOSE OF REVIEW: To update the reader about clinical management strategies for
separation from cardiopulmonary bypass. A number of new drugs are being
introduced in clinical practice, with significant utility in operative patient
management. Further, there is increased routine use of complex devices to achieve
separation from or avoidance of cardiopulmonary bypass. RECENT FINDINGS: Selected
medical and device strategies from the most recent literature will be discussed.
First, the rationale for selected innovative agents to achieve myocardial
performance is reviewed in four perioperative settings: agents for the management
of myocardial dysfunction, vasomotor dysfunction, pulmonary hypertension, and
right ventricular failure. Second is an evaluation of less commonly considered
aspects of mechanical device use in the context of failure to wean from
cardiopulmonary bypass or use to avoid cardiopulmonary bypass. Three devices will
be discussed: intra-aortic balloon pump, ventricular assist devices, and
extracorporeal membrane oxygenation. SUMMARY: As our pharmacological and
technological armamentarium improve, our population ages and procedures are
attempted on patients with increasing co-morbid conditions, it will be important
to both utilize newer pharmacological agents and consider innovative uses for
device implementation to achieve optimal perioperative outcomes.
J Cardiovasc Surg (Torino). 2010 Dec;51(6):907-14.
Respiratory tract infections after cardiac surgery: impact on hospital morbidity
and mortality.
Riera M, Ibáñez J, Herrero J, Ignacio Sáez De Ibarra J, Enríquez F, Campillo C,
Bonnín O.
Cardiac Surgery Department, Palma de Mallorca, Spain - rierasagrera@gmail.com.
AIM: Nosocomial pneumonia (NP) and tracheobronchitis after cardiac surgery are
associated with worse outcomes. The aim of this study was to identify risk
factors associated with NPand tracheobronchitis after cardiac surgery and to
determine the impact of these infections on hospital morbidity and mortality.
METHODS: We evaluated 1600 adult patients undergoing cardiac surgery under
standard cardiopulmonary bypass. Data were collected prospectively. All NP and
tracheobronchitis episodes were confirmed by a semiquantitative culture of
endotracheal aspirate. Logistic regression analysis was done to identify risk
factors for respiratory tract infection and mortality.
RESULTS: The rate of NP was 1.2% (15.6 episodes per 1000 days of mechanical
ventilation) and that of tracheobronchitis was 1.6% (21 episodes per 1000 days of
mechanical ventilation). Significant independent risk factors for respiratory
tract infection (pneumonia or tracheobronchitis) were: left ventricular ejection
fraction <30% (P=0.001), chronic renal failure (P<0.0001) and urgent surgery
(P<0.0001). Patients with NP had significantly higher mortality (42% versus 0.9%,
P<0.0001) than patients without respiratory tract infection. The median hospital
length of stay was significantly longer in patients with pneumonia (42 days) and
tracheobronchitis (28 days) than in patients without any respiratory tract
infection (11 days, P<0.0001).
CONCLUSION: NP after cardiac surgery is associated with severe outcomes.
Independent risk markers for respiratory tract infection were left ventricular
ejection fraction <30%, chronic renal failure and urgent surgery.
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