151
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Rijpkema M, Vlot EA, Stehouwer MC, Bruins P. Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass? Perfusion 2023:2676591231199218. [PMID: 37734336 DOI: 10.1177/02676591231199218] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
BACKGROUND Heparin rebound is a common observed phenomenon after cardiac surgery with CPB and is associated with increased postoperative blood loss. However, the administration of extra protamine may lead to increased blood loss as well. Therefore, we want to investigate the relation between heparin rebound and postoperative blood loss and the necessity to provide extra protamine to reverse heparin rebound. METHODS We searched PubMed, Cochrane, EMBASE, Google Scholar and Web of Science to review the question: "Does heparin rebound lead to postoperative blood loss in patients undergoing cardiac surgery with cardiopulmonary bypass." Combination of search words were framed within four major categories: heparin rebound, blood loss, cardiac surgery and cardiopulmonary bypass. All studies that met our question were included. Quality assessment was performed using the Cochrane risk of bias (RoB2) tool for randomized controlled trials and the risk of bias in non-randomized studies of intervention (ROBINS-I) for non-randomised trials. RESULTS 4 randomized and 17 non-randomized studies were included. The mean incidence of heparin rebound was 40%. The postoperative heparin levels, due to heparin rebound, were often below or equal to 0.2 IU/mL. We could not demonstrate an association between heparin rebound and postoperative blood loss or transfusion requirements. However the quality of evidence was poor due to a broad variety of definitions of heparin rebound, measured by various coagulation tests and studies with small sample sizes. CONCLUSION The influence of heparin rebound on postoperative bleeding seems to be negligible, but might get significant in conjunction with incomplete heparin reversal or other coagulopathies. For that reason, it might be useful to get a picture of the entire coagulation spectrum after cardiac surgery, as can be done by the use of a viscoelastic test in conjunction with an aggregometry test.
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Affiliation(s)
- Marije Rijpkema
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Eline A Vlot
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Marco C Stehouwer
- Department of extracorporeal circulation, St Antonius Hospital, Nieuwegein, The Netherlands
| | - Peter Bruins
- Department of Anaesthesiology, Intensive Care and Pain Management, St Antonius Hospital, Nieuwegein, The Netherlands
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152
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Li ZQ, Zhang W, Guo Z, Du XW, Wang W. Risk factors of gastrointestinal bleeding after cardiopulmonary bypass in children: a retrospective study. Front Cardiovasc Med 2023; 10:1224872. [PMID: 37795489 PMCID: PMC10545956 DOI: 10.3389/fcvm.2023.1224872] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/18/2023] [Accepted: 09/08/2023] [Indexed: 10/06/2023] Open
Abstract
Background During cardiac surgery that involved cardiopulmonary bypass (CPB) procedure, gastrointestinal (GI) system was known to be vulnerable to complications such as GI bleeding. Our study aimed to determine the incidence and risk factors associated with GI bleeding in children who received CPB as part of cardiac surgery. Methods This retrospective study enrolled patients aged <18 years who underwent cardiac surgery with CPB from 2013 to 2019 at Shanghai Children's Medical Center. The primary outcome was the incidence of postoperative GI bleeding in children, and the associated risk factors with postoperative GI bleeding episodes were evaluated. Results A total of 21,893 children who underwent cardiac surgery with CPB from 2013 to 2019 were included in this study. For age distribution, 636 (2.9%) were neonates, 10,984 (50.2%) were infants, and 10,273 (46.9%) were children. Among the 410 (1.9%) patients with GI bleeding, 345 (84.2%) survived to hospital discharge. Incidence of GI bleeding in neonates, infants and children were 22.6% (144/636), 2.0% (217/10,984) and 0.5% (49/10,273), respectively. The neonates (22.6%) group was associated with highest risk of GI bleeding. Patients with GI bleeding showed longer length of hospital stays (25.8 ± 15.9 vs. 12.5 ± 8.9, P < 0.001) and higher mortality (15.9% vs. 1.8%, P < 0.001). Multivariate logistic regression analysis showed that age, weight, complicated surgery, operation time, use of extracorporeal membrane oxygenation (ECMO), low cardiac output syndrome (LCOS), hepatic injury, artery lactate level, and postoperative platelet counts were significantly associated with increased risk of GI bleeding in children with congenital heart disease (CHD) pediatric patients that underwent CPB procedure during cardiac surgery. Conclusion The study results suggest that young age, low weight, long operation time, complicated surgery, use of ECMO, LCOS, hepatic injury, high arterial lactate level, and low postoperative platelet counts are independently associated with GI bleeding after CPB in children.
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Affiliation(s)
| | | | | | | | - Wei Wang
- Department of Cardiothoracic Surgery, Shanghai Children’s Medical Center, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
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153
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Hao X, Hu Y, Shao C, Wang X, Li C, Wang H, Hei F, Li X, Liu B, Zhang X, Jin Z, Wang W, Liu Y, Wu T, Yang F. Prevalence of burnout among perfusionists in China: A nationwide survey. Perfusion 2023:2676591231194759. [PMID: 37703429 DOI: 10.1177/02676591231194759] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/15/2023]
Abstract
BACKGROUND Burnout has gained increasing attention worldwide as a phenomenon that affects health care professionals. However, there is a lack of relevant research about its impact on practitioners in the field of cardiovascular perfusion in China. This study investigated the prevalence of and the factors associated with the burnout affecting perfusionists in mainland China. METHODS This national cross-sectional study included perfusionists from 31 provinces in mainland China. Participants were asked to complete a self-administered questionnaire, which included three parts: (1) demographic information, (2) work-related information, and (3) dissatisfaction with work and sources of pressure. The levels of burnout were calculated, and logistic regression was used to analyze the factors associated with burnout. RESULTS The questionnaire, created by the survey program "Questionnaire Star", was sent to 2211 perfusionists in mainland China. A final sample of 1813 perfusionists participated in the survey, with a participation rate of 82.0% (1813/2211). The prevalence of burnout and severe burnout was 86.0% (1559/1813, 95%CI: 84.3%-87.5%) and 13.3% (241/1813, 95%CI: 11.8%-15.0%), respectively. The logistic regression analysis revealed that age [20-29 years, odds ratio (OR) = 1; 30-39 years, OR = 2.009; 40-49 years, OR = 2.220], educational background (bachelor and below, OR = 1; postgraduate, OR = 1.472), and professional background (others, OR = 1; surgery, OR = 1.283; anesthesiology, OR = 2.004) were associated with burnout. We also found that age (20-29 years, OR = 1; 30-39 years, OR = 1.928), professional background (others, OR = 1; surgery, OR = 1.734; anesthesiology, OR = 2.257), annual cardiopulmonary bypass (CPB) case load in the most recent 3 years (< 50, OR = 1; 50-100, OR = 1.613; 100-300, OR = 1.702; ≥300, OR = 2.637), and income level [< 5000 (RMB/month), OR = 1; 5000-10,000, OR = 0.587; 10,000-20,000, OR = 0.366] were associated with severe burnout among perfusionists. CONCLUSIONS Cardiovascular perfusionists in mainland China experience high rates of burnout. Age, the professional background, annual CPB caseload in the most recent 3 years, and income level are independently associated with the burnout rates experienced by these health care professionals.
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Affiliation(s)
- Xing Hao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Yao Hu
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chengcheng Shao
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xiaomeng Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Chenglong Li
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Hong Wang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Feilong Hei
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Xin Li
- Department of Cardiovascular Surgery, Zhongshan Hospital, Fudan University, Shanghai, China
| | - Bin Liu
- Department of Anesthesiology, West China Hospital, Sichuan University, Chengdu, China
| | - Xiaohua Zhang
- Department of Cardiovascular Surgery, Guangdong Provincial People's Hospital, Guangzhou, China
| | - Zhenxiao Jin
- Department of Cardiovascular Surgery, First Affiliated Hospital, Air Force Medical University, Xi'an, China
| | - Wei Wang
- Department of Pediatric Thoracic and Cardiovascular Surgery, Shanghai Children's Medical Center Affiliated to Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Yan Liu
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan, China
| | - Ting Wu
- Department of Perfusion Department of Cardiac Surgery Intensive Care Unit, Tianjin Chest Hospital, Tianjin, China
| | - Feng Yang
- Center for Cardiac Intensive Care, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
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154
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Strobel RJ, Narahari AK, Rotar EP, Young AM, Vergales J, Mehaffey JH, Teman NR, Kern JA, Yarboro LT, Kron IL, Nelson MR, Roeser M. Effect of Cardiopulmonary Bypass on SARS-CoV-2 Vaccination Antibody Levels. J Am Heart Assoc 2023; 12:e029406. [PMID: 37589123 PMCID: PMC10547352 DOI: 10.1161/jaha.123.029406] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Accepted: 05/10/2023] [Indexed: 08/18/2023]
Abstract
Background Adults undergoing heart surgery are particularly vulnerable to respiratory complications, including COVID-19. Immunization can significantly reduce this risk; however, the effect of cardiopulmonary bypass (CPB) on immunization status is unknown. We sought to evaluate the effect of CPB on COVID-19 vaccination antibody concentration after cardiac surgery. Methods and Results This prospective observational clinical trial evaluated adult participants undergoing cardiac surgery requiring CPB at a single institution. All participants received a full primary COVID-19 vaccination series before CPB. SARS-CoV-2 spike protein-specific antibody concentrations were measured before CPB (pre-CPB measurement), 24 hours following CPB (postoperative day 1 measurement), and approximately 1 month following their procedure. Relationships between demographic or surgical variables and change in antibody concentration were assessed via linear regression. A total of 77 participants were enrolled in the study and underwent surgery. Among all participants, mean antibody concentration was significantly decreased on postoperative day 1, relative to pre-CPB levels (-2091 AU/mL, P<0.001). Antibody concentration increased between postoperative day 1and 1 month post CPB measurement (2465 AU/mL, P=0.015). Importantly, no significant difference was observed between pre-CPB and 1 month post CPB concentrations (P=0.983). Two participants (2.63%) developed symptomatic COVID-19 pneumonia postoperatively; 1 case of postoperative COVID-19 pneumonia resulted in mortality (1.3%). Conclusions COVID-19 vaccine antibody concentrations were significantly reduced in the short-term following CPB but returned to pre-CPB levels within 1 month. One case of postoperative COVID 19 pneumonia-specific mortality was observed. These findings suggest the need for heightened precautions in the perioperative period for cardiac surgery patients.
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Affiliation(s)
- Raymond J. Strobel
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | | | - Evan P. Rotar
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Andrew M. Young
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Jeffrey Vergales
- Division of Pediatric Cardiology, Department of PediatricsUniversity of VirginiaCharlottesvilleVAUSA
| | - J. Hunter Mehaffey
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Nicholas R. Teman
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - John A. Kern
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Leora T. Yarboro
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Irving L. Kron
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
| | - Michael R. Nelson
- Division of Allergy and Clinical Immunology, Department of MedicineUniversity of VirginiaCharlottesvilleVAUSA
| | - Mark Roeser
- Division of Cardiac Surgery, Department of SurgeryUniversity of VirginiaCharlottesvilleVAUSA
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155
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Martin SM, Tucci M, Spinella PC, Ducruet T, Fergusson DA, Freed DH, Lacroix J, Poirier N, Sivarajan VB, Steiner ME, Willems A, Garcia Guerra G. Effect of red blood cell storage time in pediatric cardiac surgery patients: A subgroup analysis of a randomized controlled trial. JTCVS Open 2023; 15:454-467. [PMID: 37808065 PMCID: PMC10556812 DOI: 10.1016/j.xjon.2023.04.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/14/2022] [Revised: 03/19/2023] [Accepted: 04/11/2023] [Indexed: 10/10/2023]
Abstract
Objective This study aimed to determine whether or not transfusion of fresh red blood cells (RBCs) reduced the incidence of new or progressive multiple organ dysfunction syndrome compared with standard-issue RBCs in pediatric patients undergoing cardiac surgery. Methods Preplanned secondary analysis of the Age of Blood in Children in Pediatric Intensive Care Unit study, an international randomized controlled trial. This study included children enrolled in the Age of Blood in Children in Pediatric Intensive Care Unit trial and admitted to a pediatric intensive care unit after cardiac surgery with cardiopulmonary bypass. Patients were randomized to receive either fresh (stored ≤7 days) or standard-issue RBCs. The primary outcome measure was new or progressive multiple organ dysfunction syndrome, measured up to 28 days postrandomization or at pediatric intensive care unit discharge, or death. Results One hundred seventy-eight patients (median age, 0.6 years; interquartile range, 0.3-2.6 years) were included with 89 patients randomized to the fresh RBCs group (median length of storage, 5 days; interquartile range, 4-6 days) and 89 to the standard-issue RBCs group (median length of storage, 18 days; interquartile range, 13-22 days). There were no statistically significant differences in new or progressive multiple organ dysfunction syndrome between fresh (43 out of 89 [48.3%]) and standard-issue RBCs groups (38 out of 88 [43.2%]), with a relative risk of 1.12 (95% CI, 0.81 to 1.54; P = .49) and an unadjusted absolute risk difference of 5.1% (95% CI, -9.5% to 19.8%; P = .49). Conclusions In neonates and children undergoing cardiac surgery with cardiopulmonary bypass, the use of fresh RBCs did not reduce the incidence of new or progressive multiple organ dysfunction syndrome compared with the standard-issue RBCs. A larger trial is needed to confirm these results.
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Affiliation(s)
- Sophie M. Martin
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Marisa Tucci
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Philip C. Spinella
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
| | - Thierry Ducruet
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
| | - Dean A. Fergusson
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
| | - Darren H. Freed
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
| | - Jacques Lacroix
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
| | - Venkatesan B. Sivarajan
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
| | - Marie E. Steiner
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
| | - Ariane Willems
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
| | - Gonzalo Garcia Guerra
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
| | - Age of Blood in Children in Pediatric Intensive Care Unit Trial Investigators
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
| | - the Canadian Critical Care Trials Group
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
| | - the Pediatric Acute Lung Injury and Sepsis Investigators Network
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
| | - the BloodNet Pediatric Critical Care Blood Research Network
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
| | - the Groupe Francophone de Réanimation et Urgences Pédiatriques∗
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Departments of Surgery and Critical Care Medicine, Pittsburgh University, Pittsburgh, Pa
- Unité de recherche clinique appliquée, Centre Hospitalier Universitaire Sainte-Justine, Montreal, Québec, Canada
- Clinical Epidemiology Program, Ottawa Hospital Research Institute, Ottawa, Ontario, Canada
- Department of Surgery, University of Alberta, Edmonton, Alberta, Canada
- Department of Cardiac Surgery, Sainte Justine and Montreal Heart Institute, University of Montreal, Montreal, Québec, Canada
- Pediatric Cardiac Intensive Care, Department of Pediatrics, Stollery Children's Hospital, University of Alberta, Edmonton, Alberta, Canada
- Divisions of Hematology/Oncology and Critical Care, Department of Pediatrics, University of Minnesota, Minneapolis, Minn
- Pediatric Intensive Care Unit, Department of Intensive Care, Leiden University Hospital, Leiden, The Netherlands
- Pediatric Intensive Care, Department of Pediatrics, Alberta Children's Hospital; University of Calgary, Calgary, Alberta, Canada
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156
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Oshida S, Tsuboi J, Kin H, Okabayashi H, Komoribayashi N, Akamatsu Y, Fujiwara S, Ogasawara K. Symptomatic subdural hemorrhage following heart valve surgery: a retrospective cohort study. J Neurosurg 2023; 139:741-747. [PMID: 36789990 DOI: 10.3171/2023.1.jns222059] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 01/03/2023] [Indexed: 02/16/2023]
Abstract
OBJECTIVE Subdural hemorrhage (SDH) has been reported to be the most frequent intracranial hemorrhagic complication following open heart surgery; however, its clinical features and pathophysiology remain unclear. The aim of this retrospective study was to elucidate the incidence, clinical course, and factors associated with the development of symptomatic SDH following heart valve surgery. METHODS A retrospective review of medical records on the development of symptomatic SDH after heart valve surgery involving cardiopulmonary bypass (CPB) from April 2011 to March 2016 was performed. Patients who had undergone preoperative cranial computed tomography (CT) or brain magnetic resonance imaging (MRI) were included in this study, and factors associated with SDH following heart valve surgery were analyzed. When neurological symptoms developed after heart valve surgery, cranial CT or brain MRI was performed. RESULTS A total of 556 patients who had undergone heart valve surgery were analyzed. Among these patients, symptomatic SDH occurred in 11 (2.0%). The mean duration of symptomatic onset was 10.1 days (range 2-37 days). Ten of 11 patients (90.9%) developed SDH in the posterior fossa or occipital convexity. Logistic regression analysis revealed longer aortic clamp time (95% CI 1.00-1.10, p = 0.04), higher dose of heparin after surgery (95% CI 1.00-1.02, p = 0.001), and higher pulmonary artery pressure (PAP) just before disconnection of the CPB (95% CI 1.01-1.37, p = 0.04) as significantly associated with the development of SDH. CONCLUSIONS The incidence of symptomatic SDH following heart valve surgery was 2.0%. Symptoms due to SDH usually developed a few days to 1 month after surgery. Surprisingly, most SDHs developed in the posterior fossa or occipital convexity following heart valve surgery. A longer aortic clamp time, higher dose of heparin after surgery, and higher PAP just before disconnection of the CPB were related to the development of symptomatic SDH following heart valve surgery.
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Affiliation(s)
| | - Junichi Tsuboi
- 2Cardiovascular Surgery, Iwate Medical University, Yahaba, Iwate; and
| | - Hajime Kin
- 2Cardiovascular Surgery, Iwate Medical University, Yahaba, Iwate; and
| | - Hitoshi Okabayashi
- 3Department of Cardiovascular Surgery, Mitsubishi Kyoto Hospital, Katsuragosho-cho, Kyoto, Japan
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157
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Backer CL, Overman DM, Dearani JA, Romano JC, Tweddell JS, Ram Kumar S, Marino BS, Bacha EA, Jaquiss RDB, Zaidi AN, Gurvitz M, Costello JM, Pierick TA, Ravekes WJ, Reagor JA, St Louis JD, Spaeth J, Mahle WT, Shin AY, Lopez KN, Karamlou T, Welke KF, Bryant R, Adil Husain S, Chen JM, Kaza A, Wells WJ, Glatz AC, Cohen MI, McElhinney DB, Parra DA, Pasquali SK. Recommendations for Centers Performing Pediatric Heart Surgery in the United States. World J Pediatr Congenit Heart Surg 2023; 14:642-679. [PMID: 37737602 DOI: 10.1177/21501351231190353] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
Care and outcomes for the more than 40,000 patients undergoing pediatric and congenital heart surgery in the United States annually are known to vary widely. While consensus recommendations have been published across numerous fields as one mechanism to promote a high level of care delivery across centers, it has been more than two decades since the last pediatric heart surgery recommendations were published in the United States. More recent guidance is lacking, and collaborative efforts involving the many disciplines engaged in caring for these children have not been undertaken to date. The present initiative brings together professional societies spanning numerous care domains and congenital cardiac surgeons, pediatric cardiologists, nursing, and other healthcare professionals from diverse programs around the country to develop consensus recommendations for United States centers. The focus of this initial work is on pediatric heart surgery, and it is recommended that future efforts focus in detail on the adult congenital population. We describe the background, rationale, and methodology related to this collaborative effort, and recommendations put forth for Essential Care Centers (essential services necessary for any program), and Comprehensive Care Centers (services to optimize comprehensive and high-complexity care), encompassing structure, process, and outcome metrics across 14 domains.
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Affiliation(s)
- Carl L Backer
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - David M Overman
- Division of Cardiovascular Surgery, Children's Minnesota, Mayo Clinic-Children's Minnesota Cardiovascular Collaborative, Minneapolis, MN, USA
| | | | - Jennifer C Romano
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - James S Tweddell
- Department of Surgery, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - S Ram Kumar
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Bradley S Marino
- Department of Pediatric Cardiology, Cleveland Clinic, Cleveland, OH, USA
| | - Emile A Bacha
- Department of Surgery, Columbia University/New York-Presbyterian Morgan Stanley Children's Hospital, New York, NY, USA
| | - Robert D B Jaquiss
- Department of Surgery, UT-Southwestern, Children's Health, Dallas, TX, USA
| | - Ali N Zaidi
- Department of Pediatrics, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Michelle Gurvitz
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| | - John M Costello
- Department of Pediatrics, Medical University of South Carolina, Shawn Jenkins Children's Hospital, Charleston, SC, USA
| | - Trudy A Pierick
- Department of Pediatrics, University of Iowa Stead Family Children's Hospital, Iowa City, IA, USA
| | - William J Ravekes
- Department of Pediatrics, Johns Hopkins Children's Center, Baltimore, MD, USA
| | - James A Reagor
- Department of Cardiovascular Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - James D St Louis
- Department of Surgery, Inova Children's Hospital, Fairfax, VA, USA
| | - James Spaeth
- Department of Anesthesia, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - William T Mahle
- Department of Pediatrics, Emory University, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Andrew Y Shin
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - Keila N Lopez
- Department of Pediatrics, Texas Children's Hospital, Houston, TX, USA
| | - Tara Karamlou
- Department of Thoracic and Cardiovascular Surgery, Cleveland Clinic, Cleveland, OH, USA
| | - Karl F Welke
- Department of Surgery, Atrium Health Levine Children's Hospital, Charlotte, NC, USA
| | - Roosevelt Bryant
- Department of Surgery, Phoenix Children's Hospital, Phoenix, AZ, USA
| | - S Adil Husain
- Department of Surgery, Primary Children's Hospital, Salt Lake City, UT, USA
| | - Jonathan M Chen
- Department of Cardiac Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, USA
| | - Aditya Kaza
- Department of Cardiac Surgery, Boston Children's Hospital, Boston, MA, USA
| | - Winfield J Wells
- Department of Surgery, Children's Hospital of Los Angeles, Los Angeles, CA, USA
| | - Andrew C Glatz
- Department of Pediatrics, St. Louis Children's Hospital, St. Louis, MO, USA
| | - Mitchell I Cohen
- Department of Pediatrics, Inova Children's Hospital, Fairfax, VA, USA
| | - Doff B McElhinney
- Department of Pediatrics, Stanford Medicine Children's Health, Palo Alto, CA, USA
| | - David A Parra
- Department of Pediatrics, Vanderbilt Children's Hospital, Vanderbilt, TN, USA
| | - Sara K Pasquali
- Department of Pediatrics, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
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158
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Kirklin JK. John Kirklin's Impact on the Origins of Open Heart Surgery and the Congenital Heart Surgeons' Society. World J Pediatr Congenit Heart Surg 2023; 14:552-558. [PMID: 37737605 DOI: 10.1177/21501351231176448] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/23/2023]
Abstract
John Kirklin stands out as one of the surgeons most identifiably responsible for bringing the field of open heart surgery to clinical reality and initiating scientific pursuits in the Congenital Heart Surgeons' Society. His accomplishments are perhaps best viewed in the context of other major contributions made by researchers and fellow surgeons, which collectively positioned Kirklin and other cardiac surgery pioneers to usher in the dawn of open heart surgery and later the Congenital Heart Surgeons' Society.
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159
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Karkouti K, Gross PL. What can ex vivo experiments contribute to clinical haemostasis management? Br J Anaesth 2023; 131:424-425. [PMID: 37438219 DOI: 10.1016/j.bja.2023.06.041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Revised: 05/11/2023] [Accepted: 06/18/2023] [Indexed: 07/14/2023] Open
Abstract
A recent ex vivo study found that post-cardiopulmonary bypass platelet defects can be restored with supplemental fibrinogen, but the clinical significance of this finding will require further study. We propose that the best management strategy for achieving haemostasis in bleeding surgical patients is to identify individualised coagulation defects and then use a targeted therapeutic approach that addresses each identified defect systematically.
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Affiliation(s)
- Keyvan Karkouti
- Department of Anesthesia and Pain Management, University Health Network, Sinai Health, and Women's College Hospital, University of Toronto, Toronto, ON, Canada.
| | - Peter L Gross
- Department of Medicine, Hamilton Health Sciences and McMaster University, Hamilton, ON, Canada
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160
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Ho R, McDonald C, Pauls JP, Li Z. Improving Trendelenburg position effectiveness by varying cardiopulmonary bypass flow. Perfusion 2023; 38:1213-1221. [PMID: 35703549 DOI: 10.1177/02676591221108810] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
INTRODUCTION Trendelenburg position (TP) is used to transport gaseous emboli away from the cerebral region during cardiac surgery. However, TP effectiveness has not been fully considered when combined with varying the cardiopulmonary bypass (CPB) flow. This study simulated the supine and TP at different pump flows and assessed the trapped emboli and embolic load entering the aortic arch branch arteries (AABA). METHODS A computational fluid dynamics (CFD) approach used a centrally cannulated adult patient-specific aorta model replicating a CPB circuit. Air emboli of 0.1 mm, 0.5 mm, and 1.0 mm (n = 700 each) were injected into the aorta placed in the supine position (0°) and the TP (-20°) at 2 L/min and 5 L/min. The number of emboli entering the AABA were compared. An aortic phantom flow experiment was performed to validate air bubble behaviour. RESULTS TP at 5 L/min had the lowest 0.1 mm mean (±SD) embolic load compared to the supine 2 L/min (55.3 ± 30.8 vs 64.3 ± 35.4). For both the supine and TP, the lower flow of 2 L/min had the highest number of simulated trapped emboli in higher elevated regions than at 5 L/min (541 ± 185 and 548 ± 191 vs 520 ± 159 and 512 ± 174), respectively. The flow experiment demonstrated that 2 L/min promoted bubble coalescence and high amounts of trapped emboli and 5 L/min transported air emboli away from the AABA. CONCLUSIONS TP effectiveness was improved by using CPB flow to manage air emboli. These results provide insights for predicting emboli behaviour and improving emboli de-airing procedures.
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Affiliation(s)
- Raymond Ho
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Charles McDonald
- Department of Anaesthesia and Perfusion, The Prince Charles Hospital. Chermside, QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory (ICETLAB), Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, QLD, Australia
| | - Zhiyong Li
- School of Mechanical, Medical and Process Engineering, Faculty of Engineering, Queensland University of Technology (QUT), Brisbane, QLD, Australia
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161
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Wang Y, Chen L, Yao C, Wang T, Wu J, Shang Y, Li B, Xia H, Huang S, Wang F, Wen S, Huang S, Lin Y, Dong N, Yao S. Early plasma proteomic biomarkers and prediction model of acute respiratory distress syndrome after cardiopulmonary bypass: a prospective nested cohort study. Int J Surg 2023; 109:2561-2573. [PMID: 37528797 PMCID: PMC10498873 DOI: 10.1097/js9.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/21/2023] [Indexed: 08/03/2023]
Abstract
BACKGROUND Early recognition of the risk of acute respiratory distress syndrome (ARDS) after cardiopulmonary bypass (CPB) may improve clinical outcomes. The main objective of this study was to identify proteomic biomarkers and develop an early prediction model for CPB-ARDS. METHODS The authors conducted three prospective nested cohort studies of all consecutive patients undergoing cardiac surgery with CPB at Union Hospital of Tongji Medical College Hospital. Plasma proteomic profiling was performed in ARDS patients and matched controls (Cohort 1, April 2021-July 2021) at multiple timepoints: before CPB (T1), at the end of CPB (T2), and 24 h after CPB (T3). Then, for Cohort 2 (August 2021-July 2022), biomarker expression was measured and verified in the plasma. Furthermore, lung ischemia/reperfusion injury (LIRI) models and sham-operation were established in 50 rats to explore the tissue-level expression of biomarkers identified in the aforementioned clinical cohort. Subsequently, a machine learning-based prediction model incorporating protein and clinical predictors from Cohort 2 for CPB-ARDS was developed and internally validated. Model performance was externally validated on Cohort 3 (January 2023-March 2023). RESULTS A total of 709 proteins were identified, with 9, 29, and 35 altered proteins between ARDS cases and controls at T1, T2, and T3, respectively, in Cohort 1. Following quantitative verification of several predictive proteins in Cohort 2, higher levels of thioredoxin domain containing 5 (TXNDC5), cathepsin L (CTSL), and NPC intracellular cholesterol transporter 2 (NPC2) at T2 were observed in CPB-ARDS patients. A dynamic online predictive nomogram was developed based on three proteins (TXNDC5, CTSL, and NPC2) and two clinical risk factors (CPB time and massive blood transfusion), with excellent performance (precision: 83.33%, sensitivity: 93.33%, specificity: 61.16%, and F1 score: 85.05%). The mean area under the receiver operating characteristics curve (AUC) of the model after 10-fold cross-validation was 0.839 (95% CI: 0.824-0.855). Model discrimination and calibration were maintained during external validation dataset testing, with an AUC of 0.820 (95% CI: 0.685-0.955) and a Brier Score of 0.177 (95% CI: 0.147-0.206). Moreover, the considerably overexpressed TXNDC5 and CTSL proteins identified in the plasma of patients with CPB-ARDS, exhibited a significant upregulation in the lung tissue of LIRI rats. CONCLUSIONS This study identified several novel predictive biomarkers, developed and validated a practical prediction tool using biomarker and clinical factor combinations for individual prediction of CPB-ARDS risk. Assessing the plasma TXNDC5, CTSL, and NPC2 levels might identify patients who warrant closer follow-up and intensified therapy for ARDS prevention following major surgery.
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Affiliation(s)
- Yu Wang
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Lin Chen
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | | | - Tingting Wang
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Jing Wu
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - You Shang
- Department of Critical Care Medicine, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Bo Li
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Haifa Xia
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Shiqian Huang
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Fuquan Wang
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | - Shuyu Wen
- Department of Cardiovascular Surgery
| | - Shaoxin Huang
- SpecAlly Life Technology Co., Ltd., Wuhan, Hubei, People’s Republic of China
| | - Yun Lin
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
| | | | - Shanglong Yao
- Department of Anesthesiology
- Key Laboratory of Anesthesiology and Resuscitation (Huazhong University of Science and Technology), Ministry of Education
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Schoerghuber M, Bärnthaler T, Prüller F, Mantaj P, Cvirn G, Toller W, Klivinyi C, Mahla E, Heinemann A. Supplemental fibrinogen restores thrombus formation in cardiopulmonary bypass-induced platelet dysfunction ex vivo. Br J Anaesth 2023; 131:452-462. [PMID: 37087333 PMCID: PMC10485366 DOI: 10.1016/j.bja.2023.03.010] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2022] [Revised: 02/27/2023] [Accepted: 03/02/2023] [Indexed: 04/24/2023] Open
Abstract
BACKGROUND Major cardiac surgery related blood loss is associated with increased postoperative morbidity and mortality. Platelet dysfunction is believed to contribute to post-cardiopulmonary bypass (CPB)-induced microvascular bleeding. We hypothesised that moderately hypothermic CPB induces platelet dysfunction and that supplemental fibrinogen can restore in vitro thrombus formation. METHODS Blood from 18 patients, undergoing first-time elective isolated aortic valve surgery was drawn before CPB, 30 min after initiation of CPB, and after CPB and protamine administration, respectively. Platelet aggregation was quantified by optical aggregometry, platelet activation by flow-cytometric detection of platelet surface expression of P-selectin, annexin V, and activated glycoprotein IIb/IIIa, thrombus formation under flow and effect of supplemental fibrinogen (4 mg ml-1) on in vitro thrombogenesis. RESULTS Post-CPB adenosine-diphosphate and TRAP-6-induced aggregation decreased by 40% and 10% of pre-CPB levels, respectively (P<0.0001). Although CPB did not change glycoprotein IIb/IIIa receptor expression, it increased the percentage of unstimulated P-selectin (1.2% vs 7%, P<0.01) positive cells and annexin V mean fluorescence intensity (15.5 vs 17.2, P<0.05), but decreased percentage of stimulated P-selectin (52% vs 26%, P<0.01) positive cells and annexin V mean fluorescence intensity (508 vs 325, P<0.05). Thrombus area decreased from 6820 before CPB to 5230 after CPB (P<0.05, arbitrary units [a.u.]). Supplemental fibrinogen increased thrombus formation to 20 324 and 11 367 a.u. before CPB and after CPB, respectively (P<0.001), thereby restoring post-CPB thrombus area to levels comparable with or higher than pre-CPB baseline. CONCLUSIONS Single valve surgery using moderately hypothermic CPB induces partial platelet dysfunction. Thrombus formation was restored in an experimental study design by ex vivo supplementation of fibrinogen.
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Affiliation(s)
- Michael Schoerghuber
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Thomas Bärnthaler
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria.
| | - Florian Prüller
- Clinical Institute of Medical Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Polina Mantaj
- Department of Cardiac Surgery, Medical University of Graz, Graz, Austria
| | - Gerhard Cvirn
- Otto Loewi Research Center, Division of Physiological Chemistry, Medical University of Graz, Graz, Austria
| | - Wolfgang Toller
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Christoph Klivinyi
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Elisabeth Mahla
- Department of Anesthesiology and Intensive Care Medicine, Medical University of Graz, Graz, Austria
| | - Akos Heinemann
- Otto Loewi Research Center, Division of Pharmacology, Medical University of Graz, Graz, Austria
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Taiana M, Tomasella I, Russo A, Lerose A, Ceola Graziadei M, Corubolo L, Rama J, Schweiger V, Vignola A, Polati E, Luciani GB, Onorati F, Donadello K, Gottin L. Analysis of P(v-a)CO 2/C(a-v)O 2 Ratio and Other Perfusion Markers in a Population of 98 Pediatric Patients Undergoing Cardiac Surgery. J Clin Med 2023; 12:5700. [PMID: 37685767 PMCID: PMC10488867 DOI: 10.3390/jcm12175700] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/10/2023] [Revised: 08/23/2023] [Accepted: 08/30/2023] [Indexed: 09/10/2023] Open
Abstract
BACKGROUND The so-called Low Cardiac Output Syndrome (LCOS) is one of the most common complications in pediatric patients with congenital heart disease undergoing corrective surgery. LCOS requires high concentrations of inotropes to support cardiac contractility and improve cardiac output, allowing for better systemic perfusion. To date, serum lactate concentrations and central venous oxygen saturation (ScVO2) are the most commonly used perfusion markers, but they are not completely reliable in identifying a state of global tissue hypoxia. The study aims to evaluate whether the venoarterial carbon dioxide difference/arterial-venous oxygen difference ratio [P(v-a)CO2/C(a-v)O2] can be a good index to predict the development of LCOS in the aforementioned patients, so as to treat it promptly. METHODS This study followed a population of 98 children undergoing corrective cardiac surgery from June 2018 to October 2020 at the Department of Cardiac Surgery of University Hospital Integrated Trust and their subsequent admission at the Postoperative Cardiothoracic Surgery Intensive Care Unit. During the study, central arterial and venous blood gas analyses were carried out before and after cardiopulmonary bypass (CPB) (pre-CPB and post-CPB), at admission to the intensive care unit, before and after extubation, and at any time of instability or modification of the patient's clinical and therapeutic conditions. RESULTS The data analysis shows that 46.9% of the children developed LCOS (in line with the current literature) but that there is no statistically significant association between the P(v-a)CO2/C(a-v)O2 ratio and LCOS onset. Despite the limits of statistical significance, however, a 31% increase in the ratio emerged from the pre-CPB phase to the post-CPB phase when LCOS is present. CONCLUSIONS This study confirms a statistically significant association between the most used markers in adult patients (serum lactate concentration, ScVO2, and oxygen extraction ratio-ERO2) measured in the pre-CPB phase and the incidence of LCOS onset, especially in patients with hemodynamic instability before surgery.
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Affiliation(s)
- Matteo Taiana
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Irene Tomasella
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Alessandro Russo
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Annalisa Lerose
- Anesthesia and Intensive Care Unit, Magalini Hospital ULSS 9 Scaligera, Villafranca, 37069 Verona, Italy;
| | - Marcello Ceola Graziadei
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Luisa Corubolo
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Jacopo Rama
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
| | - Vittorio Schweiger
- Anesthesia and Intensive Care Unit, Policlinico G.B. Rossi, Hospital and University Trust of Verona, P. le L. Scuro, 37129 Verona, Italy; (V.S.); (E.P.); (K.D.)
| | - Alessandro Vignola
- Emergency Medicine Department, Hospital and University Trust of Verona, P. le A. Stefani, 37126 Verona, Italy
| | - Enrico Polati
- Anesthesia and Intensive Care Unit, Policlinico G.B. Rossi, Hospital and University Trust of Verona, P. le L. Scuro, 37129 Verona, Italy; (V.S.); (E.P.); (K.D.)
| | - Giovanni Battista Luciani
- Cardiac Surgery Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37126 Verona, Italy; (G.B.L.); (F.O.)
| | - Francesco Onorati
- Cardiac Surgery Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37126 Verona, Italy; (G.B.L.); (F.O.)
| | - Katia Donadello
- Anesthesia and Intensive Care Unit, Policlinico G.B. Rossi, Hospital and University Trust of Verona, P. le L. Scuro, 37129 Verona, Italy; (V.S.); (E.P.); (K.D.)
| | - Leonardo Gottin
- Cardiothoracic and Vascular Intensive Care Unit, Hospital and University Trust of Verona, P. le A. Stefani, 37124 Verona, Italy; (I.T.); (A.R.); (M.C.G.); (L.C.); (J.R.); (L.G.)
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164
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Khuong JN, Forsyth CJ, Manuel L, Kingsford-Smith K, Srivastava A, Bassin L. Paraprotein associated heparin resistance during cardiopulmonary bypass. Perfusion 2023; 38:1319-1321. [PMID: 35700111 DOI: 10.1177/02676591221109143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Heparin resistance during cardiopulmonary bypass poses a significant intraoperative dilemma. Antithrombin deficiency related heparin resistance is well described, but less common causes are still poorly understood and inadequately managed. CASE REPORT We present a case of heparin resistance during cardiopulmonary bypass in a gentleman with no previous haematological history or thrombotic risk factors. The patient required three times the regular dose of unfractionated heparin to achieve acceptable conditions to initiate and maintain bypass. The patient was found to have elevated serum immunoglobulin M (IgM) kappa paraprotein on post-operative investigation. DISCUSSION Paraproteins may exhibit non-specific binding to long polymeric chains of unfractionated heparin and inhibits the interaction between heparin and antithrombin. As a result, excessive doses of heparin are required to overcome this, which increases the risk of perioperative bleeding and other complications. CONCLUSION Elevated serum paraprotein levels should be recognised as a cause of heparin resistance during cardiopulmonary bypass.
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Affiliation(s)
- Jacqueline N Khuong
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Cecily J Forsyth
- Department of Medicine, Gosford Hospital, Gosford, NSW, Australia
| | - Lucy Manuel
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Kate Kingsford-Smith
- Perfusion and Autotransfusion Unit, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Arpit Srivastava
- Department of Anaesthesia, Royal North Shore Hospital, Sydney, NSW, Australia
| | - Levi Bassin
- Department of Cardiothoracic Surgery, Royal North Shore Hospital, Sydney, NSW, Australia
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165
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Peer SB, Lamba HK, Shafii AE. The Transition From Temporary to Durable Mechanical Circulatory Support: Surgical Considerations. Tex Heart Inst J 2023; 50:e238227. [PMID: 37646111 PMCID: PMC10660131 DOI: 10.14503/thij-23-8227] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Syed B. Peer
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Harveen K. Lamba
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Alexis E. Shafii
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
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166
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Peer SB, Loor G. Surgical Considerations for Left Ventricular Assist Device Implantation. Tex Heart Inst J 2023; 50:e238226. [PMID: 37646110 PMCID: PMC10660416 DOI: 10.14503/thij-23-8226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/01/2023]
Affiliation(s)
- Syed B. Peer
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
| | - Gabriel Loor
- Division of Cardiothoracic Transplantation and Circulatory Support, Department of Surgery, Baylor College of Medicine, Houston, Texas
- Department of Cardiovascular Surgery, The Texas Heart Institute, Houston, Texas
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167
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Stammers AH, Chores JB, Tesdahl EA, Patel KP, Baeza J, Mosca MS, Varsamis M, Petterson CM, Firstenberg MS, Jacobs JP. Establishment of a national quality improvement process on oxygen delivery index during cardiopulmonary bypass. Perfusion 2023:2676591231198366. [PMID: 37632252 DOI: 10.1177/02676591231198366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
Targeted oxygen delivery during cardiopulmonary bypass (CPB) has received significant attention due to its influence on patient outcomes, especially in mitigating acute kidney injury. While it has gained popularity in select institutions, there remains a gap in establishing it globally across multiple centers. The purpose of this investigation was to describe the development of a quality improvement process of targeted oxygen delivery during CPB across hospitals throughout the United States. A systematic approach to utilize oxygen delivery index (DO2i) as a key performance indicator within hospitals serviced by a national provider of perfusion services. The process included a review of the current literature on DO2i, which yielded a target nadir value (272 mL/min/m2) and an area under the curve (DO2i272AUC) cut off of 632. All data is displayed on a dashboard with results categorized across multiple levels from system-wide to individual clinician performance. From January 2020 through December 2022, DO2i data from 91 hospitals and 11,165 coronary artery bypass graft procedures were collected. During this period the monthly proportion of DO2i measurements above the target nadir DO2i272 ranged from 60.5% to 78.4% with a mean+/-SD of 70.8 +/- 4.2%. Binary logistic regression for the first 7 months following monthly DO2i performance reporting has shown a statistically significant positive linear trend in the probability of achieving the target DO2i272 (p < .001), with a crude increase of approximately 7.8% for DO2i272AUC, and a 73.8% success rate (p < .001). A survey was sent to all individuals measuring oxygen delivery during CPB to assess why a target DO2i272 could not be reached. The two most common responses were an 'inability to improve CPB flow rates' and 'restrictive allogeneic red blood cell transfusion policies'. This study demonstrates that targeting a minimum level of oxygen delivery can serve as a key performance indicator during CPB using a structured quality improvement process.
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Affiliation(s)
| | | | | | - Kirti P Patel
- Medical Department, SpecialtyCare, Brentwood, TN, USA
| | | | | | | | | | | | - Jeffrey P Jacobs
- Division of Cardiovascular Surgery, Departments of Surgery and Pediatrics, University of Florida, Gainesville, FL, USA
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168
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Xu RK, Ding PC, Wang J, Liu Y, Wang L, Shi H, Wang X. A novel survival rat model of hyperkalemia and landiolol induced cardioplegic arrest and resuscitation via cardiopulmonary bypass. Perfusion 2023:2676591231199214. [PMID: 37632272 DOI: 10.1177/02676591231199214] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/27/2023]
Abstract
OBJECTIVE A small animal model would be an effective tool for research on the pathophysiology of cardiopulmonary bypass (CPB). However, numerous CPB models do not involve myocardial arrest and resuscitation. The aim of this research is to establish an easily achievable myocardial arrest and resuscitation CPB model through hyperkalemia and landiolol, simulating clinical cardiac surgery. MATERIALS AND METHODS Ten Sprague-Dawley rats were chosen for CPB. Rats underwent sevoflurane inhalation induction anesthesia and were sustained in an anesthesia state by intubation and intraperitoneal injection's of esketamine and propofol. The entire CPB circuit include a reservoir, a membrane oxygenator and a roller pump, which were connected into a complete loop via silicon tubes and infusion tube.After CPB was established through the tail artery and internal jugular vein, cardioplegic arrest was induced and maintained for 5 min at a rectum temperature of 28.5 ± 0.5°C with hyperkalemia and landiolol. Calcium chloride, epinephrine and insulin were then used for resuscitation. RESULT All rats successfully finished cardioplegic arrest, resuscitation procedure and survived 2 h postoperatively. Mean hematocrit during CPB was significantly lower than physiologic values of the baseline. The mean time of arrest-resuscitation and CPB was 5.4 ± 0.8 min and 98.5 ± 5.0 min. The blood gas at each detection point were in range with the normal standard requirement of CPB. CONCLUSION The establishment of cardioplegic arrest and resuscitation procedure via hyperkalemia and landiolol during CPB of WD rat could be achieved successfully. This animal model could be an alternative organ injury research on organ injury of patients undergoing cardiac surgery.
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Affiliation(s)
- Ru Kun Xu
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - Pei Cheng Ding
- Department of Cardiothoracic Surgery, Children's Hospital of Nanjing Medical University, Nanjing, China
| | - JianKai Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - YiMing Liu
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - Lei Wang
- Department of Thoracic and Cardiovascular Surgery, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - HongWei Shi
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
| | - XiaoLiang Wang
- Department of Anesthesiology, Nanjing First Hospital, Nanjing Medical University, Jiangsu, China
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Matsumoto R, Fujiyoshi T, Kamiya K, Matsubayashi J, Fukuda S, Nishibe T, Ogino H. Complete Resection of a Cavoatrial Metastatic Liposarcoma under Hypothermic Circulatory Arrest. Ann Thorac Cardiovasc Surg 2023; 29:206-209. [PMID: 35095053 PMCID: PMC10466114 DOI: 10.5761/atcs.cr.21-00226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Accepted: 12/19/2021] [Indexed: 11/16/2022] Open
Abstract
A patient underwent surgical resection twice for primary and metastatic dedifferentiated liposarcomas. Computed tomography revealed a tumor mass at the cavoatrial junction. Prompt surgical resection of the tumor with thrombectomy was successfully performed using cardiopulmonary bypass with hypothermic circulatory arrest. Despite the poor prognosis of metastatic or recurrent liposarcoma, the patient has survived for 8 years since the first tumor resection.
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Affiliation(s)
- Ryumon Matsumoto
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiki Fujiyoshi
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Kentaro Kamiya
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | | | - Shoji Fukuda
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Toshiya Nishibe
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
| | - Hitoshi Ogino
- Department of Cardiovascular Surgery, Tokyo Medical University, Tokyo, Japan
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170
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Hanbeyoglu O, Aydin S. Subfatin, Asprosin, Alamandine and Maresin-1 Inflammation Molecules in Cardiopulmonary Bypass. J Inflamm Res 2023; 16:3469-3477. [PMID: 37605784 PMCID: PMC10440107 DOI: 10.2147/jir.s422998] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/25/2023] [Accepted: 08/11/2023] [Indexed: 08/23/2023] Open
Abstract
Purpose Cardiopulmonary bypass (CPB) is a nonphysiological procedure in which inflammatory reactions and oxidative stress are induced, hormones and hemodynamic parameters are affected, and circulation is maintained outside the body. This study aimed to examine the effects of CPB on blood subfatin (SUB), asprossin (ASP), alamandine (ALA) and maresin-1 (MaR-1) levels. Materials and Methods Controls and patients who underwent open-heart surgery with CPB and whose age and body mass indices were compatible with each other were included in the study. Venous blood samples were collected from CPB patients (n =19) before anesthesia induction (T1), before CPB (T2), 5 min before cross-clamp removal (T3), 5 min after cross-clamp removal (T4), when taken to the intensive care unit (T5), postoperative 24th hour (T6) and 72nd hour (T7) postoperatively. Venous blood was collected from the healthy controls (n =19). The amounts of SUB, ASP, ALA, and MaR-1 in the blood samples were measured using an Enzyme-Linked Immunosorbent Assay (ELISA). Results The amounts of SUB and MaR-1 in the control group were significantly higher than those in CPB patients, while these parameters in T1-T3 blood gradually decreased in CPB patients (p<0.01). It was also reported that the amounts of ASP and ALA in the control group were significantly lower than those in CPB patients, whereas those parameters in the T1-T3 blood samples increased gradually in CPB patients, but started to decrease in T4-T7 blood samples. Conclusion These hormonal changes in the organism due to CPB demonstrate that "hormonal metabolic adaptation" mechanisms may be activated to eliminate the negative consequences of surgery. According to these data, SUB, MaR-1, anti-alamandine, and anti-asprosin could be used in CPB surgeries may come to the fore in the future to increase the safety of CPB surgeries.
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Affiliation(s)
- Onur Hanbeyoglu
- Department of Anesthesiology, Fethi Sekin City Hospital, Elazig, Turkiye
| | - Suna Aydin
- Department of Cardiovascular Surgery, Fethi Sekin City Hospital, Elazig, Turkiye
- Department of Anatomy, School of Medicine, Firat University, Elazig, Turkiye
- Department of Histology and Embryology, School of Veterinary Medicine, Firat University, Elazig, Turkiye
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Zajonz TS, Kunzemann C, Schreiner AL, Beckert F, Schneck E, Boening A, Markmann M, Sander M, Koch C. Potentials of Acetylcholinesterase and Butyrylcholinesterase Alterations in On-Pump Coronary Artery Bypass Surgery in Postoperative Delirium: An Observational Trial. J Clin Med 2023; 12:5245. [PMID: 37629287 PMCID: PMC10455192 DOI: 10.3390/jcm12165245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2023] [Revised: 07/31/2023] [Accepted: 08/09/2023] [Indexed: 08/27/2023] Open
Abstract
Cardiac surgery is regularly associated with postoperative delirium (POD), affected by neuro-inflammation and changes in cholinergic activity. Therefore, this prospective observational study aimed to evaluate whether pre- and perioperative changes in blood acetylcholinesterase (AChE) and butyrylcholinesterase (BChE) activity were associated with POD development in patients undergoing isolated elective coronary artery bypass graft (CABG) surgery. It included 93 patients. Pre- and postoperative blood AChE and BChE activities were measured with photometric rapid-point-of-care-testing. The Intensive Care Delirium Screening Checklist and the Confusion Assessment Method for the Intensive Care Unit were used to screen patients for POD. POD developed in 20 patients (21.5%), who were older (p = 0.003), had higher EuroSCOREs (p ≤ 0.001), and had longer intensive care unit stays (p < 0.001). On postoperative day one, BChE activity decreased from preoperative values more in patients with (31.9%) than without (23.7%) POD (group difference p = 0.002). Applying a cutoff of ≥32.0% for BChE activity changes, receiver operating characteristic analysis demonstrated a moderate prediction capability for POD (area under the curve = 0.72, p = 0.002). The risk of developing POD was 4.31 times higher with a BChE activity change of ≥32.0% (p = 0.010). Monitoring the pre- to postoperative reduction in BChE activity might be a clinically practicable biomarker for detecting patients at risk of developing POD after CABG surgery.
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Affiliation(s)
- Thomas S. Zajonz
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Christian Kunzemann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Anna Lena Schreiner
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Frauke Beckert
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Emmanuel Schneck
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Andreas Boening
- Department of Cardiac and Vascular Surgery, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany;
| | - Melanie Markmann
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Michael Sander
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
| | - Christian Koch
- Department of Anesthesiology, Operative Intensive Care Medicine and Pain Therapy, University Hospital of Giessen and Marburg, Justus Liebig University of Giessen, 35392 Giessen, Germany; (C.K.); (A.L.S.); (F.B.); (E.S.); (M.M.); (M.S.); (C.K.)
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Jungner Å, Lennartsson F, Björkman-Burtscher I, Blennow K, Zetterberg H, Ley D. Perioperative brain injury marker concentrations in neonatal open-heart surgery: a prospective observational study. Front Pediatr 2023; 11:1186061. [PMID: 37622081 PMCID: PMC10445649 DOI: 10.3389/fped.2023.1186061] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2023] [Accepted: 06/29/2023] [Indexed: 08/26/2023] Open
Abstract
Neonates with critical congenital heart defects undergoing open-heart surgery on cardiopulmonary bypass circulation are at risk for white matter brain injury. This article reports on pre- and postoperative plasma concentrations of brain injury markers glial fibrillary acidic protein (GFAP), neurofilament light (NfL) and Tau, and their respective associations with white matter lesions detected on postoperatively performed brain MRI. Forty term newborns with isolated critical congenital heart defects were included in a prospective observational study. Brain injury marker plasma concentrations were determined prior to surgery and at postoperative days 1, 2 and 3. Brain magnetic resonance imaging was performed pre- and postoperatively. Concentrations of brain injury markers were analysed using ultrasensitive single molecule array technology. Absolute pre- and postoperative plasma biomarker concentrations, and postoperative concentrations adjusted for preoperative concentrations were used for subsequent analysis. Plasma concentrations of GFAP, NfL and Tau displayed a well-defined temporal trajectory after neonatal cardiopulmonary bypass circulation. GFAP and Tau reached peak concentrations at postoperative day 2 (median concentrations 170.5 and 67.2 pg/ml, respectively), whereas NfL continued to increase throughout the study period (median concentration at postoperative day 3 191.5 pg/ml). Adjusted Tau at postoperative day 2 was significantly higher in infants presenting with white matter lesions on postoperative MRI compared to infants without white matter injury.
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Affiliation(s)
- Åsa Jungner
- Pediatric Surgery and Neonatal Care, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Finn Lennartsson
- Diagnostic radiology, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
| | - Isabella Björkman-Burtscher
- Department of Radiology, Sahlgrenska University Hospital, Region Västra Götaland, Gothenburg, Sweden
- Department of Radiology, Institute of Clinical Sciences, Sahlgrenska Academy, University of Gothenburg, Gothenburg, Sweden
| | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Region Västra Götaland, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, Sahlgrenska Academy, University of Gothenburg, Mölndal, Sweden
- Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Region Västra Götaland, Mölndal, Sweden
- Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
- UK Dementia Research Institute at UCL, London, UK
- Hong Kong Center for Neurodegenerative Diseases, Clear Water Bay, Hong Kong, Hong Kong SAR, China
- Wisconsin Alzheimer’s Disease Research Center, University of Wisconsin School of Medicine and Public Health, University of Wisconsin-Madison, Madison, WI, United States
| | - David Ley
- Pediatric Surgery and Neonatal Care, Department of Clinical Sciences Lund, Lund University, Skåne University Hospital, Lund, Sweden
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173
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Beukers AM, Hugo JDV, Haumann RG, Boltje JWT, Ie ELK, Loer SA, Bulte CSE, Vonk A. Changes in colloid oncotic pressure during cardiac surgery with different prime fluid strategies. Perfusion 2023:2676591231193626. [PMID: 37553122 DOI: 10.1177/02676591231193626] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/10/2023]
Abstract
OBJECTIVE In cardiac surgery, colloid oncotic pressure (COP) is affected by haemodilution that results from composition and volume of prime fluid of cardiopulmonary bypass (CPB). However, the extent to which different priming strategies alter COP is largely unknown. Therefore, we investigated the effect of different priming strategies on COP in on-pump cardiac surgery. METHODS Patients (n = 60) were divided into 3 groups (n = 20 each), based on the center in which they were operated and the specific prime fluid strategy used in that center during the inclusion period. CPB prime fluids were either gelofusine-, albumin-, or crystalloid based, the latter two with or without retrograde autologous priming. RESULTS In all groups, COP was lowest after weaning from CPB and one hour after CPB. Between groups, COP was lowest with gelofusine prime fluid (16.4, 16.8 mmHg, respectively) compared with crystalloids (MD: -1.9; 95% CI:-3.6, -0.2; p = .02 and MD: -2.4, 95% CI: -4.2, -0.7; p = .002) and albumin (MD: -1.8, 95% CI: -3.5, -0.50; p = .041 and MD: -2.4, 95% CI: -4.1, -0.7; p = .002). In all groups, the decrease in COP one hour after bypass compared to baseline correlated positively with fluid balance at the end of surgery (p < .001). CONCLUSIONS COP significantly decrease during CPB surgery with the largest decrease in COP at the end of surgery, while at the same time fluid balance increases. We suggest that prime fluid strategy should be carefully selected when maintenance of COP during cardiac surgery is desirable.
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Affiliation(s)
- Anne Maria Beukers
- Department of Anaesthesiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Juan de Villiers Hugo
- Department of Cardiothoracic Surgery, LUMC, Leiden University, Leiden, The Netherlands
| | | | - Jan Willem Taco Boltje
- Department of Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
| | - Evy Loan Khiam Ie
- Department of Anaesthesiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Stephan Alexander Loer
- Department of Anaesthesiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
| | - Carolien Suzanna Enna Bulte
- Department of Anaesthesiology, Amsterdam UMC location Vrije Universiteit Amsterdam, Amsterdam, The Netherlands
- Amsterdam Cardiovascular Sciences, Amsterdam, The Netherlands
| | - Alexander Vonk
- Department of Cardiothoracic Surgery, Amsterdam UMC location University of Amsterdam, Amsterdam, The Netherlands
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174
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Chiari P, Desebbe O, Durand M, Fischer MO, Lena-Quintard D, Palao JC, Samson G, Varillon Y, Vaz B, Joseph P, Ferraris A, Jacquet-Lagreze M, Pozzi M, Maucort-Boulch D, Ovize M, Bidaux G, Mewton N, Fellahi JL. A Multimodal Cardioprotection Strategy During Cardiac Surgery: The ProCCard Study. J Cardiothorac Vasc Anesth 2023; 37:1368-1376. [PMID: 37202231 DOI: 10.1053/j.jvca.2023.04.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 04/03/2023] [Accepted: 04/07/2023] [Indexed: 05/20/2023]
Abstract
OBJECTIVE The ProCCard study tested whether combining several cardioprotective interventions would reduce the myocardial and other biological and clinical damage in patients undergoing cardiac surgery. DESIGN Prospective, randomized, controlled trial. SETTING Multicenter tertiary care hospitals. PARTICIPANTS 210 patients scheduled to undergo aortic valve surgery. INTERVENTIONS A control group (standard of care) was compared to a treated group combining five perioperative cardioprotective techniques: anesthesia with sevoflurane, remote ischemic preconditioning, close intraoperative blood glucose control, moderate respiratory acidosis (pH 7.30) just before aortic unclamping (concept of the "pH paradox"), and gentle reperfusion just after aortic unclamping. MEASUREMENTS AND MAIN RESULTS The primary outcome was the postoperative 72-h area under the curve (AUC) for high-sensitivity cardiac troponin I (hsTnI). Secondary endpoints were biological markers and clinical events occurring during the 30 postoperative days and the prespecified subgroup analyses. The linear relationship between the 72-h AUC for hsTnI and aortic clamping time, significant in both groups (p < 0.0001), was not modified by the treatment (p = 0.57). The rate of adverse events at 30 days was identical. A non-significant reduction of the 72-h AUC for hsTnI (-24%, p = 0.15) was observed when sevoflurane was administered during cardiopulmonary bypass (46% of patients in the treated group). The incidence of postoperative renal failure was not reduced (p = 0.104). CONCLUSION This multimodal cardioprotection has not demonstrated any biological or clinical benefit during cardiac surgery. The cardio- and reno-protective effects of sevoflurane and remote ischemic preconditioning therefore remain to be demonstrated in this context.
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Affiliation(s)
- Pascal Chiari
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France..
| | - Olivier Desebbe
- Service d'Anesthésie-Réanimation, Clinique de la Sauvegarde, Ramsay Générale de Santé, Lyon, France
| | - Michel Durand
- Pole d'Anesthésie-Réanimation, Hôpital Albert Michallon, Centre Hospitalier Universitaire de Grenoble-Alpes, Grenoble, France
| | - Marc-Olivier Fischer
- Service d'Anesthésie-Réanimation, Centre Hospitalier Universitaire de Caen, Université de Normandie, UNICAEN, Caen, France
| | - Diane Lena-Quintard
- Service d'Anesthésie-Réanimation, Institut Arnault Tzanck, Saint Laurent du Var, France
| | - Jean-Charles Palao
- Service d'Anesthésie-Réanimation, Hôpital Nord, Centre Hospitalier Universitaire de Saint Etienne, Saint Etienne, France
| | - Géraldine Samson
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Yvonne Varillon
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Bernadette Vaz
- Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Pierre Joseph
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Arnaud Ferraris
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Matthias Jacquet-Lagreze
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
| | - Matteo Pozzi
- Service de Chirurgie Cardiaque, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Delphine Maucort-Boulch
- Service de Biostatistique-Bioinformatique, Pôle Santé Publique, Hospices Civils de Lyon, Lyon, France; Université de Lyon, Lyon, France; Université Lyon 1, Villeurbanne, France; CNRS, UMR5558, Laboratoire de Biométrie et Biologie Évolutive, Équipe Biostatistique-Santé, Villeurbanne France
| | - Michel Ovize
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.; Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France
| | - Gabriel Bidaux
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
| | - Nathan Mewton
- Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France.; Centre d'Investigation Clinique de Lyon (CIC 1407 Inserm), Hospices Civils de Lyon, Lyon, France; Service d'Insuffisance Cardiaque, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Louis Pradel, Hospices Civils de Lyon, Lyon, France; Inserm U1060, Laboratoire CarMeN, IHU OPeRa, Lyon, France
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Keeling-Johnson K, Baker D, Want T, Tuazon DM. Immediate Postoperative Management of Cardiac Surgery Patients. Methodist Debakey Cardiovasc J 2023; 19:97-99. [PMID: 37547891 PMCID: PMC10402809 DOI: 10.14797/mdcvj.1274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2023] [Accepted: 07/02/2023] [Indexed: 08/08/2023] Open
Abstract
Cardiac surgery is quite common in the United States. Outcomes after cardiac surgery are not only dependent on how the surgery went and how the anesthesia care was provided intraoperatively but also on the optimal management in the postoperative critical care setting. It is of paramount importance that the cardiac intensivist has a comprehensive understanding of cardiopulmonary physiology and the sequelae of cardiopulmonary bypass. Most preventable deaths after cardiac surgery have been linked to postoperative problems in the intensive care unit (ICU).1,2 Failure to recognize and rescue a patient from potentially reversible complications is a cause of perioperative morbidity and mortality. Patients who undergo cardiac surgery often present with multiple rapidly changing clinical problems; they are initially unstable with extremely fluid and dynamic clinical status. Postoperative care of these patients requires knowledge of general fundamental concepts of patient care as well as concepts unique to this set of patients. The initial management of these patients as they return from the operating room is critical, because clinical errors at this time can have far-reaching implications. The initial management should begin even before the patient arrives in the cardiovascular intensive care unit (CVICU). It is vital that the cardiac intensivist reviews the chart and notes the type of surgery, indications, preoperative hemodynamic data, comorbid conditions, medications, and allergies. Upon the patient's arrival in the CVICU, a careful systematic assessment of the patient begins with obtaining a comprehensive handoff from the surgical and anesthesia team. The cardiac intensivist should ascertain what procedure was done in the operating room and inquire as to any intraoperative events that might impact the patient's postoperative course. Then, they should physically examine the patient as part of this initial evaluation. During the initial assessment, the intensivist should avoid focusing on any one issue and attempt to get a global picture of the patient's clinical status. A thorough knowledge of the specific monitoring and drug delivery lines is imperative, as is knowledge of where the drains are placed. Once the initial assessment is complete, specific issues can be identified, prioritized, and addressed.3,4.
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Affiliation(s)
| | | | - Todd Want
- Houston Methodist, Houston, Texas, US
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Zhang Q, Gao Y, Tian Y, Gao S, Diao X, Ji H, Wang Y, Ji B. A transfusion risk stratification score to facilitate quality management in cardiopulmonary bypass. Transfusion 2023; 63:1495-1505. [PMID: 37458390 DOI: 10.1111/trf.17487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/14/2023] [Revised: 05/19/2023] [Accepted: 06/09/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Our previous showed that a blood management program in the cardiopulmonary bypass (CPB) department, reduced red blood cell (RBC) transfusion and complications, but assessing transfusion practice solely based on transfusion rates was insufficient. This study aimed to design a risk stratification score to predict perioperative RBC transfusion to guide targeted measures for on-pump cardiac surgery patients. STUDY DESIGN AND METHODS We analyzed data from 42,435 adult cardiac patients. Eight predictors were entered into the final model including age, sex, anemia, New York Heart Association classification, body surface area, cardiac surgery history, emergency surgery, and surgery type. We then simplified the score to an integer-based system. The area under the receiver operating characteristic curve (AUC), Hosmer-Lemeshow goodness-of-fit test, and a calibration curve were used for its performance test. The score was compared to existing scores. RESULTS The final score included eight predictors. The AUC for the model was 0.77 (95% CI, 0.76-0.77) and 0.77 (95% CI, 0.76-0.78) in the training and test set, respectively. The calibration curves showed a good fit. The risk score was finally grouped into low-risk (score of 0-13 points), medium-risk (14-19 points), and high-risk (more than 19 points). The score had better predictive power compared to the other two existing risk scores. DISCUSSION We developed an effective risk stratification score with eight variables to predict perioperative RBC transfusion for on-pump cardiac surgery. It assists perfusionists in proactively preparing blood conservation measures for high-risk patients before surgery.
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Affiliation(s)
- Qiaoni Zhang
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yuchen Gao
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yu Tian
- Department of Anesthesiology, Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Sizhe Gao
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Xiaolin Diao
- Department of Information Center, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Hongwen Ji
- Department of Anesthesiology, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
| | - Yuefu Wang
- Surgery Intensive Care Unit & Center of Anesthesia, Beijing Shijitan Hospital, Capital Medical University, Beijing, China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass, Fuwai Hospital, Chinese Academy of Medical Science and Peking Union Medical College, National Clinical Research Center for Cardiovascular Disease, Beijing, China
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177
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Kitaura A, Iwamoto T, Hamasaki S, Tsukimoto S, Nakajima Y. Successful Nafamostat Mesilate Administration for Andexanet Alfa-Induced Heparin Resistance. Cureus 2023; 15:e44003. [PMID: 37746371 PMCID: PMC10516723 DOI: 10.7759/cureus.44003] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/23/2023] [Indexed: 09/26/2023] Open
Abstract
Andexanet alfa is an analog of activated factor X and is used as an antagonist of anti-activated factor X agents. Andexanet alfa is useful for hemostasis in emergent bleeding during direct oral anticoagulant administration, which contributes to safety. In patients undergoing surgery with cardiopulmonary bypass because of heparin resistance, anesthesiologists are faced with a choice of anticoagulants. Herein, we experienced anesthesia for vascular prostheses with cardiopulmonary bypass for acute aortic dissection in a patient who had received andexanet alfa preoperatively. Heparin was initially used as the anticoagulant during cardiopulmonary bypass; however, despite the administration of large doses and antithrombin III preparations, anticoagulation was insufficient. Therefore, nafamostat mesilate was administered and sufficient anticoagulation was attained. The patient completed surgery under cardiopulmonary bypass, coagulation function was recovered shortly after withdrawal, and no obvious adverse effects were observed.
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178
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Rajkumar KP, Hicks MH, Marchant B, Khanna AK. Blood Pressure Goals in Critically Ill Patients. Methodist Debakey Cardiovasc J 2023; 19:24-37. [PMID: 37547901 PMCID: PMC10402811 DOI: 10.14797/mdcvj.1260] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 06/08/2023] [Indexed: 08/08/2023] Open
Abstract
Blood pressure goals in the intensive care unit (ICU) have been extensively investigated in large datasets and have been associated with various harm thresholds at or greater than a mean pressure of 65 mm Hg. While it is difficult to perform interventional randomized trials of blood pressure in the ICU, important evidence does not support defense of a higher pressure, except in retrospective database analyses. Perfusion pressure may be a more important target than mean pressure, even more so in the vulnerable patient population. In the cardiac ICU, blood pressure targets are tailored to specific cardiac pathophysiology and patient characteristics. Generally, the goal is to maintain adequate blood pressure within a certain range to support cardiac function and to ensure end organ perfusion. Individualized targets demand the use of both invasive and noninvasive monitoring modalities and frequent titration of medications and/or mechanical circulatory support where necessary. In this review, we aim to identify appropriate blood pressure targets in the ICU, recognizing special patient populations and outlining the risk factors and predictors of end organ failure.
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Affiliation(s)
- Karuna Puttur Rajkumar
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Megan Henley Hicks
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Bryan Marchant
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
| | - Ashish K. Khanna
- Wake Forest University School of Medicine, Atrium Health Wake Forest Baptist Medical Center, Winston-Salem, North Carolina, US
- Outcomes Research Consortium, Cleveland, Ohio, US
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179
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Zhao D, Yang R, Liu S, Ge D, Su X. Study on the Characteristics of Early Cytokine Storm Response to Cardiac Surgery. J Interferon Cytokine Res 2023; 43:351-358. [PMID: 37566476 DOI: 10.1089/jir.2023.0044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/13/2023] Open
Abstract
Cardiac surgery can provoke an acute cytokine storm that may contribute to the development of postoperative multiple organ dysfunction syndrome. We prospectively observed patients undergoing cardiac surgery and divided them into two groups: the severe group and the mild group. Healthy individuals were enrolled acting as the control group for comparison. Plasma samples and clinical data were recorded at the initiation of cardiac-pulmonary bypass (CPB) and 3, 6, 12, 24, and 48 h after initiation of CPB. Cytokine levels were detected using the Luminex® technique. Thirty-nine adults were enrolled in this study (14 in the severe group, 15 in the mild group, and 10 in the control group). Cytokine concentrations were significantly higher in the severe group. Principal component analysis was used to establish a cytokine storm intensity curve, which represented the overall trend of 10 cytokines. The peak concentrations of interleukin (IL)-6, IL-10, and IL-16 were 425.1, 198.5, and 623.0 pg/mL, which were more than 1,200, 1,800, and 240 times the normal level, respectively. The maximum cytokine storm intensity predated the maximum Vasoactive-Inotropic Score (VIS) and Sequential Organ Failure Assessment (SOFA) score in the severe group. Cytokine storm response to cardiac surgery occurred early and was associated with disease severity. Interventions to cytokine storm should be initiated early as guided by cytokine storm biomarkers such as IL-6, IL-10, and IL-16 in severe patients undergoing cardiac surgery. Clinical Trial Registration: ChiCTR1900021351.
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Affiliation(s)
- Danyang Zhao
- Department of Nephrology, Qingdao West Coast New District People's Hospital, Qingdao, China
| | - Rongli Yang
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Sibo Liu
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Dong Ge
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
| | - Xiaolei Su
- Department of Critical Care Medicine, Central Hospital of Dalian University of Technology, Dalian, China
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180
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Nakajima T, Shibata T, Mukawa K, Nakanishi K, Mizuno T, Arihara A, Miura S, Nakazawa J, Iba Y, Kawaharada N. Outcomes of Vascular Surgery Performed Jointly With Other Departments. Cureus 2023; 15:e43833. [PMID: 37736440 PMCID: PMC10509632 DOI: 10.7759/cureus.43833] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/20/2023] [Indexed: 09/23/2023] Open
Abstract
OBJECTIVE The purpose of this study is to evaluate the results of vascular surgery performed at our hospital, a tertiary emergency general hospital, in patients undergoing surgery in other departments. The results of the study were reviewed. METHODS The study included cases in which cardiovascular surgery was performed at the request of other departments over a 15-year period from January 2006 to October 2022. Patient backgrounds, departments that requested surgery, surgical procedures, use of extracorporeal circulation, and surgical techniques were reviewed. Patients with femoral artery exposure or ECMO removal during transcatheter aortic valve implantation (TAVI) requested by cardiology were excluded. RESULTS There were 58 vascular surgery cases requested by other departments during the study period. The age was 63±14 years, 43 (74%) were male and 15 (26%) were female. The departments of the patients were urology in 29 (50%), gastroenterology in 18 (31%), orthopedics in seven (12%), emergency department in three (5%), and obstetrics and gynecology in one (2%). The following surgical procedures were performed: tumor resection and reconstruction due to tumor invasion of the inferior vena cava in 27 cases (47%), bypass to secure intraperitoneal arterial blood flow in 15 cases (26%), bypass during resection of the femoral tumor in four cases (7%), hemostasis due to trauma in three cases (5%), intraperitoneal hemostasis in three cases (5%), thrombectomy in two cases (3%), and others in four cases (7%). Extracorporeal circulation was used in six (10%) of the patients. CONCLUSION A 15-year case study of vascular surgery supports operations requested by other departments at our hospital. All reconstructed sites were open at the time of discharge.
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Affiliation(s)
| | - Tsuyoshi Shibata
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Kei Mukawa
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | | | - Takakimi Mizuno
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Ayaka Arihara
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Shuhei Miura
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Junji Nakazawa
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
| | - Yutaka Iba
- Cardiovascular Surgery, Sapporo Medical University, Sapporo, JPN
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181
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Nakanaga H, Kinoshita T, Fujii H, Nagashima K, Tabata M. Temporary venovenous extracorporeal membrane oxygenation after cardiopulmonary bypass in minimally invasive cardiac surgery via right minithoracotomy. JTCVS Tech 2023; 20:99-104. [PMID: 37555056 PMCID: PMC10405151 DOI: 10.1016/j.xjtc.2023.04.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2023] [Revised: 04/08/2023] [Accepted: 04/16/2023] [Indexed: 08/10/2023] Open
Abstract
OBJECTIVES In minimally invasive cardiac surgery, it can be difficult at times to maintain adequate oxygenation with single-lung ventilation after weaning from cardiopulmonary bypass (CPB), and intermittent double-lung ventilation is required during hemostasis. Venovenous extracorporeal membrane oxygenation (VV-ECMO) after weaning from CPB eliminates the necessity of overinflation of the left lung and intermittent double-lung ventilation and enables secure and fast hemostasis. We investigated the effectiveness and safety of temporary VV-ECMO in MICS. METHODS Between May 2018 and March 2021, 149 patients underwent temporary VV-ECMO during minimally invasive cardiac surgery in our institutions. After weaning from CPB, the arterial circuit was reconnected to the right internal jugular venous cannula, the femoral venous cannula was pulled down by 20 cm, and VV-ECMO was established using the CPB machine and cannulas. After starting VV-ECMO, we administered protamine and performed hemostasis. Operative data and outcomes were retrospectively reviewed. RESULTS The mean VV-ECMO time and flow were 26 ± 13 minutes and 2.38 ± 0.40 L/m2, respectively. There was no thrombus in the CPB circuit, including the oxygenator. The trans-oxygenator pressure gradient index at the end of VV-ECMO significantly correlated with that at the start of VV-ECMO (r = 0.88; 95% CI, 0.79-0.94; P = .01). The 30-day mortality rate was 2.0%. The incidences of unilateral pulmonary edema, prolonged ventilation, and re-exploration for bleeding were 2.7%, 5.4%, and 2.0%, respectively. CONCLUSIONS Temporary VV-ECMO is safe and useful to maintain single-lung ventilation without overinflation after weaning from CPB for secure and fast hemostasis in minimally invasive cardiac surgery. No thrombotic event was found during temporary VV-ECMO without heparinization.
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Affiliation(s)
- Hiroshi Nakanaga
- Department of Cardiovascular Surgery, Cardiovascular Center, Toranomon Hospital, Tokyo, Japan
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Takeshi Kinoshita
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
| | - Hiromi Fujii
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
| | - Kohei Nagashima
- Department of Clinical Engineering, Toranomon Hospital, Tokyo, Japan
| | - Minoru Tabata
- Department of Cardiovascular Surgery, Cardiovascular Center, Toranomon Hospital, Tokyo, Japan
- Department of Cardiovascular Surgery, Juntendo University Hospital, Tokyo, Japan
- Department of Cardiovascular Surgery, Tokyo Bay Urayasu Ichikawa Medical Center, Chiba, Japan
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182
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Ali EA, Syed A, Khailova L, Iguidbashian JP, Suarez‐Pierre A, Klawitter J, Stone M, Mancuso CA, Frank BS, Davidson JA. Novel Biomarkers of Necrotizing Enterocolitis in Neonates Undergoing Congenital Heart Disease Surgery: A Pilot Cohort Study. J Am Heart Assoc 2023; 12:e030712. [PMID: 37489765 PMCID: PMC10492979 DOI: 10.1161/jaha.123.030712] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2023] [Accepted: 06/29/2023] [Indexed: 07/26/2023]
Affiliation(s)
- Eiman A. Ali
- Children’s Hospital ColoradoResearch InstituteAuroraCOUSA
| | - Aneesa Syed
- Children’s Hospital ColoradoResearch InstituteAuroraCOUSA
| | - Ludmila Khailova
- University of Colorado‐School of MedicineDepartment of PediatricsAuroraCOUSA
| | | | | | - Jelena Klawitter
- University of Colorado‐School of MedicineDepartment of AnesthesiologyAuroraCOUSA
| | - Matthew Stone
- University of Colorado‐School of MedicineDepartment of SurgeryAuroraCOUSA
| | - Christopher A. Mancuso
- University of Colorado‐School of Public HealthDepartment of Biostatistics and InformaticsAuroraCOUSA
| | - Benjamin S. Frank
- University of Colorado‐School of MedicineDepartment of PediatricsAuroraCOUSA
| | - Jesse A. Davidson
- University of Colorado‐School of MedicineDepartment of PediatricsAuroraCOUSA
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183
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Vespe MW, Stone ME, Lin HM, Ouyang Y. Accurate protamine:heparin matching (not just smaller protamine doses) decreases postoperative bleeding in cardiac surgery; results from a high-volume academic medical center. Perfusion 2023:2676591231190739. [PMID: 37493300 DOI: 10.1177/02676591231190739] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/27/2023]
Abstract
BACKGROUND A multidisciplinary Quality Assurance/Performance Improvement study to identify the incidence of "heparin rebound" in our adult cardiac surgical population instead detected a thromboelastometry pattern suggestive of initial protamine overdose in 34% despite Hepcon-guided anticoagulation management. Analysis of our practice led to an intervention that made an additional lower-range Hepcon cartridge available to the perfusionists. METHODS One year later, an IRB-approved retrospective study was conducted in >500 patients to analyze the effects of the intervention, specifically focusing on the impact of the initial protamine dose accuracy and 18-h mediastinal chest tube drainage (MCTd). RESULTS No differences were observed between group demographics, surgical procedures, duration of CPB or perioperative blood product transfusion. Both groups were managed using the same perfusion and anesthesia equipment, strategies, and protocols. The median initial protamine dose decreased by 19% (p < .001) in the intervention group (170 [IQR 140-220] mg; n = 295) versus the control group (210 [180-250] mg; n = 257). Mean 18-h MCTd decreased by 13% (p < .001) in the intervention group (405.15 ± 231.54 mL; n = 295) versus the control group (466.13 ± 286.73 mL; n = 257). Covariate-adjusted mixed effects model showed a significant reduction of MCTd in the intervention group, starting from hour 11 after surgery (group by time interaction p = .002). CONCLUSION Though previous investigators have associated lower protamine doses with less MCTd, this study demonstrates that more accurately matching the initial protamine dose to the remaining circulating heparin concentration reduces postoperative bleeding.
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Affiliation(s)
| | - Marc E Stone
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hung-Mo Lin
- Department of Anesthesiology and Yale Center for Analytical Science, Yale Schoold of Medicine, New Haven, CT, USA
| | - Yuxia Ouyang
- Icahn School of Medicine at Mount Sinai, New York, NY, USA
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184
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Brooks BA, Sinha P, Staffa SJ, Jacobs MB, Freishtat RJ, Patregnani JT. Children with single ventricle heart disease have a greater increase in sRAGE after cardiopulmonary bypass. Perfusion 2023:2676591231189357. [PMID: 37465929 DOI: 10.1177/02676591231189357] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/20/2023]
Abstract
INTRODUCTION Reducing cardiopulmonary bypass (CPB) induced inflammatory injury is a potentially important strategy for children undergoing multiple operations for single ventricle palliation. We sought to characterize the soluble receptor for advanced glycation end products (sRAGE), a protein involved in acute lung injury and inflammation, in pediatric patients with congenital heart disease and hypothesized that patients undergoing single ventricle palliation would have higher levels of sRAGE following bypass than those with biventricular physiologies. METHODS This was a prospective, observational study of children undergoing CPB. Plasma samples were obtained before and after bypass. sRAGE levels were measured and compared between those with biventricular and single ventricle heart disease using descriptive statistics and multivariate analysis for risk factors for lung injury. RESULTS sRAGE levels were measured in 40 patients: 19 with biventricular and 21 with single ventricle heart disease. Children undergoing single ventricle palliation had a higher factor and percent increase in sRAGE levels when compared to patients with biventricular circulations (4.6 vs. 2.4, p = 0.002) and (364% vs. 181%, p = 0.014). The factor increase in sRAGE inversely correlated with the patient's preoperative oxygen saturation (Pearson correlation (r) = -0.43, p = 0.005) and was positively associated with red blood cell transfusion (coefficient = 0.011; 95% CI: 0.004, 0.017; p = 0.001). CONCLUSIONS Children with single ventricle physiology have greater increase in sRAGE following CPB as compared to children undergoing biventricular repair. Larger studies delineating the role of sRAGE in children undergoing single ventricle palliation may be beneficial in understanding how to prevent complications in this high-risk population.
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Affiliation(s)
- Bonnie A Brooks
- Division of Pediatric Critical Care Medicine, Mattel Children's Hospital, University of California Los Angeles, Los Angeles, CA, USA
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Pranava Sinha
- Department of Pediatric Cardiac Surgery, M Health Fairview University of Minnesota, Minneapolis MN, USA
- Division of Cardiovascular Surgery, Children's National Hospital, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Steven J Staffa
- Department of Anesthesiology, Critical Care and Pain Medicine, Harvard University, Boston Children's Hospital, Boston, MA, USA
| | - Marni B Jacobs
- Department of Obstetrics, Gynecology, and Reproductive Sciences, University of California, San Diego, CA, USA
- Division of Biostatistics and Study Methodology, Children's National Hospital, Washington, DC, USA
| | - Robert J Freishtat
- Center for Genetic Medicine Research, Children's National Hospital, Washington, DC, USA
- Departments of Pediatrics, Emergency Medicine, and Genomics & Precision Medicine, George Washington University School of Medicine and Health Sciences, Washington, DC, USA
| | - Jason T Patregnani
- Division of Pediatric Critical Care Medicine, Maine Medical Center, Tufts University School of Medicine, Barbara Bush Children's Hospital, Portland, ME, USA
- Division of Pediatric Cardiac Critical Care, Children's National Hospital, George Washington University School of Medicine, Washington, DC, USA
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185
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Vandestienne M, Braik R, Lavillegrand JR, Hariri G, Demailly Z, Ben Hamouda N, Tamion F, Clavier T, Ait-Oufella H. Soluble TREM-1 plasma levels are associated with acute kidney injury, acute atrial fibrillation and prolonged ICU stay after cardiac surgery- a proof-concept study. Front Cardiovasc Med 2023; 10:1098914. [PMID: 37522081 PMCID: PMC10373879 DOI: 10.3389/fcvm.2023.1098914] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2023] [Accepted: 06/27/2023] [Indexed: 08/01/2023] Open
Abstract
Background Cardiopulmonary bypass (CPB) during cardiac surgery leads to deleterious systemic inflammation. We hypothesized that TREM-1, a myeloid receptor shed after activation, drives systemic inflammation during CPB. Methods Prospective observational bi-centric study. Blood analysis (flow cytometry and ELISA) before and at H2 and H24 after CPB. Inclusion of adult patients who underwent elective cardiac surgery with CPB. Results TREM-1 expression on neutrophils decreased between H0 and H2 while soluble (s)TREM-1 plasma levels increased. sTREM-1 levels increased at H2 and at H24 (p < 0.001). IL-6, IL-8, G-CSF and TNF-α, but not IL-1β, significantly increased at H2 compared to H0 (p < 0.001), but dropped at H24. Principal component analysis showed a close relationship between sTREM-1 and IL-8. Three patterns of patients were identified: Profile 1 with high baseline sTREM-1 levels and high increase and profile 2/3 with low/moderate baseline sTREM-1 levels and no/moderate increase overtime. Profile 1 patients developed more severe organ failure after CPB, with higher norepinephrine dose, higher SOFA score and more frequently acute kidney injury at both H24 and H48. Acute atrial fibrillation was also more frequent in profile 1 patients at H24 (80% vs. 19.4%, p = 0.001). After adjustment on age and duration of CPB, H0, H2 and H24 sTREM-1 levels remained associated with prolonged ICU and hospital length of stay. Conclusions Baseline sTREM-1 levels as well as early kinetics after cardiac surgery identified patients at high risk of post-operative complications and prolonged length of stay.
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Affiliation(s)
- Marie Vandestienne
- Centre de Recherche Cardiovasculaire de Paris (PARCC), Université de Paris, Inserm U970, Paris, France
| | - Rayan Braik
- Centre de Recherche Cardiovasculaire de Paris (PARCC), Université de Paris, Inserm U970, Paris, France
| | - Jean-Rémi Lavillegrand
- Centre de Recherche Cardiovasculaire de Paris (PARCC), Université de Paris, Inserm U970, Paris, France
| | - Geoffroy Hariri
- Service de Réanimation Chirurgicale, Assistance Publique – Hôpitaux de Paris, Groupe Hospitalier Pitié-Salpétrière, Institut du Coeur, Paris, France
| | - Zoe Demailly
- Université de Normandie, UNIROUEN, Inserm U1096, FHU REMOD-VHF, Rouen, France
- Service D’anesthésie-Réanimation Chirurgicale, CHU De Rouen, Rouen, France
| | - Nadine Ben Hamouda
- Service D’Immunologie, Hôpital Européen Georges Pompidou, Assistance Publique – Hôpitaux de Paris, Paris, France
| | - Fabienne Tamion
- Université de Normandie, UNIROUEN, Inserm U1096, FHU REMOD-VHF, Rouen, France
- Service de Médecine Intensive-Réanimation, CHU De Rouen, Rouen, France
| | - Thomas Clavier
- Université de Normandie, UNIROUEN, Inserm U1096, FHU REMOD-VHF, Rouen, France
- Service D’anesthésie-Réanimation Chirurgicale, CHU De Rouen, Rouen, France
| | - Hafid Ait-Oufella
- Centre de Recherche Cardiovasculaire de Paris (PARCC), Université de Paris, Inserm U970, Paris, France
- Service de Médecine Intensive-Réanimation, Assistance Publique – Hôpitaux de Paris, Sorbonne Université, Paris, France
- Hôpital Saint-Antoine, Sorbonne Université, Paris, France
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186
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Milojevic M, Milosevic G, Nikolic A, Petrovic M, Petrovic I, Bojic M, Jagodic S. Mastering the Best Practices: A Comprehensive Look at the European Guidelines for Cardiopulmonary Bypass in Adult Cardiac Surgery. J Cardiovasc Dev Dis 2023; 10:296. [PMID: 37504552 PMCID: PMC10380276 DOI: 10.3390/jcdd10070296] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/03/2023] [Revised: 07/05/2023] [Accepted: 07/06/2023] [Indexed: 07/29/2023] Open
Abstract
The successful outcome of a cardiac surgery procedure is significantly dependent on the management of cardiopulmonary bypass (CPB). Even if a cardiac operation is technically well-conducted, a patient may suffer CPB-related complications that could result in severe comorbidities, reduced quality of life, or even death. However, the role of clinical perfusionists in perioperative patient care, which is critical, is often overlooked. Therefore, the European Association for Cardio-Thoracic Surgery (EACTS), the European Association of Cardiothoracic Anaesthesiology (EACTA), and the European Board of Cardiovascular Perfusion (EBCP) have agreed to develop joint clinical practice guidelines (CPGs) for CPB due to its significant impact on patient care and significant variations in practice patterns between countries. The European guidelines, based on the EACTS standardized framework for the development of CPGs, cover the entire spectrum of CPB management in adult cardiac surgery. This includes training and education of clinical perfusionists, machine hardware, disposables, preparation for initiation of CPB, a complete set of procedures during CPB to help maintain end-organ function and anticoagulation, weaning from CPB, and the gaps in evidence and future research directions. This comprehensive coverage ensures that all aspects of CPB management are addressed, providing clinicians with a standardized approach to CPB management based on the latest evidence and best practices. To ensure better integration of these evidence-based recommendations into daily practice, this review aims to provide a general understanding of guideline development and an overview of essential treatment recommendations for CPB management.
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Affiliation(s)
- Milan Milojevic
- Department of Cardiac Surgery and Cardiovascular Research, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Erasmus University Medical Center, Department of Cardiothoracic Surgery, 3015 GD Rotterdam, The Netherlands
| | - Goran Milosevic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Aleksandar Nikolic
- Department of Cardiac Surgery, Acibadem-Sistina Hospital, 1000 Skopje, North Macedonia
| | - Masa Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
| | - Ivana Petrovic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Milovan Bojic
- Center of Excellence, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
| | - Sinisa Jagodic
- Department of Perfusion Technology, Dedinje Cardiovascular Institute, 11000 Belgrade, Serbia
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187
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Carrel T. Reduced Invasiveness of Cardiopulmonary Bypass: The Mini-Circuit and the Micro-Cardioplegia. J Cardiovasc Dev Dis 2023; 10:290. [PMID: 37504545 PMCID: PMC10380229 DOI: 10.3390/jcdd10070290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
The aim of cardiopulmonary bypass is the maintenance of a sufficient whole body perfusion and gas exchange during open or closed heart surgery procedure (coronary artery bypass grafting, valve repair and replacement, surgical intervention on the ascending aorta and/or aortic arch, repair of congenital malformations, and finally implantation of ventricular assist devices or cardiac transplantation). The main components of cardiopulmonary bypass are the pump that supplies the circulation and the oxygenator that regulates gas exchange. However, even though this technology has been extensively developed and improved over the last decades, one of the major drawbacks-which is the fact that blood has to flow through tubing systems with foreign surfaces-persists so far. Nevertheless, interesting innovations have been made more recently in order to better control the side-effects that culminate into a major activation of the coagulation and inflammatory systems: among them, miniaturization of the circuits, together with reduction of the priming volume and a simplified cardioplegia concept. All of these lead to a significant decrease of hemodilution and thereby a significant reduction of volume overload during surgery. In this brief review we will present some of these most interesting topics around minimized circuits and the simplified low-volume cardioplegia and discuss their potential benefits on the clinical outcome.
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Affiliation(s)
- Thierry Carrel
- Departement of Cardiac Surgery, University of Zürich, CH-8006 Zürich, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, CH-4052 Basel, Switzerland
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188
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Belletti A, Lee DK, Yanase F, Naorungroj T, Eastwood GM, Bellomo R, Weinberg L. Changes in SedLine-derived processed electroencephalographic parameters during hypothermia in patients undergoing cardiac surgery with cardiopulmonary bypass. Front Cardiovasc Med 2023; 10:1084426. [PMID: 37469479 PMCID: PMC10352607 DOI: 10.3389/fcvm.2023.1084426] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Accepted: 06/19/2023] [Indexed: 07/21/2023] Open
Abstract
Objective Processed electroencephalography (pEEG) is used to monitor depth-of-anesthesia during cardiopulmonary bypass (CPB). The SedLine device has been recently introduced for pEEG monitoring. However, the effect of hypothermia on its parameters during CPB is unknown. Accordingly, we aimed to investigate temperature-induced changes in SedLine-derived pEEG parameters during CPB. Design Prospective observational study. Setting Cardiac surgery operating theatre. Participants 28 patients undergoing elective cardiac surgery with CPB. Interventions We continuously measured patient state index (PSI), suppression ratio (SR), bilateral spectral edge frequency (SEF) and temperature. We used linear mixed modelling with fixed and random effects to study the interactions between pEEG parameters and core temperature. Measurements and main results During CPB maintenance, the median temperature was 32.1°C [interquartile range (IQR): 29.8-33.6] at the end of cooling and 32.8°C (IQR: 30.1-34.0) at rewarming initiation. For each degree Celsius change in temperature during cooling and rewarming the PSI either decreased by 0.8 points [95% confidence interval (CI): 0.7-1.0; p < 0.001] or increased by 0.7 points (95% CI: 0.6-0.8; p < 0.001). The SR increased by 2.9 (95% CI: 2.3-3.4); p < 0.001) during cooling and decreased by 2.2 (95% CI: 1.7-2.7; p < 0.001) during rewarming. Changes in the SEF were not related to changes in temperature. Conclusions During hypothermic CPB, temperature changes led to concordant changes in the PSI. The SR increased during cooling and decreased during rewarming. Clinicians using SedLine for depth-of-anesthesia monitoring should be aware of these effects when interpreting the PSI and SR values.
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Affiliation(s)
- Alessandro Belletti
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Dong-Kyu Lee
- Department of Anesthesiology and Pain Medicine, Dongguk University Ilsan Hospital, Goyang, Republic of Korea
| | - Fumitaka Yanase
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
| | - Thummaporn Naorungroj
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Department of Intensive Care, Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Glenn M. Eastwood
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
| | - Rinaldo Bellomo
- Department of Intensive Care, Austin Hospital, Heidelberg, VIC, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC, Australia
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Data Analytics Research and Evaluation Centre, The University of Melbourne and The Austin Hospital, Melbourne, VIC, Australia
| | - Laurence Weinberg
- Department of Critical Care, The University of Melbourne, Melbourne, VIC, Australia
- Department of Anaesthesia, Austin Hospital, Heidelberg, VIC, Australia
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189
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Kashyap NK, Mehsare P, Saurabh G, Chakraborty N, Wasnik M. Central Aortic Cannula Disruption Following Left Atrial Myxoma Excision. Cureus 2023; 15:e41908. [PMID: 37583721 PMCID: PMC10423941 DOI: 10.7759/cureus.41908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 08/17/2023] Open
Abstract
Central aortic cannulation is used to give oxygenated blood to the patient through a heart-lung machine. Central aortic cannula disruption during cardiopulmonary bypass (CPB) is a rare complication. This could result in aortic dissection, extensive tears, bleeding, posterior aortic wall injury, oesophageal trauma, and cardiac arrest. We are reporting a central aortic cannula disruption during a left atrium (LA) myxoma excision in which the metal tip part of the cannula detached from its body, resulting in massive blood loss. The intraoperative blood salvage technique was used to maintain hemodynamics during surgery. Pre-procedural visual inspection of all cardiac consumables, including cannula, should be performed to eliminate this complication. All surgical team members should be observant to avoid such complications.
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Affiliation(s)
- Nitin Kumar Kashyap
- Cardiothoracic Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Pranay Mehsare
- Cardiothoracic Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Gaind Saurabh
- Cardiothoracic Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Nirupam Chakraborty
- Cardiothoracic Surgery, All India Institute of Medical Sciences, Raipur, Raipur, IND
| | - Minal Wasnik
- Transfusion Medicine & Blood Bank, All India Institute of Medical Sciences, Raipur, Raipur, IND
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190
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Ishida O, Hagisawa K, Yamanaka N, Nakashima H, Kearney BM, Tsutsumi K, Takeoka S, Kinoshita M. In vitro study on the effect of fibrinogen γ-chain peptide-coated ADP-encapsulated liposomes on post cardiopulmonary bypass coagulopathy using patient blood. J Thromb Haemost 2023; 21:1934-1942. [PMID: 36990156 DOI: 10.1016/j.jtha.2023.03.018] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 03/01/2023] [Accepted: 03/21/2023] [Indexed: 03/30/2023]
Abstract
BACKGROUND Fibrinogen γ-chain peptide-coated, adenosine 5'-diphosphate (ADP)-encapsulated liposomes (H12-ADP-liposomes) are potent hemostatic adjuvants that promote platelet thrombi formation at bleeding sites. Although we have reported the efficacy of these liposomes in a rabbit model of cardiopulmonary bypass coagulopathy, we are yet to address the possibility of their hypercoagulative potential, especially in human beings. OBJECTIVES Considering its future clinical applications, we herein investigated the safety of using H12-ADP-liposomes in vitro using blood samples from patients who had received platelet transfusion after cardiopulmonary bypass surgeries. METHODS Ten patients receiving platelet transfusions after cardiopulmonary bypass surgery were enrolled. Blood samples were collected at the following 3 points: at the time of incision, at the end of the cardiopulmonary bypass, and immediately after platelet transfusion. After incubating the samples with H12-ADP-liposomes or phosphate-buffered saline (PBS, as a control), blood coagulation, platelet activation, and platelet-leukocyte aggregate formation were evaluated. RESULTS Patients' blood incubated with H12-ADP-liposomes did not differ from that incubated with PBS in coagulation ability, degree of platelet activation, and platelet-leukocyte aggregation at any of the time points. CONCLUSION H12-ADP-liposomes did not cause abnormal coagulation, platelet activation, or platelet-leukocyte aggregation in the blood of patients who received platelet transfusion after a cardiopulmonary bypass. These results suggest that H12-ADP-liposomes could likely be safely used in these patients, providing hemostasis at the bleeding sites without causing considerable adverse reactions. Future studies are needed to ensure robust safety in human beings.
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Affiliation(s)
- Osamu Ishida
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan.
| | - Kohsuke Hagisawa
- Department of Physiology, National Defense Medical College, Tokorozawa, Japan
| | - Nozomu Yamanaka
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Hiroyuki Nakashima
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| | - Bradley M Kearney
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
| | - Koji Tsutsumi
- Department of Cardiovascular Surgery, National Defense Medical College, Tokorozawa, Japan
| | - Shinji Takeoka
- Research Institute for Science and Engineering, Waseda University, Tokyo, Japan
| | - Manabu Kinoshita
- Department of Immunology and Microbiology, National Defense Medical College, Tokorozawa, Japan
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191
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Khan MS, Jan A, Ahmed H, Khan M, Khan AD, Shakil R, Khan B, Aman Z, Ali WS, Mahmood A. Outcomes of Surgical Repair of Tetralogy of Fallot: A Comparison Between the Adult and Pediatric Population. Cureus 2023; 15:e41467. [PMID: 37546072 PMCID: PMC10404136 DOI: 10.7759/cureus.41467] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/06/2023] [Indexed: 08/08/2023] Open
Abstract
Introduction Tetralogy of Fallot (TOF) is the most common cyanotic congenital heart disease. Early detection and timely treatment have provided successful repair of the anomaly in the developed world. However, in the developing world, there is still a burden of uncorrected TOF patients reaching adulthood. The goal of this study is to determine whether there is any difference in postoperative complications between adult and pediatric populations following surgical correction for TOF. Methods This study involved all those patients who received primary or secondary surgical repair for TOF in our facility between January 2017 and December 2020. The patients were split according to their age into the pediatric group if they were under 18 years and the adult group if they were 18 years or older. Patients with absent pulmonary valve or pulmonary atresia were not included in this study. Patients with large major aortopulmonary collateral arteries (MAPCA) were also excluded from this study. All patients underwent total correction through a median sternotomy approach. The ventricular septal defect was closed with a Bard knitted fiber patch. The right ventricular outflow tract (RVOT) was augmented by excising muscle bands or fibrous bands in the RVOT. If the annulus was smaller than the 3.5 z score, then a transannular patch was done using an autologous pericardium. The main pulmonary artery was augmented in every surgery using an autologous pericardial patch. All patients were shifted to the ICU on the ventilator and were extubated after fulfillment of the extubation criteria. Postoperative complications measured included re-opening, re-intubation, prolonged ventilation (>24 hours), and mortality within the index hospital admission. The clinical data of all patients were prospectively collected and analyzed using the chi-square test and t-test. A p-value of less than or equal to 0.05 was considered significant. Results The total number of patients was 134. This included 83 males (60.1%). A total of 114 patients who were aged below 18 years were included in the pediatric group, and 20 patients aged equal to or more than 18 years were included in the adult group. The mean average perfusion time in minutes in the adult group was 125.8 and in the pediatric group, it was 98.79. Similarly, the mean average of the cross-clamp time was also longer in the adult group at 89.55 minutes versus 69.63 minutes in the pediatric group. Overall, in the adult group, three (15%) patients had postoperative complications, while in the pediatric group, a total of 14 (11.9%) patients had postoperative complications (p = 0.001). However, there was no significant difference in the number of re-openings (8.5% vs. 10%; p = 0.8). The total mortality observed was 16 (11.59%). This included 14 (11.9%) in the pediatric group and two (10%) in the adult group. There was no significant difference between the two groups (p = 0.8). Conclusions Surgical repair of TOF can be performed in both adult and pediatric populations with acceptable outcomes. The mortality rate was found to be slightly greater in the pediatric population compared to the adults. However, it can be seen that the number of postoperative complications is greater in adults. Further research is needed to optimize outcomes for both pediatric and adult patients with TOF.
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Affiliation(s)
| | - Azam Jan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Haseeb Ahmed
- Cardiothoracic and Vascular Surgery, Rehman Medical Institute, Peshawar, PAK
| | | | - Ahmad D Khan
- Endodontics, Sardar Begum Dental College, Peshawar, PAK
| | - Rafat Shakil
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Bahauddin Khan
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Zarkesha Aman
- Ophthalmology, Hayatabad Medical Complex, Peshawar, PAK
| | - Waleed S Ali
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
| | - Ahmad Mahmood
- Cardiothoracic Surgery, Rehman Medical Institute, Peshawar, PAK
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192
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Kumari V, Kumari U, Batool SA, Daggula NR, Khan A. Home health care and cardiac rehabilitation following major cardiac surgeries in Pakistan. Ann Med Surg (Lond) 2023; 85:3748-3749. [PMID: 37427225 PMCID: PMC10328695 DOI: 10.1097/ms9.0000000000000865] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2023] [Accepted: 05/14/2023] [Indexed: 07/11/2023] Open
Abstract
Cardiovascular disorders are a leading cause of morbidity and mortality globally, and coronary artery bypass graft surgery is one of the most effective procedures for coronary artery disease. Cardiac rehabilitation (CR) has been shown to offer benefits beyond reducing mortality and morbidity rates, including enhancing patients' quality of life and reducing healthcare costs. Home-based CR programs offer personalized plans tailored to individual needs and availability and have been shown to be more effective in sustaining improvements than center-based CR programs. However, there are challenges associated with providing home care services in developing countries, including personnel shortages, lack of financing and policies, and limited access to end-of-life or hospice services. The use of multidisciplinary telehealth and telecare homecare programs that make use of web-based technologies to monitor postoperative outcomes in patients undergoing cardiac surgery may provide a solution to some of these challenges. This manuscript emphasizes the potential of home health care and CR in improving postoperative outcomes in Pakistan and identifies some of the challenges and potential solutions associated with providing home care services.
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Affiliation(s)
- Varsha Kumari
- Department of Medicine, Dow University of Health Sciences, Karachi
| | - Usha Kumari
- Department of Medicine, Dow University of Health Sciences, Karachi
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193
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Cartwright B, Mundell N. Anticoagulation for cardiopulmonary bypass, Part 2: alternatives and pathological states. BJA Educ 2023; 23:256-263. [PMID: 37389280 PMCID: PMC10300449 DOI: 10.1016/j.bjae.2023.03.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2021] [Accepted: 03/28/2023] [Indexed: 07/01/2023] Open
Affiliation(s)
- B. Cartwright
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
- University of Sydney, Sydney, NSW, Australia
| | - N. Mundell
- Royal Prince Alfred Hospital, Camperdown, NSW, Australia
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194
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Levy JH, Ghadimi K, Kizhakkedathu JN, Iba T. What's fishy about protamine? Clinical use, adverse reactions, and potential alternatives. J Thromb Haemost 2023; 21:1714-1723. [PMID: 37062523 DOI: 10.1016/j.jtha.2023.04.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Revised: 03/30/2023] [Accepted: 04/04/2023] [Indexed: 04/18/2023]
Abstract
Protamine, a highly basic protein isolated from salmon sperm, is the only clinically available agent to reverse the anticoagulation of unfractionated heparin. Following intravenous administration, protamine binds to heparin in a nonspecific electrostatic interaction to reverse its anticoagulant effects. In clinical use, protamine is routinely administered to reverse high-dose heparin anticoagulation in cardiovascular procedures, including cardiac surgery with cardiopulmonary bypass. Despite the lack of supportive evidence regarding protamine's effectiveness to reverse low-molecular-weight heparin, it is recommended in guidelines with low-quality evidence. Different dosing strategies have been reported for reversing heparin in cardiac surgical patients based on empiric dosing, pharmacokinetics, or point-of-care measurements of heparin levels. Protamine administration is associated with a spectrum of adverse reactions that range from vasodilation to life-threatening cardiopulmonary dysfunction and shock. The life-threatening responses appear to be hypersensitivity reactions due to immunoglobulin E and/or immunoglobulin G antibodies. However, protamine and heparin-protamine complexes can activate complement inflammatory pathways and inhibit other coagulation factors. Although alternative agents for reversing heparin are not currently available for clinical use, additional research continues evaluating novel therapeutic approaches.
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Affiliation(s)
- Jerrold H Levy
- Departments of Anesthesiology, Critical Care, and Surgery (Cardiothoracic), Duke University School of Medicine, Durham, North Carolina, USA.
| | - Kamrouz Ghadimi
- Departments of Anesthesiology and Critical Care, Duke University School of Medicine, Durham, North Carolina, USA
| | - Jayachandran N Kizhakkedathu
- Centre for Blood Research, Department of Pathology and Laboratory Medicine, The School of Biomedical Engineering, The University of British Columbia, Vancouver, British Colombia, Canada
| | - Toshiaki Iba
- Department of Emergency and Disaster Medicine, Juntendo University Graduate School of Medicine, Tokyo, Japan
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195
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Evans MA, Namburi N, Allison HR, Saleem K, Lee LS. Nontechnical Skills for Surgeons as a Framework to Evaluate Cardiopulmonary Bypass Management Skills of Resident Trainees. J Surg Educ 2023; 80:965-970. [PMID: 37198079 DOI: 10.1016/j.jsurg.2023.04.011] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 04/14/2023] [Indexed: 05/19/2023]
Abstract
BACKGROUND Nontechnical skills are critical in cardiac surgery but currently there is no formal paradigm to teach these in residency training. We investigated the use of the Nontechnical skills for surgeons (NOTSS) system as a framework to assess and teach nontechnical skills related to cardiopulmonary bypass (CPB) management. METHODS Single-center retrospective analysis of Integrated and Independent pathway thoracic surgery residents who participated in dedicated nontechnical skills evaluation and training. Two CPB management simulation scenarios were utilized. All residents received a lecture on CPB fundamentals and then individually participated in the first simulation ("Pre-NOTSS"). Immediately following this, nontechnical skills were rated by self-assessment and by a NOTSS trainer. All residents then underwent group NOTSS training followed by the second individual simulation ("Post-NOTSS"). Nontechnical skills were rated as before. NOTSS categories assessed included Situation Awareness, Decision Making, Communication and Teamwork, and Leadership. RESULTS Nine residents were divided into 2 groups: Junior (n = 4, PGY1-4) and Senior (n = 5, PGY5-8). Pre-NOTSS resident self-ratings were higher for Senior than Junior in the categories of Decision Making, Communication and Teamwork, and Leadership while trainer ratings were similar between the groups. Post-NOTSS, resident self-ratings were higher for Senior than Junior in Situation Awareness and Decision Making while trainer scores were higher for both groups in Communication and Teamwork and Leadership. CONCLUSIONS The NOTSS framework in conjunction with simulation scenarios provides a practical framework to evaluate and teach nontechnical skills related to CPB management. NOTSS training can lead to improvements in both subjective and objective ratings of nontechnical skills for all PGY levels.
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Affiliation(s)
- Megan A Evans
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Niharika Namburi
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Hannah R Allison
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Kashif Saleem
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana
| | - Lawrence S Lee
- Division of Cardiothoracic Surgery, Indiana University School of Medicine, Indianapolis, Indiana; Division of Cardiac Surgery, Tufts Medical Center, Tufts University School of Medicine, Boston, Massachusetts.
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196
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Sun M, Yang L, Zong Q, Ying L, Liu X, Lin R. Serum soluble triggering receptor levels expressed on myeloid cells2 identify early acute kidney injury in infants and young children after pediatric cardiopulmonary bypass. Front Pediatr 2023; 11:1185151. [PMID: 37435171 PMCID: PMC10330694 DOI: 10.3389/fped.2023.1185151] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/13/2023] [Accepted: 06/05/2023] [Indexed: 07/13/2023] Open
Abstract
Background Acute kidney injury (AKI) is a potential complication after cardiopulmonary bypass (CPB) of pediatric cardiac surgery and contributes to a certain amount of perioperative mortality. Serum soluble triggering receptor expressed on myeloid cells2 (sTREM2) is an inflammation-associated cytokine in circulation. Alterations of sTREM2 level have been reported in Alzheimer's disease, sepsis, and some other pathologic conditions. This study aimed to investigate the role of sTREM2 as a forecasting factor for AKI in infants and young children and other factors associated with early renal injury after pediatric CPB. Methods A prospective cohort study with consecutive infants and young children ≤ 3 years old undergoing CPB from September 2021 to August 2022 was conducted in an affiliated university children's hospital. These patients were divided into an AKI group (n = 10) and a non-AKI group (n = 60). Children's characteristics and clinical data were measured. Perioperative sTREM2 levels were analyzed with enzyme-linked immunosorbent assay (ELISA). Results In children developing AKI, the sTREM2 levels significantly decreased at the beginning of CPB compared to the non-AKI group. Based on binary logistic regression analysis and multivariable regression analysis, risk-adjusted classification for congenital heart surgery (RACHS-1), operation time, and the s-TREM2 level at the beginning of CPB (AUC = 0.839, p = 0.001, optimal cut-off value: 716.0 pg/ml) had predictive value for post-CPB AKI. When combining the sTREM2 level at the beginning of CPB and other indicators together, the area under the ROC curve enlarged. Conclusions Operation time, RACHS-1 score, and sTREM2 level at the beginning of CPB were independent prognosis factors of post-CPB AKI in infants and young children ≤ 3 years old. Decreased sTREM2 identified post-CPB AKI, and ultimately hampered the outcomes. Our findings indicated that sTREM2 may be a protective factor for AKI after CPB in infants and young children ≤ 3 years old.
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Affiliation(s)
- Mingwei Sun
- Department of CPB/ECMO, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Lijun Yang
- Department of CPB/ECMO, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Qing Zong
- Department of CPB/ECMO, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Liyang Ying
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Xiwang Liu
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
| | - Ru Lin
- Department of CPB/ECMO, National Clinical Research Center for Child Health, The Children's Hospital, Zhejiang University School of Medicine, Hangzhou, China
- Department of Heart Center, National Clinical Research Center for Child Health, The Children's Hospital of Zhejiang University School of Medicine, Hangzhou, China
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197
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Fan J, Sun Y, Liang B, Zhang X, Xiao C, Huang Z. [Role of gut microbiota in perioperative neurocognitive disorders after cardiopulmonary bypass surgery in rats with humanized gut flora]. Nan Fang Yi Ke Da Xue Xue Bao 2023; 43:964-969. [PMID: 37439168 DOI: 10.12122/j.issn.1673-4254.2023.06.11] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 07/14/2023]
Abstract
OBJECTIVE To investigate whether gut microbiota disturbance after cardiopulmonary bypass (CPB) contributes to the development of perioperative neurocognitive disorders (PND). METHODS Fecal samples were collected from healthy individuals and patients with PND after CPB to prepare suspensions of fecal bacteria, which were transplanted into the colorectum of two groups of pseudo-germ-free adult male SD rats (group NP and group P, respectively), with the rats without transplantation as the control group (n=10). The feces of the rats were collected for macrogenomic sequencing analysis, and serum levels of IL-1β, IL-6 and TNF-α were measured with ELISA. The expression levels of GFAP and p-Tau protein in the hippocampus of the rats were detected using Western blotting, and the cognitive function changes of the rats were assessed with Morris water maze test. RESULTS In all the 3 groups, macrogenomic sequencing analysis showed clustering and clear partitions of the gut microbiota after the transplantation. The relative abundances of Klebsiella in the control group (P < 0.005), Akkermansia in group P (P < 0.005) and Bacteroides in group NP (P < 0.005) were significantly increased after the transplantation. Compared with those in the control group, the rats in group NP and group P showed significantly decreased serum levels of IL-1β, IL-6 and TNF-α and lowered expression levels of GFAP and p-Tau proteins (all P < 0.05). Escape platform crossings and swimming duration in the interest quadrant increased significantly in group NP (P < 0.05), but the increase was not statistically significant in group N. Compared with those in group P, the rats in group NP had significantly lower serum levels of IL-1β, IL-6 and TNF-α and protein expressions of GFAP and p-Tau (all P < 0.05) with better performance in water maze test (P < 0.05). CONCLUSION In patients receiving CPB, disturbances in gut mirobiota contributes to the development of PND possibly in relation with inflammatory response.
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Affiliation(s)
- J Fan
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang 110042, China
| | - Y Sun
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - B Liang
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - X Zhang
- Department of Anesthesiology, General Hospital of Northern Theater Command, Shenyang 110016, China
| | - C Xiao
- Health Service Team, No.96852 Troop of PLA, Shenyang 110124, China
| | - Z Huang
- Department of Anesthesiology, Cancer Hospital of China Medical University, Liaoning Cancer Hospital & Institute, Shenyang 110042, China
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Reiff DD, Cron RQ. Cytokine Storm Syndrome Triggered by Extracorporeal Membrane Oxygenation in Pediatric Patients. Children (Basel) 2023; 10:1052. [PMID: 37371283 DOI: 10.3390/children10061052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Revised: 06/05/2023] [Accepted: 06/09/2023] [Indexed: 06/29/2023]
Abstract
Cytokine storm syndrome (CSS) is a serious and potentially life-threatening condition caused by severe systemic inflammation, immune activation, and a positive feedback loop of cytokine release. Typically triggered by systemic infection, malignancy, monogenic or rheumatic disease, similar patterns of hyper-inflammation have been seen in patients undergoing cardiopulmonary bypass (CPB) and in patients treated with extracorporeal membrane oxygenation (ECMO). Typical treatments used for the prevention and treatment of CPB/ECMO-induced hyper-inflammation have not been shown to be substantially effective. Two patients suffering from ECMO-related CSS were identified by their severe hyper-inflammatory profile and life-threatening sequelae of vasodilatory shock and respiratory failure. Anakinra, an interleukin-1 receptor antagonist, was employed as specific cytokine-directed therapy for the treatment of CSS in these two patients to good effect, with significant improvement in hyper-inflammation and cardiorespiratory status. The use of cytokine-directed therapies in CPB/ECMO-related CSS has great potential to improve the treatment and outcomes of this serious condition.
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Affiliation(s)
- Daniel D Reiff
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
| | - Randy Q Cron
- Department of Pediatrics, Division of Rheumatology, University of Alabama at Birmingham, Birmingham, AL 35233, USA
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van den Brom CE, Bulte CSE. Editorial: Microvascular dysfunction and organ failure during cardiac surgery. Front Med (Lausanne) 2023; 10:1231464. [PMID: 37378297 PMCID: PMC10291680 DOI: 10.3389/fmed.2023.1231464] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2023] [Accepted: 05/31/2023] [Indexed: 06/29/2023] Open
Affiliation(s)
- Charissa E. van den Brom
- Department of Anesthesiology, Amsterdam UMC, VU University, Amsterdam, Netherlands
- Department of Intensive Care Medicine, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Carolien S. E. Bulte
- Department of Anesthesiology, Amsterdam UMC, VU University, Amsterdam, Netherlands
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Foote HP, Wu H, Balevic SJ, Thompson EJ, Hill KD, Graham EM, Hornik CP, Kumar KR. Using Pharmacokinetic Modeling and Electronic Health Record Data to Predict Clinical and Safety Outcomes after Methylprednisolone Exposure during Cardiopulmonary Bypass in Neonates. CONGENIT HEART DIS 2023; 18:295-313. [PMID: 37484782 PMCID: PMC10361697 DOI: 10.32604/chd.2023.026262] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/01/2022] [Accepted: 02/08/2023] [Indexed: 07/25/2023]
Abstract
Background Infants undergoing cardiac surgery with cardiopulmonary bypass (CPB) frequently receive intraoperative methylprednisolone (MP) to suppress CPB-related inflammation; however, the optimal dosing strategy and efficacy of MP remain unclear. Methods We retrospectively analyzed all infants under 90 days-old who received intra-operative MP for cardiac surgery with CPB from 2014-2017 at our institution. We combined real-world dosing data from the electronic health record (EHR) and two previously developed population pharmacokinetic/pharmacodynamic models to simulate peak concentration (Cmax) and area under the concentration-time curve for 24 h (AUC24) for MP and the inflammatory cytokines interleukin-6 (IL-6) and interleukin-10 (IL-10). We evaluated the relationships between post-operative, safety, and other clinical outcomes obtained from the EHR with each predicted exposure using non-parametric tests. Results A total of 142 infants with median post-natal age 8 (interquartile range [IQR]: 5, 37) days received a total dose of 30 (19, 49) mg/kg of MP. Twelve (8%) died, 37 (26%) met the composite post-operative outcome, 114 (80%) met the composite safety outcome, and 23 (16%) had a major complication. Predicted median Cmax and AUC24 IL-6 exposure was significantly higher for infants meeting the composite post-operative outcome and those with major complications. Predicted median Cmax and AUC24 MP exposure was significantly higher for infants requiring insulin. No exposure was associated with death or other safety outcomes. Conclusions Pro-inflammatory IL-6, but not MP exposure, was associated with post-operative organ dysfunction, suggesting current MP dosing may not adequately suppress IL-6 or increase IL-10 to impact clinical outcomes. Prospective study will be required to define the optimal exposure-efficacy and exposure-safety profiles in these infants.
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Affiliation(s)
| | - Huali Wu
- Duke Clinical Research Institute, Durham, USA
| | - Stephen J. Balevic
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Elizabeth J. Thompson
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Kevin D. Hill
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Eric M. Graham
- Department of Pediatrics, Medical University of South Carolina, Charleston, USA
| | - Christoph P. Hornik
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
| | - Karan R. Kumar
- Department of Pediatrics, Duke University, Durham, USA
- Duke Clinical Research Institute, Durham, USA
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