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Faisal SA, Apatov DA, Ramakrishna H, Weiner MM. Levosimendan in Cardiac Surgery: Evaluating the Evidence. J Cardiothorac Vasc Anesth 2019; 33:1146-1158. [DOI: 10.1053/j.jvca.2018.05.035] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/18/2018] [Indexed: 11/11/2022]
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Yu PJ, Lin D, Catalano M, Cassiere H, Kohn N, Hartman A. Predictors of Increased Length of Hospital Stay in Patients with Severe Cardiomyopathy Undergoing Coronary Artery Bypass Grafting. J Cardiothorac Vasc Anesth 2019; 33:2703-2708. [PMID: 31084990 DOI: 10.1053/j.jvca.2019.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Revised: 03/06/2019] [Accepted: 03/08/2019] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Predictors of operative outcome in patients with severely depressed left ventricular ejection fraction (LVEF) undergoing coronary artery bypass grafting (CABG) remain poorly defined. This study aims to identify preoperative variables that are associated with increased postoperative length of hospital stay or operative mortality in this patient population. DESIGN Retrospective study. SETTING Single tertiary care university hospital. PARTICIPANTS Patients undergoing isolated CABG between January 2012 and March 2017 with an LVEF ≤ 25%. INTERVENTIONS Isolated CABG. MEASUREMENTS AND MAIN RESULTS Primary endpoint was a composite of prolonged length of stay, defined as postoperative length of stay >7 days or operative mortality. Of the 201 patients, 99 (49.3%) met the primary endpoint. Patient comorbidities, clinical presentation, presence of Q-waves on electrocardiogram, and echocardiographic parameters including ventricular dimensions and right heart dysfunction were not associated with the primary endpoint. On multivariable analysis, patients who were not on preoperative beta-blockers, patients with preoperative albumin of <3.5 g/dL, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score were associated with increased prolonged length of stay or death. CONCLUSIONS More than half of patients with severely depressed LVEF undergoing isolated CABG are able to be discharged within 7 days postoperatively. The absence of preoperative beta-blockers, low preoperative albumin levels, and higher Society of Thoracic Surgeons Predicted Risk of Mortality score are associated with more complicated or slower postoperative recovery after CABG in this patient population.
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Affiliation(s)
- Pey-Jen Yu
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY.
| | - Dishen Lin
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Michael Catalano
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Hugh Cassiere
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
| | - Nina Kohn
- The Feinstein Institute for Medical Research, Manhasset, NY
| | - Alan Hartman
- Division of Cardiovascular and Thoracic Surgery, Zucker School of Medicine at Hofstra/Northwell, Manhasset, NY
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Levosimendan use in patients with preoperative low ejection fraction undergoing cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. J Clin Anesth 2019; 52:37-47. [DOI: 10.1016/j.jclinane.2018.08.019] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2018] [Revised: 08/13/2018] [Accepted: 08/16/2018] [Indexed: 12/20/2022]
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Use of Levosimendan in Cardiac Surgery: An Update After the LEVO-CTS, CHEETAH, and LICORN Trials in the Light of Clinical Practice. J Cardiovasc Pharmacol 2019; 71:1-9. [PMID: 29076887 PMCID: PMC5768218 DOI: 10.1097/fjc.0000000000000551] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
Levosimendan is a calcium sensitizer and adenosine triphosphate-dependent potassium channel opener, which exerts sustained hemodynamic, symptomatic, and organ-protective effects. It is registered for the treatment of acute heart failure, and when inotropic support is considered appropriate. In the past 15 years, levosimendan has been widely used in clinical practice and has also been tested in clinical trials to stabilize at-risk patients undergoing cardiac surgery. Recently, 3 randomized, placebo-controlled, multicenter studies (LICORN, CHEETAH, and LEVO-CTS) have been published reporting on the perioperative use of levosimendan in patients with compromised cardiac ventricular function. Taken together, many smaller trials conducted in the past suggested beneficial outcomes with levosimendan in perioperative settings. By contrast, the latest 3 studies were neutral or inconclusive. To understand the reasons for such dissimilarity, a group of experts from Austria, Belgium, Finland, France, Germany, Italy, Switzerland, and Russia, including investigators from the 3 most recent studies, met to discuss the study results in the light of both the previous literature and current clinical practice. Despite the fact that the null hypothesis could not be ruled out in the recent multicenter trials, we conclude that levosimendan can still be viewed as a safe and effective inodilator in cardiac surgery.
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Cuminetti G, Bonadei I, Vizzardi E, Sciatti E, Lorusso R. On-Pump Coronary Artery Bypass Graft: The State of the Art. Rev Recent Clin Trials 2019; 14:106-115. [PMID: 30836924 DOI: 10.2174/1574887114666190301142114] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 05/21/2017] [Accepted: 12/05/2018] [Indexed: 06/09/2023]
Abstract
BACKGROUND Coronary artery bypass grafting (CABG) remains the standard of care for patients with coronary artery disease (CAD). Debate exists concerning several factors, which include percutaneous coronary intervention (PCI) vs. CABG, single vs. bilateral mammary artery grafts, radial artery vs. saphenous vein grafts, right internal mammary artery vs. radial artery grafts, endoscopic vs. open vein-graft harvesting, and on-pump vs. off- pump surgery. Moreover, challenging is the management of diabetic patients with CAD undergoing CABG. This review reports current indications, practice patterns, and outcomes of CABG. METHODS Randomized controlled trials comparing CABG to other therapeutical strategies for CAD were searched through MEDLINE, EMBASE, Cochrane databases, and proceedings of international meetings. RESULTS Large multicenter randomized and observational studies (SYNTAX, BEST, PRECOMBAT, ASCERT) have reported excellent outcomes in CABG patients, with always fewer rates of operative mortality and major morbidity, than PCI. The 10-year follow-up of ARTS II trial showed no difference between single and bilateral mammary artery. BARI 2D, MASS II, CARDia, FREEDOM trials showed that CABG is the best choice for diabetic patients. CONCLUSION CABG still represents one of the most widespread major surgeries, with well-known benefits on symptoms and prognosis in patients with CAD. However, further studies and follow-up data are needed to validate these evidences.
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Affiliation(s)
- Giovanni Cuminetti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Ivano Bonadei
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Enrico Vizzardi
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Edoardo Sciatti
- Cardiology Unit, Department of Experimental and Applied Medicine, University of Brescia, Brescia, Italy
| | - Roberto Lorusso
- Cardio-Thoracic Surgery Department, Heart & Vascular Centre, Maastricht University Medical Centre, Maastricht, Netherlands
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Belletti A, Jacobs S, Affronti G, Mladenow A, Landoni G, Falk V, Schoenrath F. Incidence and Predictors of Postoperative Need for High-Dose Inotropic Support in Patients Undergoing Cardiac Surgery for Infective Endocarditis. J Cardiothorac Vasc Anesth 2018; 32:2528-2536. [DOI: 10.1053/j.jvca.2017.12.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/15/2017] [Indexed: 12/15/2022]
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Litton E, Bass F, Delaney A, Hillis G, Marasco S, McGuinness S, Myles PS, Reid CM, Smith JA, Bagshaw SM, Keri-Anne Cowdrey HB, Frengley R, Ferrier J, Gilder E, Henderson S, Larobina M, Merthens J, Morgan M, Navarra L, Rudas M, Turner L, Reid K, Wise M, Young N, Young P, McGiffin D, Duncan J, Kaczmarek M, Seevanayagam S, Shaw M, Shardey G, Skillington P, Chorley T, Baker L, Zhang B, Bright C, Baker R, Canning N, Gilfillan, Kruger R, Fayers T, Kyte M, Doran C, Smith J, Baxter H, Seah P, Scaybrook S, James A, Goodwin K, Dignan R, Hewitt N, Gerrard K, Curtis L, Smith J, Baxter H, Tiruvoipati R, Broukal N, Wolfenden H, Muir, Worthington M, Wong C, Tatoulis J, Wynne R, Marshman D, Sze D, Wilson M, Turner L, Passage J, Kolybaba M, Fermanis G, Newbon P, Passage J, Kolybaba M, Newcomb A, Mack J, Duve K, Jansz P, Hunter T, Bissaker P, Dennis N, Burke N, Yadav S, Cooper K, Chard R, Halaka M, Tran L, Huq M, Billah B, Reid CM. Six-Month Outcomes After High-Risk Coronary Artery Bypass Graft Surgery and Preoperative Intra-aortic Balloon Counterpulsation Use: An Inception Cohort Study. J Cardiothorac Vasc Anesth 2018; 32:2067-2073. [DOI: 10.1053/j.jvca.2018.01.005] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2017] [Indexed: 11/11/2022]
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Bomberg H, Stroeder J, Karrenbauer K, Groesdonk HV, Wagenpfeil S, Klingele M, Bücker A, Schäfers HJ, Minko P. Establishment of Predictive Models for Nonocclusive Mesenteric Ischemia Comparing 8,296 Control with 452 Study Patients. J Cardiothorac Vasc Anesth 2018; 33:1290-1297. [PMID: 30245114 DOI: 10.1053/j.jvca.2018.08.194] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2018] [Indexed: 01/14/2023]
Abstract
OBJECTIVE The aim of this study was to develop clinical preoperative, intraoperative, and postoperative scores for early identification of patients who are at risk of nonocclusive mesenteric ischemia (NOMI). DESIGN A retrospective analysis. SETTING Single center. PARTICIPANTS From January 2008 to December 2014, all patients from the Department of Thoracic and Cardiovascular Surgery were included on the basis of the hospital database. INTERVENTIONS All mesenteric angiographically identified NOMI patients were compared with non-NOMI patients. MEASUREMENTS AND MAIN RESULTS The study population of 8,748 patients was randomized into a cohort for developing the scores (non-NOMI 4,214 and NOMI 235) and a cohort for control (non-NOMI 4,082 and NOMI 217). Risk factors were identified using forward and backward Wald test and were included in the predictive scores for the occurrence of NOMI. C statistic showed that the scores had a high discrimination for the prediction of NOMI preoperatively (C statistic 0.79; p < 0.001), intraoperatively (C statistic 0.68; p < 0.001), and postoperatively (C statistic 0.85; p < 0.001). A combination of the preoperative, intraoperative, and postoperative risk scores demonstrated the highest discrimination (C statistic 0.87; p < 0.001). The combined score included the following risk factors: renal insufficiency (preoperative); use of cardiopulmonary bypass and intra-aortic balloon pump support (intraoperative); and reexploration for bleeding, renal replacement therapy, and packed red blood cells ≥ 4 units (postoperative). The results were similar in the control group. CONCLUSIONS These scores could be useful to identify patients at risk for NOMI and promote a rapid diagnosis and therapy.
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Affiliation(s)
- Hagen Bomberg
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany; Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany.
| | - Jonas Stroeder
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Kathrin Karrenbauer
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Heinrich V Groesdonk
- Department of Anesthesiology, Intensive Care Medicine and Pain Medicine, Saarland University Medical Center, Homburg/Saar, Germany
| | - Stefan Wagenpfeil
- Institute for Medical Biometry, Epidemiology and Medical Informatics, Saarland University Medical Center, Homburg/Saar, Germany
| | - Matthias Klingele
- Department of Medicine, Division of Nephrology and Hypertension, Saarland University Medical Center, Homburg/Saar, Germany; Department of Nephrology, Hochtaunus-Kliniken, Bad Homburg, Germany
| | - Arno Bücker
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
| | - Hans-Joachim Schäfers
- Department of Thoracic and Cardiovascular Surgery, Saarland University Medical Center, Homburg/Saar, Germany
| | - Peter Minko
- Department of Diagnostic and Interventional Radiology, Saarland University Medical Center, Homburg/Saar, Germany
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Nguyen LS, Squara P, Amour J, Carbognani D, Bouabdallah K, Thierry S, Apert-Verneuil C, Moyne A, Cholley B. Intravenous ivabradine versus placebo in patients with low cardiac output syndrome treated by dobutamine after elective coronary artery bypass surgery: a phase 2 exploratory randomized controlled trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:193. [PMID: 30115103 PMCID: PMC6097391 DOI: 10.1186/s13054-018-2124-8] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/15/2017] [Accepted: 07/10/2018] [Indexed: 01/06/2023]
Abstract
BACKGROUND Low cardiac output syndrome (LCOS) is a severe condition which can occur after cardiac surgery, especially among patients with pre-existing left ventricular dysfunction. Dobutamine, its first-line treatment, is associated with sinus tachycardia. This study aims to assess the ability of intravenous ivabradine to decrease sinus tachycardia associated with dobutamine infused for LCOS after coronary artery bypass graft (CABG) surgery. METHODS In a phase 2, multi-center, single-blind, randomized controlled trial, patients with left ventricular ejection fraction below 40% presenting sinus tachycardia of at least 100 beats per minute (bpm) following dobutamine infusion for LCOS after CABG surgery received either intravenous ivabradine or placebo (three ivabradine for one placebo). Treatment lasted until dobutamine weaning or up to 48 h. The primary endpoint was the proportion of patients achieving a heart rate (HR) in the 80- to 90-bpm range. Secondary endpoints were invasive and non-invasive hemodynamic parameters and arrhythmia events. RESULTS Nineteen patients were included. More patients reached the primary endpoint in the ivabradine than in the placebo group (13 (93%) versus 2 (40%); P = 0.04). Median times to reach target HR were 1.0 h in the ivabradine group and 5.7 h in the placebo group. Ivabradine decreased HR (112 to 86 bpm, P <0.001) while increasing cardiac index (P = 0.02), stroke volume (P <0.001), and systolic blood pressure (P = 0.03). In the placebo group, these parameters remained unchanged from baseline. In the ivabradine group, five patients (36%) developed atrial fibrillation (AF) and one (7%) was discontinued for sustained AF; two (14%) were discontinued for bradycardia. CONCLUSION Intravenous ivabradine achieved effective and rapid correction of sinus tachycardia in patients who received dobutamine for LCOS after CABG surgery. Simultaneously, stroke volume and systolic blood pressure increased, suggesting a beneficial effect of this treatment on tissue perfusion. TRIAL REGISTRATION European Clinical Trials Database: EudraCT 2009-018175-14 . Registered February 2, 2010.
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Affiliation(s)
- Lee S Nguyen
- Critical Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Pierre Squara
- Critical Care Medicine, CMC Ambroise Paré, Neuilly-sur-Seine, France
| | - Julien Amour
- Anesthesiology and Critical Care Medicine, Hôpital de la Pitié-Salpétrière, AP-HP, and Université Pierre et Marie Curie, Paris, France
| | - Daniel Carbognani
- Anesthesiology and Critical Care Medicine, Institut Mutualiste Monsouris, Paris, France
| | - Kamel Bouabdallah
- Anesthesiology and Critical Care Medicine, Institut Mutualiste Monsouris, Paris, France
| | - Stéphane Thierry
- Anesthesiology and Critical Care Medicine, Centre Cardiologique du Nord, Saint-Denis, France
| | | | - Aurélie Moyne
- Institut de Recherches Internationales Servier, Suresnes, France
| | - Bernard Cholley
- Anesthesiology and Critical Care Medicine Department, Hôpital Européen Georges Pompidou, AP-HP, and Université Paris Descartes-Sorbonne Paris Cité, Paris, France.
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Krichevskiy LA, Kozlov IA. Natriuretic Peptides in Cardiac Anesthesia and Intensive Care. J Cardiothorac Vasc Anesth 2018; 33:1407-1419. [PMID: 30228053 DOI: 10.1053/j.jvca.2018.08.019] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2018] [Indexed: 01/16/2023]
Abstract
Natriuretic peptides, predominantly B-type, are widely used in cardiology as prognostic and diagnostic biomarkers or, much less often, as a substantive treatment tool. They are hormones that are produced mainly in the myocardium in response to overload and ischemia, and their level quite accurately reflects the degree of myocardial dysfunction. Although their use in cardiac anesthesia and intensive care setting seems to be very beneficial for assessing the risk of acute disturbance of myocardial function or its laboratory monitoring, the actual significance of natriuretic peptides in this area is not yet recognized. This is due to the lack of clear diagnostic and prognostic values for these biomarkers supported by high-quality researches. On the basis of the available data, main advantages, existing difficulties, and most effective ways of using natriuretic peptides for determining the risk of heart surgery and assessing the severity of sepsis, pneumonia, and other critical conditions have been discussed in this review. In addition, the expediency of using natriuretic peptides as target parameters for goal-oriented therapy and as a substantive tool for treatment is considered.
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Affiliation(s)
- Lev A Krichevskiy
- Department of Anesthesiology and Intensive Care, City Clinical Hospital n.a. S.S.Yudin, Department of Health of Moscow, Moscow, Russia.
| | - Igor A Kozlov
- Department of Anaesthesiology, Moscow Regional Research Clinical Institute n.a. M.F. Vladimirskiy, Moscow, Russia
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Xing Z, Tang L, Chen P, Huang J, Peng X, Hu X. Levosimendan in patients with left ventricular dysfunction undergoing cardiac surgery: a meta-analysis and trial sequential analysis of randomized trials. Sci Rep 2018; 8:7775. [PMID: 29773835 PMCID: PMC5958056 DOI: 10.1038/s41598-018-26206-w] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/08/2018] [Accepted: 05/08/2018] [Indexed: 01/18/2023] Open
Abstract
Patients with left ventricular dysfunction (LVD) undergoing cardiac surgery have a high mortality rate. Levosimendan, a calcium sensitizer, improves myocardial contractility without increasing myocardial oxygen demand. It is not clear whether levosimendan can reduce mortality in cardiac surgery patients with LVD. The PubMed, Embase, and Cochrane Central databases were searched to identify randomized trials comparing levosimendan with conventional treatment in cardiac surgery patients with LVD. We derived pooled risk ratios (RRs) with random effects models. The primary endpoint was perioperative mortality. Secondary endpoints were renal replacement treatment, atrial fibrillation, myocardial infarction, ventricular arrhythmia, and hypotension. Fifteen studies enrolling 2606 patients were included. Levosimendan reduced the incidence of perioperative mortality (RR: 0.64, 95%CI: 0.45–0.91) and renal replacement treatment (RR:0.71, 95%CI:0.52–0.95). However, sensitivity analysis, subgroup analysis and Trial Sequential Analysis (TSA) indicated that more evidence was needed. Furthermore, levosimendan did not reduce the incidence of atrial fibrillation (RR:0.82, 95%CI:0.64–1.07), myocardial infarction (RR:0.56, 95%CI:0.26–1.23), or ventricular arrhythmia (RR:0.74, 95%CI:0.49–1.11), but it increased the incidence of hypotension (RR:1.11,95%CI:1.00–1.23). There was not enough high-quality evidence to either support or contraindicate the use of levosimendan in cardiac surgery patients with LVD.
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Affiliation(s)
- Zhenhua Xing
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Liang Tang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Pengfei Chen
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Jiabing Huang
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xiaofan Peng
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China
| | - Xinqun Hu
- Department of Cardiovascular Medicine, The Second Xiangya Hospital, Central South University, Changsha, Hunan 410011, China.
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Wang B, He X, Gong Y, Cheng B. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery: An Update Meta-Analysis and Trial Sequential Analysis. BIOMED RESEARCH INTERNATIONAL 2018; 2018:7563083. [PMID: 29854789 PMCID: PMC5964575 DOI: 10.1155/2018/7563083] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/03/2018] [Revised: 03/19/2018] [Accepted: 03/28/2018] [Indexed: 01/07/2023]
Abstract
BACKGROUND Recent studies suggest that levosimendan does not provide mortality benefit in patients with low cardiac output syndrome undergoing cardiac surgery. These results conflict with previous findings. The aim of the current study is to assess whether levosimendan reduces postoperative mortality in patients with impaired left ventricular function (mean EF ≤ 40%) undergoing cardiac surgery. METHODS We conducted a comprehensive search of PubMed, EMBASE, and Cochrane Library Database through November 20, 2017. Inclusion criteria were random allocation to treatment with at least one group receiving levosimendan and another group receiving placebo or other treatments and cardiac surgery patients with a left ventricular ejection fraction of 40% or less. The primary endpoint was postoperative mortality. Secondary outcomes were cardiac index, pulmonary capillary wedge pressure (PCWP), length of intensive care unit (ICU) stay, postoperative atrial fibrillation, and postoperative renal replacement therapy. We performed trial sequential analysis (TSA) to evaluate the reliability of the primary endpoint. RESULTS Data from 2,152 patients in 15 randomized clinical trials were analyzed. Pooled results demonstrated a reduction in postoperative mortality in the levosimendan group [RR = 0.53, 95% CI (0.38-0.73), I2 = 0]. However, the result of TSA showed that the conclusion may be a false positive. Secondary outcomes demonstrated that PCWP, postoperative renal replacement therapy, and length of ICU stay were significantly reduced. Cardiac index was greater in the levosimendan group. No difference was found in the rate of postoperative atrial fibrillation. CONCLUSIONS Levosimendan reduces the rate of death and other adverse outcomes in patients with low ejection fraction who were undergoing cardiac surgery, but results remain inconclusive. More large-volume randomized clinical trials (RCTs) are warranted.
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Affiliation(s)
- Benji Wang
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Xiaojie He
- School of Ophthalmology and Optometry and Eye Hospital, Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Yuqiang Gong
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
| | - Bihuan Cheng
- Department of Anesthesiology, Critical Care and Pain Medicine, The Second Affiliated Hospital and Yuying Children's Hospital of Wenzhou Medical University, Wenzhou, Zhejiang 325000, China
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Ellenberger C, Sologashvili T, Cikirikcioglu M, Verdon G, Diaper J, Cassina T, Licker M. Risk factors of postcardiotomy ventricular dysfunction in moderate-to-high risk patients undergoing open-heart surgery. Ann Card Anaesth 2018; 20:287-296. [PMID: 28701592 PMCID: PMC5535568 DOI: 10.4103/aca.aca_60_17] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/05/2023] Open
Abstract
Introduction: Ventricular dysfunction requiring inotropic support frequently occurs after cardiac surgery, and the associated low cardiac output syndrome largely contributes to postoperative death. We aimed to study the incidence and potential risk factors of postcardiotomy ventricular dysfunction (PCVD) in moderate-to-high risk patients scheduled for open-heart surgery. Methods: Over a 5-year period, we prospectively enrolled 295 consecutive patients undergoing valve replacement for severe aortic stenosis or coronary artery bypass surgery who presented with Bernstein-Parsonnet scores >7. The primary outcome was the occurrence of PCVD as defined by the need for sustained inotropic drug support and by transesophageal echography. The secondary outcomes included in-hospital mortality and the incidence of any major adverse events as well as Intensive Care Unit (ICU) and hospital length of stay. Results: The incidence of PCVD was 28.4%. Patients with PCVD experienced higher in-hospital mortality (12.6% vs. 0.6% in patients without PCVD) with a higher incidence of cardiopulmonary and renal complications as well as a prolonged stay in ICU (median + 2 days). Myocardial infarct occurred more frequently in patients with PCVD than in those without PCVD (19 [30.2%] vs. 12 [7.6%]). By logistic regression analysis, we identified four independent predictors of PCVD: left ventricular ejection fraction <40% (odds ratio [OR] = 6.36; 95% confidence interval [CI], 2.59–15.60), age older than 75 years (OR = 3.35; 95% CI, 1.64–6.81), prolonged aortic clamping time (OR = 3.72; 95% CI, 1.66–8.36), and perioperative bleeding (OR = 2.33; 95% CI, 1.01–5.41). The infusion of glucose-insulin-potassium was associated with lower risk of PCVD (OR = 0.14; 95% CI, 0.06–0.33). Conclusions: This cohort study indicates that age, preoperative ventricular function, myocardial ischemic time, and perioperative bleeding are predictors of PCVD which is associated with poor clinical outcome.
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Affiliation(s)
- Christoph Ellenberger
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Tornike Sologashvili
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Mustafa Cikirikcioglu
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - Gabriel Verdon
- Division of Cardiovascular Surgery, University Hospital of Geneva, Geneva, Switzerland
| | - John Diaper
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva, Geneva, Switzerland
| | - Tiziano Cassina
- Department of Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano; Faculty of Medicine, University of Geneva, Geneva, Switzerland
| | - Marc Licker
- Department of Anaesthesiology, Pharmacology and Intensive Care, University Hospital of Geneva; Faculty of Medicine, University of Geneva, Geneva, Switzerland
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Amabili P, Benbouchta S, Roediger L, Senard M, Hubert MB, Donneau AF, Brichant JF, Hans GA. Low Cardiac Output Syndrome After Adult Cardiac Surgery. Anesth Analg 2018; 126:1476-1483. [DOI: 10.1213/ane.0000000000002605] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Levosimendan versus placebo in cardiac surgery: a systematic review and meta-analysis. Interact Cardiovasc Thorac Surg 2018; 27:677-685. [DOI: 10.1093/icvts/ivy133] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 03/25/2018] [Indexed: 11/14/2022] Open
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Fernando RJ, Johnson SD, Augoustides JG, Patel PA, Gutsche JT, Ha B, Feinman JW, Weiss SJ, Cheruku S, McCartney SL, Dave N, Fabbro M, Morris BN. The Hostile Thoracic Aorta: Management Considerations for Severe Aortic Atheroma in a Challenging Case of Coronary Artery Bypass Grafting and Mitral Valve Replacement. J Cardiothorac Vasc Anesth 2018; 33:223-231. [PMID: 29685800 DOI: 10.1053/j.jvca.2018.03.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/10/2018] [Indexed: 11/11/2022]
Affiliation(s)
- Rohesh J Fernando
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - Sean D Johnson
- Cardiothoracic Section, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
| | - John G Augoustides
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA.
| | - Prakash A Patel
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jacob T Gutsche
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Bao Ha
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Jared W Feinman
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Stuart J Weiss
- Cardiovascular and Thoracic Section, Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA
| | - Sreekanth Cheruku
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, University of Texas Southwestern Medical Center, Dallas, TX
| | - Sharon L McCartney
- Divisions of Cardiothoracic and Critical Care Anesthesiology, Department of Anesthesiology, Duke University, Durham, NC
| | - Nisha Dave
- Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Michael Fabbro
- Cardiothoracic Anesthesiology, Department of Anesthesiology, Perioperative Medicine and Pain Management, Miller School of Medicine, University of Miami, Miami, FL
| | - Benjamin N Morris
- Cardiothoracic and Critical Care Sections, Department of Anesthesiology, Wake Forest School of Medicine, Wake Forest University, Winston-Salem, NC
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Nielsen DV, Torp-Pedersen C, Skals RK, Gerds TA, Karaliunaite Z, Jakobsen CJ. Intraoperative milrinone versus dobutamine in cardiac surgery patients: a retrospective cohort study on mortality. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:51. [PMID: 29482650 PMCID: PMC5828330 DOI: 10.1186/s13054-018-1969-1] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/06/2017] [Accepted: 01/31/2018] [Indexed: 02/10/2023]
Abstract
Background Several choices of inotropic therapy are available and used in relation to cardiac surgery. Comparisons are necessary to select optimal therapy. In Denmark, dobutamine and milrinone are the two inotropic agents most commonly used to treat post-bypass low cardiac output syndrome. This study compares all-cause mortality with these drugs. Methods In a retrospective observational study we investigated 10,700 consecutive patients undergoing cardiac surgery from 1 April 2006 to 31 December 2013 at Aarhus and Aalborg University Hospitals in the Central and Northern Denmark Region. Prospectively entered data in the Western Danish Heart Registry on intraoperative use of inotropes were used to identify 952 patients treated with milrinone, 418 patients treated with dobutamine, and 82 patients receiving a combination of the two inotropes. All-cause mortality among patients receiving dobutamine was compared to all-cause mortality among milrinone receivers. Multiple logistic regression analyses including preoperative and intraoperative variables along with g-formula analyses were used to model 30-day and 1-year mortality risks. Reported were standardized mortality risk differences between the treatment groups. Results Among patients receiving intraoperative dobutamine, 18 (4.3%) died within 30 days and 49 (11.7%) within 1 year. Corresponding 30-day and 1-year mortality for milrinone receivers were 81 (8.5%) and 170 (17.9%). Risk of death within 30 days and 1 year was increased for intraoperative milrinone compared to dobutamine with a standardized risk difference of 4.06% (confidence interval (CI) 1.23; 6.89, p = 0.005) and 4.77% (CI 0.39; 9.15, p = 0.033), respectively. Sensitivity analyses including adjustment for milrinone preference, hemodynamic instability prior to cardiopulmonary bypass, and separate analyses on hospital level all confirmed a sign toward increased mortality among milrinone receivers. Conclusions Intraoperative use of milrinone in cardiac surgery may be associated with an increase in all-cause mortality compared to use of dobutamine. Electronic supplementary material The online version of this article (10.1186/s13054-018-1969-1) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Dorthe Viemose Nielsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark.
| | - Christian Torp-Pedersen
- Department of Health, Science and Technology, Aalborg University, Frederiks Bajersvej, 9220, Aalborg, Denmark
| | - Regitze Kuhr Skals
- Unit of Epidemiology and Biostatistics, Aalborg University Hospital, Forskningens Hus, Sdr. Skovvej 15, 9000, Aalborg, Denmark
| | - Thomas A Gerds
- Department of Public Health, Section of Biostatistics, University of Copenhagen, Oester Farimagsgade 5, 1014, Copenhagen, Denmark
| | - Zidryne Karaliunaite
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
| | - Carl-Johan Jakobsen
- Department of Anesthesia and Intensive Care, Aarhus University Hospital, Palle Juul-Jensens Boulevard, 8200, Aarhus N, Denmark
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Xu Y, Li Y, Bao W, Qiu S. Protective effects of recombinant human brain natriuretic peptide in perioperative period during open heart surgery. Exp Ther Med 2018; 15:2869-2873. [PMID: 29456690 PMCID: PMC5795603 DOI: 10.3892/etm.2018.5750] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2017] [Accepted: 08/22/2017] [Indexed: 11/18/2022] Open
Abstract
The aim of the present study was to evaluate the protective effects and safety aspects of recombinant human brain natriuretic peptide (rhBNP) on cardiac functions of patients undergoing open-heart surgery during perioperative period. In total, 150 patients undergoing open heart surgery in the Second Hospital of Shandong Universty from August 2015 to July 2016 were randomly divided into control group and observation group each with 75 cases. Patients in control group were treated by routine rehabilitation while patients in the observation group were treated by both the routine rehabilitation and rhBNP. All the observations were made before operation, after operation and 7 days after operation. The changes of N-terminal pro-brain natriuretic peptide (NT-proBNP) of patients, the left ventricular ejection fraction (LVEF), cardiac function [Cardiac output (CO), pulmonary capillary wedge pressure (PAWP) and central venous pressure (CVP)] of patients were measured. Further, respirator support time, ICU stay time, incidence of complications and vital signs (BP, HR, SaO2) of patients in the two groups were also compared. NT-proBNP levels of all patients improved after operation but it decreased in both groups after 7 days of operation. The decrease of NT-proBNP levels in observation group was significantly higher than that of control group. Whereas, LVEF, CO, PAWP and CVP of patients in both the groups increased after operation but effects were significantly higher in the observation group after 7 days of medication. Respirator support time and ICU stay time of patients in observation group were significantly shorter than those in control group, and the incidence of postoperative complications of patients in the observation group were significantly lower than the control group. Moreover, BP, HR and SaO2 of patients in observation group were significantly elevated in comparison to control group (P<0.05). Recombinant human brain natriuretic peptide (rhBNP) could significantly improve the cardiac functions of patients after open heart surgery, and is safe as well as reliable.
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Affiliation(s)
- Yunbin Xu
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
| | - Yong Li
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
| | - Weiguo Bao
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
| | - Shi Qiu
- Department of Cardiovascular Surgery, The Second Hospital of Shandong University, Jinan, Shandong 250033, P.R. China
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Iyengar A, Kwon OJ, Bailey KL, Ashfaq A, Abdelkarim A, Shemin RJ, Benharash P. Predictors of cardiogenic shock in cardiac surgery patients receiving intra-aortic balloon pumps. Surgery 2018; 163:1317-1323. [PMID: 29395233 DOI: 10.1016/j.surg.2017.11.021] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2017] [Revised: 10/03/2017] [Accepted: 11/22/2017] [Indexed: 10/18/2022]
Abstract
BACKGROUND Cardiogenic shock after cardiac surgery leads to severely increased mortality. Intra-aortic balloon pumps may be used during the preoperative period to increase coronary perfusion. The purpose of this study was to characterize predictors of postoperative cardiogenic shock in cardiac surgery patients with and without intra-aortic balloon pumps support. METHODS We performed a retrospective analysis of our institutional database of the Society of Thoracic Surgeons for patients operated between January 2008 to July 2015. Multivariable logistic regression was used to model postoperative cardiogenic shock in both the intra-aortic balloon pumps and matched control cohorts. RESULTS Overall, 4,741 cardiac surgery patients were identified during the study period, of whom 192 (4%) received a preoperative intra-aortic balloon pump. Intra-aortic balloon pumps patients had a greater prevalence of diabetes, previous cardiac surgery, congestive heart failure, and an urgent/emergent status (P < .001). Intra-aortic balloon pumps patients also had greater 30-day mortality and more postoperative cardiogenic shock (9% vs 3%, P < .001). On multivariable analysis of the matched control cohort, postoperative cardiogenic shock remained multifactorial. Among the intra-aortic balloon pumps cohort, only sex, previous percutaneous coronary intervention and preoperative arrhythmia remained significant on multivariable analysis (all P < .05). CONCLUSION Factors associated with cardiogenic shock among postcardiac surgery patients differ between those patients receiving intra-aortic balloon pumps and those who do not. Further analysis of the effects of prophylactic intra-aortic balloon pumps support is warranted. (Surgery 2017;160:XXX-XXX.).
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Affiliation(s)
- Amit Iyengar
- David Geffen School of Medicine, University of California, Los Angeles; Los Angeles, CA, USA
| | - Oh Jin Kwon
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Katherine L Bailey
- David Geffen School of Medicine, University of California, Los Angeles; Los Angeles, CA, USA
| | - Adeel Ashfaq
- David Geffen School of Medicine, University of California, Los Angeles; Los Angeles, CA, USA
| | - Ayman Abdelkarim
- David Geffen School of Medicine, University of California, Los Angeles; Los Angeles, CA, USA
| | - Richard J Shemin
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA
| | - Peyman Benharash
- Division of Cardiac Surgery, David Geffen School of Medicine, University of California, Los Angeles, CA, USA.
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Vasodilatory Shock in the ICU: Perils, Pitfalls and Therapeutic Options. ANNUAL UPDATE IN INTENSIVE CARE AND EMERGENCY MEDICINE 2018 2018. [DOI: 10.1007/978-3-319-73670-9_9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
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Sun S, Ma F, Li Q, Bai M, Li Y, Yu Y, Huang C, Wang H, Ning X. Risk model for deaths and renal replacement therapy dependence in patients with acute kidney injury after cardiac surgery. Interact Cardiovasc Thorac Surg 2017; 25:548-554. [PMID: 28655154 DOI: 10.1093/icvts/ivx210] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2016] [Accepted: 04/14/2017] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Acute kidney injury (AKI) is a serious complication after cardiac surgery and is associated with increased in-hospital deaths. Renal replacement therapy (RRT) is becoming a routine strategy for severe AKI. Our goal was to evaluate the risk factors for death and RRT dependence in patients with AKI after cardiac surgery. METHODS We included 190 eligible adult patients who had AKI following cardiac surgery and who required RRT at our centre from November 2010 to March 2015. We collected preoperative, intraoperative, postoperative and RRT data for all patients. RESULTS In this cohort, 87 patients had successful RRT in the hospital, whereas 103 patients had RRT that failed (70 deaths and 33 cases of RRT dependence). The multivariable logistic analysis identified old age [odds ratio (OR): 1.042, 95% confidence interval (CI): 1.012-1.074; P = 0.011], serum uric acid (OR: 1.015, 95% CI: 1.003-1.031; P = 0.024), intraoperative concentrated red blood cell transfusions (OR: 1.144, 95% CI: 1.006-1.312; P = 0.041), postoperative low cardiac output syndrome (OR: 3.107, 95% CI: 1.179-8.190; P = 0.022) and multiple organ failure (OR: 5.786, 95% CI: 2.115-15.832; P = 0.001) as factors associated with a higher risk for RRT failure. The prediction model (-4.3 + 0.002 × preuric acid + 0.10 × concentrated red blood cells + 0.04 × age + 1.12 × [low cardiac output syndrome = 1] + 1.67 × [multiple organ failure = 1]) based on the multivariate analysis had statistically significant different incriminatory power with an area under the curve of 0.786. CONCLUSIONS The prediction model may serve as a simple, accurate tool for predicting in-hospital RRT failure for patients with AKI following cardiac surgery.
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Affiliation(s)
- Shiren Sun
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Feng Ma
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Qiaoneng Li
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Ming Bai
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yangping Li
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Yan Yu
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Chen Huang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Hanmin Wang
- Department of Nephrology, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
| | - Xiaoxuan Ning
- Department of Geriatrics, Xijing Hospital, Fourth Military Medical University, Xi'an, Shaanxi, China
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Putzu A, Clivio S, Belletti A, Cassina T. Perioperative levosimendan in cardiac surgery: A systematic review with meta-analysis and trial sequential analysis. Int J Cardiol 2017; 251:22-31. [PMID: 29126653 DOI: 10.1016/j.ijcard.2017.10.077] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2017] [Revised: 09/24/2017] [Accepted: 10/17/2017] [Indexed: 12/30/2022]
Abstract
BACKGROUND Several studies suggested beneficial effects of perioperative levosimendan on postoperative outcome after cardiac surgery. However, three large randomized controlled trials (RCTs) have been recently published and presented neutral results. We performed a systematic review with meta-analysis and trial sequential analysis (TSA) to assess benefits and harms of perioperative levosimendan therapy in cardiac surgery. METHODS Electronic databases were searched up to September 2017 for RCTs on preoperative levosimendan versus any type of control. The Cochrane methodology was employed. We calculated odds ratio (OR) or Risk Ratio (OR) and 95% confidence interval (CI) using fixed-effects meta-analyses and we further performed TSA. RESULTS We included data from 40 RCTs and 4246 patients. Pooled analysis of 5 low risk of bias trials (1910 patients) showed no association between levosimendan and mortality (OR 0.86 [95% CI, 0.62, 1.18], p=0.34, TSA inconclusive), acute kidney injury, need of renal replacement therapy, myocardial infarction, ventricular arrhythmias, and serious adverse events, but an association with higher incidence of supraventricular arrhythmias (RR 1.11 [95% CI, 1.00, 1.24], p=0.05, TSA inconclusive) and hypotension (RR 1.15 [95% CI, 1.01, 1.30], p=0.04, TSA inconclusive). Analysis including all 40 trials found that levosimendan was associated with lower postoperative mortality (OR 0.56 [95% CI, 0.44, 0.71], p<0.00001, TSA conclusive), acute kidney injury, and renal replacement therapy, and higher incidence of hypotension. CONCLUSIONS There is not enough high-quality evidence to neither support nor discourage the systematic use of levosimendan in cardiac surgery.
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Affiliation(s)
- Alessandro Putzu
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Sara Clivio
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Milan, Italy
| | - Tiziano Cassina
- Department of Cardiovascular Anesthesia and Intensive Care, Cardiocentro Ticino, Lugano, Switzerland.
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Sanfilippo F, Knight JB, Scolletta S, Santonocito C, Pastore F, Lorini FL, Tritapepe L, Morelli A, Arcadipane A. Levosimendan for patients with severely reduced left ventricular systolic function and/or low cardiac output syndrome undergoing cardiac surgery: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:252. [PMID: 29047417 PMCID: PMC5648477 DOI: 10.1186/s13054-017-1849-0] [Citation(s) in RCA: 34] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Accepted: 09/28/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND Previous studies have shown beneficial effects of levosimendan in high-risk patients undergoing cardiac surgery. Two large randomized controlled trials (RCTs), however, showed no advantages of levosimendan. METHODS We performed a systematic review and meta-analysis (MEDLINE and Embase from inception until March 30, 2017), investigating whether levosimendan offers advantages compared with placebo in high-risk cardiac surgery patients, as defined by preoperative left ventricular ejection fraction (LVEF) ≤ 35% and/or low cardiac output syndrome (LCOS). The primary outcomes were mortality at longest follow-up and need for postoperative renal replacement therapy (RRT). Secondary postoperative outcomes investigated included myocardial injury, supraventricular arrhythmias, development of LCOS, acute kidney injury (AKI), duration of mechanical ventilation, intensive care unit and hospital lengths of stay, and incidence of hypotension during drug infusion. RESULTS Six RCTs were included in the meta-analysis, five of which investigated only patients with LVEF ≤ 35% and one of which included predominantly patients with LCOS. Mortality was similar overall (OR 0.64 [0.37, 1.11], p = 0.11) but lower in the subgroup with LVEF < 35% (OR 0.51 [0.32, 0.82], p = 0.005). Need for RRT was reduced by levosimendan both overall (OR 0.63 [0.42, 0.94], p = 0.02) and in patients with LVEF < 35% (OR 0.55 [0.31, 0.97], p = 0.04). Among secondary outcomes, we found lower postoperative LCOS in patients with LVEF < 35% receiving levosimendan (OR 0.49 [0.27, 0.89], p = 0.02), lower overall AKI (OR 0.62 [0.42, 0.92], p = 0.02), and a trend toward lower mechanical support, both overall (p = 0.07) and in patients with LVEF < 35% (p = 0.05). CONCLUSIONS Levosimendan reduces mortality in patients with preoperative severely reduced LVEF but does not affect overall mortality. Levosimendan reduces the need for RRT after high-risk cardiac surgery.
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Affiliation(s)
- Filippo Sanfilippo
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.
| | - Joshua B Knight
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy.,Department of Anesthesiology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Sabino Scolletta
- Unit of Anesthesia and Critical Care Medicine, Department of Medical Biotechnologies, Azienda Ospedaliera Universitaria Senese, Siena, Italy
| | - Cristina Santonocito
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Federico Pastore
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
| | - Ferdinando L Lorini
- Department of Anaesthesia and Intensive Care, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luigi Tritapepe
- Department of Cardiovascular, Respiratory, Nephrological, Anaesthetic and Geriatric Sciences, Sapienza University of Rome, Rome, Italy
| | - Andrea Morelli
- Department of Anesthesiology and Intensive Care, Policlinico Umberto 1, Sapienza University of Rome, Rome, Italy
| | - Antonio Arcadipane
- Department of Anesthesia and Intensive Care, Istituto Mediterraneo per i Trapianti e Terapie ad alta specializzazione (IRCCS-ISMETT), Via Tricomi 5, 90127, Palermo, Italy
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Kumar A, Puri GD, Bahl A. Transesophageal Echocardiography, 3-Dimensional and Speckle Tracking Together as Sensitive Markers for Early Outcome in Patients With Left Ventricular Dysfunction Undergoing Cardiac Surgery. J Cardiothorac Vasc Anesth 2017; 31:1695-1701. [DOI: 10.1053/j.jvca.2017.04.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Indexed: 01/01/2023]
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Cholley B, Caruba T, Grosjean S, Amour J, Ouattara A, Villacorta J, Miguet B, Guinet P, Lévy F, Squara P, Aït Hamou N, Carillon A, Boyer J, Boughenou MF, Rosier S, Robin E, Radutoiu M, Durand M, Guidon C, Desebbe O, Charles-Nelson A, Menasché P, Rozec B, Girard C, Fellahi JL, Pirracchio R, Chatellier G. Effect of Levosimendan on Low Cardiac Output Syndrome in Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass: The LICORN Randomized Clinical Trial. JAMA 2017; 318:548-556. [PMID: 28787507 PMCID: PMC5817482 DOI: 10.1001/jama.2017.9973] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
IMPORTANCE Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function. OBJECTIVE To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome. DESIGN, SETTING, AND PARTICIPANTS Randomized, double-blind, placebo-controlled trial conducted in 13 French cardiac surgical centers. Patients with a left ventricular ejection fraction less than or equal to 40% and scheduled for isolated or combined coronary artery bypass grafting with cardiopulmonary bypass were enrolled from June 2013 until May 2015 and followed during 6 months (last follow-up, November 30, 2015). INTERVENTIONS Patients were assigned to a 24-hour infusion of levosimendan 0.1 µg/kg/min (n = 167) or placebo (n = 168) initiated after anesthetic induction. MAIN OUTCOMES AND MEASURES Composite end point reflecting low cardiac output syndrome with need for a catecholamine infusion 48 hours after study drug initiation, need for a left ventricular mechanical assist device or failure to wean from it at 96 hours after study drug initiation when the device was inserted preoperatively, or need for renal replacement therapy at any time postoperatively. It was hypothesized that levosimendan would reduce the incidence of this composite end point by 15% in comparison with placebo. RESULTS Among 336 randomized patients (mean age, 68 years; 16% women), 333 completed the trial. The primary end point occurred in 87 patients (52%) in the levosimendan group and 101 patients (61%) in the placebo group (absolute risk difference taking into account center effect, -7% [95% CI, -17% to 3%]; P = .15). Predefined subgroup analyses found no interaction with ejection fraction less than 30%, type of surgery, and preoperative use of β-blockers, intra-aortic balloon pump, or catecholamines. The prevalence of hypotension (57% vs 48%), atrial fibrillation (50% vs 40%), and other adverse events did not significantly differ between levosimendan and placebo. CONCLUSIONS AND RELEVANCE Among patients with low ejection fraction who were undergoing coronary artery bypass grafting with cardiopulmonary bypass, levosimendan compared with placebo did not result in a significant difference in the composite end point of prolonged catecholamine infusion, use of left ventricular mechanical assist device, or renal replacement therapy. These findings do not support the use of levosimendan for this indication. TRIAL REGISTRATION EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.
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Affiliation(s)
- Bernard Cholley
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Thibaut Caruba
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Sandrine Grosjean
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalo-Universitaire de Dijon-Bourgogne, France
| | - Julien Amour
- Department of Anesthesiology and Critical Care Medicine, Hôpital de La Pitié Salpêtrière, AP-HP, and University Pierre & Marie Curie, Paris, France
| | - Alexandre Ouattara
- Department Department of Anaesthesiology and Critical Care II, Magellan Medico-Surgical Center, and University of Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, Bordeaux, France
| | - Judith Villacorta
- Department of Anesthesiology and Critical Care, CHU La Timone, Marseille, France
| | - Bertrand Miguet
- Department of Anesthesiology and Critical Care Medicine, Hôpital Laënnec, Nantes, France
| | - Patrick Guinet
- Department of Anesthesiology and Critical Care Medicine, Hôpital Pontchaillou, Rennes, France
| | - François Lévy
- Department of Anesthesiology and Critical Care, Nouvel Hôpital Civil, Strasbourg, France
| | - Pierre Squara
- Department of Anesthesiology and Critical Care, Clinique Ambroise Paré, Neuilly, France
| | - Nora Aït Hamou
- Department of Anesthesiology and Critical Care Medicine, Hôpital de La Pitié Salpêtrière, AP-HP, and University Pierre & Marie Curie, Paris, France
| | - Aude Carillon
- Department of Anesthesiology and Critical Care Medicine, Hôpital de La Pitié Salpêtrière, AP-HP, and University Pierre & Marie Curie, Paris, France
| | - Julie Boyer
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalo-Universitaire de Dijon-Bourgogne, France
| | - Marie-Fazia Boughenou
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Sebastien Rosier
- Department of Anesthesiology and Critical Care Medicine, Hôpital Pontchaillou, Rennes, France
| | - Emmanuel Robin
- Department of Anesthesiology and Critical Care, Hôpital Claude Huriez, Lille, France
| | - Mihail Radutoiu
- Department of Anesthesiology and Critical Care, CHU Côte de Nacre, Caen, France
| | - Michel Durand
- Department of Anesthesiology and Critical Care, CHU Grenoble Alpes, Grenoble, France
| | - Catherine Guidon
- Department of Anesthesiology and Critical Care, CHU La Timone, Marseille, France
| | - Olivier Desebbe
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel and INSERM U1060, University Claude Bernard, Lyon, France
| | - Anaïs Charles-Nelson
- Department of Biostatistics, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Philippe Menasché
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Bertrand Rozec
- Department of Anesthesiology and Critical Care Medicine, Hôpital Laënnec, Nantes, France
| | - Claude Girard
- Department of Anesthesiology and Critical Care Medicine, Centre Hospitalo-Universitaire de Dijon-Bourgogne, France
| | - Jean-Luc Fellahi
- Department of Anesthesiology and Critical Care, Hôpital Cardiologique Louis Pradel and INSERM U1060, University Claude Bernard, Lyon, France
| | - Romain Pirracchio
- Department of Anesthesiology and Critical Care Medicine, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
| | - Gilles Chatellier
- Department of Biostatistics, Hôpital Européen Georges Pompidou, AP-HP, and University Paris Descartes-Sorbonne Paris Cité, Paris, France
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Low cardiac output syndrome in the postoperative period of cardiac surgery. Profile, differences in clinical course and prognosis. The ESBAGA study. Med Intensiva 2017; 42:159-167. [PMID: 28736085 DOI: 10.1016/j.medin.2017.05.009] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2017] [Revised: 05/14/2017] [Accepted: 05/26/2017] [Indexed: 11/21/2022]
Abstract
OBJECTIVES An analysis is made of the clinical profile, evolution and differences in morbidity and mortality of low cardiac output syndrome (LCOS) in the postoperative period of cardiac surgery, according to the 3 diagnostic subgroups defined by the SEMICYUC Consensus 2012. DESIGN A multicenter, prospective cohort study was carried out. SETTING ICUs of Spanish hospitals with cardiac surgery. PATIENTS A consecutive sample of 2,070 cardiac surgery patients was included, with the analysis of 137 patients with LCOS. INTERVENTIONS No intervention was carried out. RESULTS The mean patient age was 68.3±9.3 years (65.2% males), with a EuroSCORE II of 9.99±13. NYHA functional class III-IV (52.9%), left ventricular ejection fraction<35% (33.6%), AMI (31.9%), severe PHT (21.7%), critical preoperative condition (18.8%), prior cardiac surgery (18.1%), PTCA/stent placement (16.7%). According to subgroups, 46 patients fulfilled hemodynamic criteria of LCOS (group A), 50 clinical criteria (group B), and the rest (n=41) presented cardiogenic shock (group C). Significant differences were observed over the evolutive course between the subgroups in terms of time subjected to mechanical ventilation (114.4, 135.4 and 180.3min in groups A, B and C, respectively; P<.001), renal replacement requirements (11.4, 14.6 and 36.6%; P=.007), multiorgan failure (16.7, 13 and 47.5%), and mortality (13.6, 12.5 and 35.9%; P=.01). The mean maximum lactate concentration was higher in cardiogenic shock patients (P=.002). CONCLUSIONS The clinical evolution of these patients leads to high morbidity and mortality. We found differences between the subgroups in terms of the postoperative clinical course and mortality.
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Mehta RH, Leimberger JD, van Diepen S, Meza J, Wang A, Jankowich R, Harrison RW, Hay D, Fremes S, Duncan A, Soltesz EG, Luber J, Park S, Argenziano M, Murphy E, Marcel R, Kalavrouziotis D, Nagpal D, Bozinovski J, Toller W, Heringlake M, Goodman SG, Levy JH, Harrington RA, Anstrom KJ, Alexander JH. Levosimendan in Patients with Left Ventricular Dysfunction Undergoing Cardiac Surgery. N Engl J Med 2017; 376:2032-2042. [PMID: 28316276 DOI: 10.1056/nejmoa1616218] [Citation(s) in RCA: 178] [Impact Index Per Article: 25.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
Abstract
BACKGROUND Levosimendan is an inotropic agent that has been shown in small studies to prevent or treat the low cardiac output syndrome after cardiac surgery. METHODS In a multicenter, randomized, placebo-controlled, phase 3 trial, we evaluated the efficacy and safety of levosimendan in patients with a left ventricular ejection fraction of 35% or less who were undergoing cardiac surgery with the use of cardiopulmonary bypass. Patients were randomly assigned to receive either intravenous levosimendan (at a dose of 0.2 μg per kilogram of body weight per minute for 1 hour, followed by a dose of 0.1 μg per kilogram per minute for 23 hours) or placebo, with the infusion started before surgery. The two primary end points were a four-component composite of death through day 30, renal-replacement therapy through day 30, perioperative myocardial infarction through day 5, or use of a mechanical cardiac assist device through day 5; and a two-component composite of death through day 30 or use of a mechanical cardiac assist device through day 5. RESULTS A total of 882 patients underwent randomization, 849 of whom received levosimendan or placebo and were included in the modified intention-to-treat population. The four-component primary end point occurred in 105 of 428 patients (24.5%) assigned to receive levosimendan and in 103 of 421 (24.5%) assigned to receive placebo (adjusted odds ratio, 1.00; 99% confidence interval [CI], 0.66 to 1.54; P=0.98). The two-component primary end point occurred in 56 patients (13.1%) assigned to receive levosimendan and in 48 (11.4%) assigned to receive placebo (adjusted odds ratio, 1.18; 96% CI, 0.76 to 1.82; P=0.45). The rate of adverse events did not differ significantly between the two groups. CONCLUSIONS Prophylactic levosimendan did not result in a rate of the short-term composite end point of death, renal-replacement therapy, perioperative myocardial infarction, or use of a mechanical cardiac assist device that was lower than the rate with placebo among patients with a reduced left ventricular ejection fraction who were undergoing cardiac surgery with the use of cardiopulmonary bypass. (Funded by Tenax Therapeutics; LEVO-CTS ClinicalTrials.gov number, NCT02025621 .).
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Affiliation(s)
- Rajendra H Mehta
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jeffrey D Leimberger
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Sean van Diepen
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - James Meza
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Alice Wang
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Rachael Jankowich
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert W Harrison
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Douglas Hay
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Stephen Fremes
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Andra Duncan
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward G Soltesz
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Luber
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Soon Park
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Michael Argenziano
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Edward Murphy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Randy Marcel
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dimitri Kalavrouziotis
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Dave Nagpal
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John Bozinovski
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Wolfgang Toller
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Matthias Heringlake
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Shaun G Goodman
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Jerrold H Levy
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Robert A Harrington
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - Kevin J Anstrom
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
| | - John H Alexander
- From the Duke Clinical Research Institute, Duke University School of Medicine, Durham (R.H.M., J.D.L., J.M., A.W., R.W.H., J.H.L., K.J.A., J.H.A.), and Tenax Therapeutics, Morrisville (R.J., D.H.) - both in North Carolina; the Canadian VIGOUR (Virtual Coordinating Centre for Global Collaborative Cardiovascular Research) Centre, University of Alberta, Edmonton (S.D., S.G.G.), Sunnybrook Health Sciences Centre, Toronto (S.F.), the Quebec Heart and Lung Institute, Quebec (D.K.), London Health Sciences Centre, London, ON (D.N.), and the Victoria Heart Institute Foundation, Victoria, BC (J.B.) - all in Canada; Cleveland Clinic Foundation (A.D., E.G.S.) and University Hospitals Cleveland Medical Center (S.P.) - both in Cleveland; Franciscan Health System, Tacoma, WA (J.L.); Columbia University Medical Center, New York (M.A.); Spectrum Health, Grand Rapids, MI (E.M.); the Heart Hospital Baylor Plano, Plano, TX (R.M.); the Medical University of Graz, Graz, Austria (W.T.); the University of Luebeck, Luebeck, Germany (M.H.); and the Department of Medicine, Stanford University, Stanford, CA (R.A.H.)
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Balderas-Muñoz K, Rodríguez-Zanella H, Fritche-Salazar JF, Ávila-Vanzzini N, Juárez Orozco LE, Arias-Godínez JA, Calvillo-Argüelles O, Rivera-Peralta S, Sauza-Sosa JC, Ruiz-Esparza ME, Bucio-Reta E, Rómero A, Espinola-Zavaleta N, Domínguez-Mendez B, Gaxiola-Macias M, Martínez-Ríos MA. Improving risk assessment for post-surgical low cardiac output syndrome in patients without severely reduced ejection fraction undergoing open aortic valve replacement. The role of global longitudinal strain and right ventricular free wall strain. Int J Cardiovasc Imaging 2017; 33:1483-1489. [DOI: 10.1007/s10554-017-1139-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2017] [Accepted: 04/11/2017] [Indexed: 10/19/2022]
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79
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Mehta RH, Van Diepen S, Meza J, Bokesch P, Leimberger JD, Tourt-Uhlig S, Swartz M, Parrotta J, Jankowich R, Hay D, Harrison RW, Fremes S, Goodman SG, Luber J, Toller W, Heringlake M, Anstrom KJ, Levy JH, Harrington RA, Alexander JH. Levosimendan in patients with left ventricular systolic dysfunction undergoing cardiac surgery on cardiopulmonary bypass: Rationale and study design of the Levosimendan in Patients with Left Ventricular Systolic Dysfunction Undergoing Cardiac Surgery Requiring Cardiopulmonary Bypass (LEVO-CTS) trial. Am Heart J 2016; 182:62-71. [PMID: 27914501 DOI: 10.1016/j.ahj.2016.09.001] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 09/06/2016] [Indexed: 10/21/2022]
Abstract
BACKGROUND Low cardiac output syndrome is associated with increased mortality and occurs in 3% to 14% of patients undergoing cardiac surgery on cardiopulmonary bypass (CPB). Levosimendan, a novel calcium sensitizer and KATP channel activator with inotropic, vasodilatory, and cardioprotective properties, has shown significant promise in reducing the incidence of low cardiac output syndrome and related adverse outcomes in patients undergoing cardiac surgery on CPB. METHODS LEVO-CTS is a phase 3 randomized, controlled, multicenter study evaluating the efficacy, safety, and cost-effectiveness of levosimendan in reducing morbidity and mortality in high-risk patients with reduced left ventricular ejection fraction (≤35%) undergoing cardiac surgery on CPB. Patients will be randomly assigned to receive either intravenous levosimendan (0.2 μg kg-1 min-1 for the first hour followed by 0.1 μg/kg for 23hours) or matching placebo initiated within 8hours of surgery. The co-primary end points are (1) the composite of death or renal replacement therapy through day 30 or perioperative myocardial infarction, or mechanical assist device use through day 5 (quad end point tested at α<.01), and (2) the composite of death through postoperative day 30 or mechanical assist device use through day 5 (dual end point tested at α<.04). Safety end points include new atrial fibrillation and death through 90days. In addition, an economic analysis will address the cost-effectiveness of levosimendan compared with placebo in high-risk patients undergoing cardiac surgery on CPB. Approximately 880 patients will be enrolled at approximately 60 sites in the United States and Canada between July 2014 and September 2016, with results anticipated in January 2017. CONCLUSION LEVO-CTS, a large randomized multicenter clinical trial, will evaluate the efficacy, safety, and cost-effectiveness of levosimendan in reducing adverse outcomes in high-risk patients undergoing cardiac surgery on CPB. CLINICAL TRIAL REGISTRATION ClinicalTrials.gov (NCT02025621).
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80
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Dos Santos ER, Lopes CT, Maria VLR, de Barros ALBL. Risk factors for decreased cardiac output after coronary artery bypass grafting: a prospective cohort study. Eur J Cardiovasc Nurs 2016; 16:352-359. [PMID: 27888199 DOI: 10.1177/1474515116681373] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND No previous study has investigated the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after coronary artery bypass grafting (CABG). AIMS This study aimed to identify the predictive risk factors of the nursing diagnosis of risk for decreased cardiac output after CABG. METHODS This was a prospective cohort study performed at a cardiac university hospital in São Paulo, Brazil and 257 adult patients undergoing CABG were included. Potential risk factors for low cardiac output in the immediate post-operative period were investigated using the patients' medical records. Univariate analysis and logistic regression were used to identify the predictive risk factors of decreased cardiac output. The area under the receiver operating characteristic curve was calculated as a measure of accuracy. The variables that could not be analysed through logistic regression were analysed through Fisher's exact test. RESULTS One hundred and ninety-five patients had low cardiac output in the immediate post-operative period. The predictive risk factors included age ⩾60 years, decreased left ventricle ejection fraction, not using the radial artery graft, positive fluid balance and post-operative arrhythmia that differed from the pre-operative arrhythmia. This model predicted the outcome with a sensitivity of 62.9%, a specificity of 87.2% and an accuracy of 81.5%. The variables analysed through Fisher's exact test included heart failure, re-exploration and bleeding-related re-exploration. CONCLUSIONS The predictive risk factors for the nursing diagnosis of risk for decreased cardiac output after CABG were found. These results can be used to direct nurses in patient monitoring, staff training and nursing team staffing.
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Affiliation(s)
- Eduarda Ribeiro Dos Santos
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil.,2 Faculdade Israelita de Ciências da Saúde Albert Einstein, Brazil
| | - Camila Takao Lopes
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil
| | - Vera Lucia Regina Maria
- 1 Paulista Nursing School, Federal University of São Paulo (EPE-UNIFESP), Brazil.,3 Universidade São Camilo, Brazil
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81
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Plicner D, Stoliński J, Wąsowicz M, Gawęda B, Hymczak H, Kapelak B, Drwiła R, Undas A. Preoperative values of inflammatory markers predict clinical outcomes in patients after CABG, regardless of the use of cardiopulmonary bypass. Indian Heart J 2016; 68 Suppl 3:S10-S15. [PMID: 28038718 PMCID: PMC5198874 DOI: 10.1016/j.ihj.2016.10.002] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/12/2016] [Revised: 09/25/2016] [Accepted: 10/18/2016] [Indexed: 12/12/2022] Open
Abstract
Objective The impact of systemic inflammation on clinical outcomes after CABG surgery is still controversial. In this study, we evaluated the impact of the markers of inflammation, endothelial damage and platelet activation on clinical outcomes after on- and off-pump CABG. Methods A group of 191 consecutive on- and off-pump CABG patients were prospectively studied. Blood samples were drawn before surgery, 18–36 h after the procedure and 5–7 days postoperatively and analyzed for 8-iso-prostaglandin F2α (8-iso-PGF2α), asymmetric dimethylarginine (ADMA) and β-thromboglobulin (β-TG). White blood count and C-reactive protein were measured twice, first before and then during the first 18–36 h after CABG. The primary clinical end-points were: low cardiac output syndrome (LCOS), postoperative myocardial infarction (PMI) and in-hospital cardiovascular death. Results Elevation of 8-iso-PGF2α, ADMA and β-TG before surgery was associated with an increased risk of morbidity and mortality after CABG. There were no differences in analyzed markers and clinical outcomes between the on- and off-pump groups. Even during the uncomplicated postoperative course the inflammatory response was enhanced and still remained higher than baseline 5–7 days after surgery. Conclusion Links between preoperative 8-iso-PGF2α, ADMA and β-TG and unfavorable early post-CABG outcomes suggest that these markers could be useful in identifying patients with increased risk of LCOS, PMI and in-hospital cardiovascular death following elective CABG.
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Affiliation(s)
- Dariusz Plicner
- Department of Cardiosurgery, John Paul II Hospital, Krakow, Poland.
| | | | - Marcin Wąsowicz
- Department of Anesthesia, Toronto General Hospital, University of Toronto, Toronto, Canada
| | - Bugusław Gawęda
- Department of Cardiosurgery, John Paul II Hospital, Krakow, Poland
| | - Hubert Hymczak
- Department of Anesthesia, John Paul II Hospital, Krakow, Poland
| | - Bogusław Kapelak
- Department of Cardiosurgery, John Paul II Hospital, Krakow, Poland; Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
| | - Rafał Drwiła
- Department of Anesthesia, John Paul II Hospital, Krakow, Poland
| | - Anetta Undas
- Institute of Cardiology, Jagiellonian University Medical College, Krakow, Poland
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82
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Pieri M, Belletti A, Monaco F, Pisano A, Musu M, Dalessandro V, Monti G, Finco G, Zangrillo A, Landoni G. Outcome of cardiac surgery in patients with low preoperative ejection fraction. BMC Anesthesiol 2016; 16:97. [PMID: 27760527 PMCID: PMC5069974 DOI: 10.1186/s12871-016-0271-5] [Citation(s) in RCA: 57] [Impact Index Per Article: 7.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2016] [Accepted: 10/12/2016] [Indexed: 01/28/2023] Open
Abstract
Background In patients undergoing cardiac surgery, a reduced preoperative left ventricular ejection fraction (LVEF) is common and is associated with a worse outcome. Available outcome data for these patients address specific surgical procedures, mainly coronary artery bypass graft (CABG). Aim of our study was to investigate perioperative outcome of surgery on patients with low pre-operative LVEF undergoing a broad range of cardiac surgical procedures. Methods Data from patients with pre-operative LVEF ≤40 % undergoing cardiac surgery at a university hospital were reviewed and analyzed. A subgroup analysis on patients with pre-operative LVEF ≤30 % was also performed. Results A total of 7313 patients underwent cardiac surgery during the study period. Out of these, 781 patients (11 %) had a pre-operative LVEF ≤40 % and were included in the analysis. Mean pre-operative LVEF was 33.9 ± 6.1 % and in 290 patients (37 %) LVEF was ≤30 %. The most frequently performed operation was CABG (31 % of procedures), followed by mitral valve surgery (22 %) and aortic valve surgery (19 %). Overall perioperative mortality was 5.6 %. Mitral valve surgery was more frequent among patients who did not survive, while survivors underwent more frequently CABG. Post-operative myocardial infarction occurred in 19 (2.4 %) of patients, low cardiac output syndrome in 271 (35 %). Acute kidney injury occurred in 195 (25 %) of patients. Duration of mechanical ventilation was 18 (12–48) hours. Incidence of complications was higher in patients with LVEF ≤30 %. Stepwise multivariate analysis identified chronic obstructive pulmonary disease, pre-operative insertion of intra-aortic balloon pump, and pre-operative need for inotropes as independent predictors of mortality among patients with LVEF ≤40 %. Conclusions We confirmed that patients with low pre-operative LVEF undergoing cardiac surgery are at higher risk of post-operative complications. Cardiac surgery can be performed with acceptable mortality rates; however, mitral valve surgery, was found to be associated with higher mortality rates in this population. Accurate selection of patients, risk/benefit evaluation, and planning of surgical and anesthesiological management are mandatory to improve outcome. Electronic supplementary material The online version of this article (doi:10.1186/s12871-016-0271-5) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marina Pieri
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Fabrizio Monaco
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Antonio Pisano
- Cardiac Anesthesia and Intensive Care Unit, Monaldi Hospital A.O.R.N. "Dei Colli", Naples, Italy
| | - Mario Musu
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Veronica Dalessandro
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Giacomo Monti
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy
| | - Gabriele Finco
- Department of Medical Sciences "M. Aresu", University of Cagliari, Cagliari, Italy
| | - Alberto Zangrillo
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.,Vita-Salute San Raffaele University, Milan, Italy
| | - Giovanni Landoni
- Department of Anesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute, Via Olgettina 60, 20132, Milan, Italy.
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83
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Rizza A, Bignami E, Belletti A, Polito A, Ricci Z, Isgrò G, Locatelli A, Cogo P. Vasoactive Drugs and Hemodynamic Monitoring in Pediatric Cardiac Intensive Care: An Italian Survey. World J Pediatr Congenit Heart Surg 2016; 7:25-31. [PMID: 26714990 DOI: 10.1177/2150135115606626] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
BACKGROUND Little is known about practitioner preference, the availability of technology, and variability in practice with respect to hemodynamic monitoring and vasoactive drug use after congenital heart surgery. The aim of this study was to characterize current hospital practices related to the management of low cardiac output syndrome (LCOS) across Italy. METHODS We issued a 22-item questionnaire to 14 Italian hospitals performing pediatric cardiac surgery. RESULTS Electrocardiogram, invasive blood pressure, central venous pressure, pulse oximetry, diuresis, body temperature, arterial lactate, and blood gas analysis were identified as routine in hemodynamic monitoring. With regard to advanced hemodynamic monitoring, pulmonary arterial catheter and transpulmonary thermodilution were available in 43% of the centers, uncalibrated pulse contour methods in 29% of the centers, and transesophageal/transthoracic echocardiograms in all of the centers. Dopamine added to milrinone was the most frequent drug regimen for LCOS prevention after cardiopulmonary bypass. Overall, 86% of centers used milrinone alone as the initial treatment for LCOS with elevated systemic vascular resistances and levosimendan, the second preferred choice. In cases of LCOS with low vascular resistance, epinephrine was the first choice (10 centers), dopamine was the second choice (4 centers), followed by vasopressin and norepinephrine (3 centers). For treatment of LCOS with elevated pulmonary resistances, milrinone was the first choice (eight centers), followed by inhaled nitric oxide (five centers). CONCLUSIONS The survey shows that advanced hemodynamic monitoring is rarely performed. The most commonly used vasoactive drugs are milrinone, levosimendan, dopamine, epinephrine, vasopressin, and norepinephrine. Guidelines on the topic are warranted.
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Affiliation(s)
- Alessandra Rizza
- Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Elena Bignami
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Alessandro Belletti
- Department of Anesthesia and Intensive Care, San Raffaele Scientific Institute, Milan, Italy
| | - Angelo Polito
- Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Zaccaria Ricci
- Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
| | - Giuseppe Isgrò
- Department of Cardiothoracic and Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese (Milan), Italy
| | | | - Paola Cogo
- Pediatric Cardiac Anesthesia/Intensive Care Unit, Department of Pediatric Cardiology and Cardiac Surgery, Bambino Gesù Children's Hospital, Rome, Italy
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84
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Caruba T, Hourton D, Sabatier B, Rousseau D, Tibi A, Hoffart-Jourdain C, Souag A, Freitas N, Yjjou M, Almeida C, Gomes N, Aucouturier P, Djadi-Prat J, Menasché P, Chatellier G, Cholley B. Rationale and design of the multicenter randomized trial investigating the effects of levosimendan pretreatment in patients with low ejection fraction (≤40 %) undergoing CABG with cardiopulmonary bypass (LICORN study). J Cardiothorac Surg 2016; 11:127. [PMID: 27496105 PMCID: PMC4974786 DOI: 10.1186/s13019-016-0530-z] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2016] [Accepted: 07/28/2016] [Indexed: 12/04/2022] Open
Abstract
Background Patients with a left ventricular ejection fraction (LVEF) of less than 40 % are at high risk of developing postoperative low cardiac output syndrome (LCOS). Despite actual treatments (inotropic agents and/or mechanical assist devices), the mortality rate of such patients remains very high (13 to 24 %). The LICORN trial aims at assessing the efficacy of a preoperative infusion of levosimendan in reducing postoperative LCOS in patients with poor LVEF undergoing coronary artery bypass grafting (CABG). Methods/Design LICORN study is a multicenter, randomized double-blind, placebo-controlled trial in parallel groups. 340 patients with LVEF ≤40 %, undergoing CABG will be recruited from 13 French hospitals. The study drug will be started after anaesthesia induction and infused over 24 h (0.1 μg/kg/min). The primary outcome (postoperative LCOS) is evaluated using a composite criterion composed of: 1) need for inotropic agents beyond 24 h following discontinuation of the study drug; 2) need for post-operative mechanical assist devices or failure to wean from these techniques when inserted pre-operatively; 3) need for renal replacement therapy. Secondary outcomes include: 1) mortality at Day 28 and Day 180; 2) each item of the composite criterion of the primary outcome; 3) the number of “ventilator-free” days and “out of intensive care unit” days at Day 28. Discussion The usefulness of levosimendan in the perioperative period has not yet been documented with a high level of evidence. The LICORN study is the first randomized controlled trial evaluating the clinical value of preoperative levosimendan in high risk cardiac surgical patients undergoing CABG. Trial registration number NCT02184819 (ClinicalTrials.gov).
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Affiliation(s)
- Thibaut Caruba
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Delphine Hourton
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Brigitte Sabatier
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,INSERM Centre de Recherche des Cordeliers UMR S 872 eq 22 Université Paris Descartes, Paris, France
| | - Dominique Rousseau
- Department of Pharmacy, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Annick Tibi
- Agence Générale des Equipements et des Produits de Santé (AGEPS), AP-HP, Paris, France
| | - Cécile Hoffart-Jourdain
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Akim Souag
- Département de la Recherche Clinique et du Développement (DRCD), Hôpital Saint-Louis, (AP-HP), Paris, France
| | - Nelly Freitas
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Mounia Yjjou
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Carla Almeida
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Nathalie Gomes
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Pascaline Aucouturier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Juliette Djadi-Prat
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France
| | - Philippe Menasché
- Department of Cardiovascular Surgery, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Gilles Chatellier
- Clinical Trial Unit and INSERM CIC-141, Hôpital Européen Georges Pompidou, AP-HP, Paris, France.,Université Paris Descartes, Sorbonne Paris Cité, Paris, France
| | - Bernard Cholley
- Department of Anaesthesiology and Intensive Care, Hôpital Européen Georges Pompidou, AP-HP, 20 rue Leblanc, 75015, Paris, France. .,Université Paris Descartes, Sorbonne Paris Cité, Paris, France.
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Lomivorotov VV, Efremov SM, Kirov MY, Fominskiy EV, Karaskov AM. Low-Cardiac-Output Syndrome After Cardiac Surgery. J Cardiothorac Vasc Anesth 2016; 31:291-308. [PMID: 27671216 DOI: 10.1053/j.jvca.2016.05.029] [Citation(s) in RCA: 156] [Impact Index Per Article: 19.5] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/18/2016] [Indexed: 12/11/2022]
Affiliation(s)
- Vladimir V Lomivorotov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia.
| | - Sergey M Efremov
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Mikhail Y Kirov
- Department of Anesthesiology and Intensive Care Medicine, Northern State Medical University, Arkhangelsk, Russia
| | - Evgeny V Fominskiy
- Department of Anesthesiology and Intensive Care, Research Institute of Circulation Pathology, Novosibirsk, Russia
| | - Alexander M Karaskov
- Department of Cardiac Surgery, Research Institute of Circulation Pathology, Novosibirsk, Russia
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86
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Umminger J, Reitz M, Rojas SV, Stiefel P, Shrestha M, Haverich A, Ismail I, Martens A. Does the surgeon's experience have an impact on outcome after total arterial revascularization with composite T-grafts? A risk factor analysis. Interact Cardiovasc Thorac Surg 2016; 23:749-756. [PMID: 27390370 DOI: 10.1093/icvts/ivw207] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2015] [Revised: 04/06/2016] [Accepted: 05/26/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES When composite T-grafting is performed, total arterial revascularization (TAR) can be accomplished with only two grafts. There is the belief that composite grafting poses a risk of graft failure due to its single inflow via the left internal thoracic artery (LITA). High surgical quality is essential for left internal thoracic artery preparation, T-grafting and length estimation. We investigated whether the surgeon's experience influences postoperative outcome. METHODS We analysed the data of 1080 consecutive patients (88% male, age: 62 ± 9 years) who underwent composite T-grafting between 1996 and 2011 in our institution. Patients were operated on either by experienced surgeons (Group A) or by surgeons early on in their career (Group B). Primary end-points were mortality, myocardial ischaemia, graft dysfunction and low cardiac output syndrome. Secondary end-points were persistent neurologic deficits (PNDs), blood transfusions and re-thoracotomy. Logistic regression analysis was performed to reveal independent risk factors for adverse outcome. RESULTS Patients in Group B had a lower logistic EuroSCORE (2.8 vs 2.3%; P < 0.05), longer operative times (cross-clamp time: 41 ± 11 vs 47 ± 14 min; P < 0.001) and received less anastomoses (3.2 ± 0.7 vs 3.1 ± 0.7, P = 0.005). Mortality was low in both groups (Group A 0.6% vs Group B 0.4%; P = 1.0). Myocardial ischaemia occurred in 2.3% (Group A) and 2.5% (Group B; P = 0.82). Graft dysfunction was seen in 0.6% (Group A) and 1.4% (Group B; P = 0.25). Incidence of postoperative low cardiac output syndrome was comparable (Group A 1.4% vs Group B 0.7%; P = 0.53). Both groups showed similar incidence of secondary end-points (persistent neurologic deficit: Group A 2.9 vs 3.2% in Group B; P = 0.84; re-thoracotomy: 1.6% in Group A vs 1.8% in Group B, P = 1.0). Blood transfusions were more common in Group B (P = 0.005). Less surgical experience could only be identified as an independent risk factor for blood transfusion (P = 0.001). CONCLUSIONS Total arterial revascularization with composite T-grafts can be performed safely by surgeons with different surgical experience. Despite differences in surgical performance parameters (e.g. operation times, blood transfusions), complication rates were extremely low, irrespective of the surgeon's operative experience. Surgeons can be introduced to these procedures in an early phase of training.
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Affiliation(s)
- Julia Umminger
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Michael Reitz
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Sebastian V Rojas
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Penelope Stiefel
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Malakh Shrestha
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Axel Haverich
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Issam Ismail
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - Andreas Martens
- Clinic for Cardiothoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany
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87
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Anastasiadis K, Antonitsis P, Vranis K, Kleontas A, Asteriou C, Grosomanidis V, Tossios P, Argiriadou H. Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study. Interact Cardiovasc Thorac Surg 2016; 23:740-747. [PMID: 27378790 DOI: 10.1093/icvts/ivw213] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 05/01/2016] [Accepted: 05/10/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative low cardiac output syndrome occurs in 3-14% of patients undergoing isolated coronary artery bypass grafting (CABG), leading to significant increase in major morbidity and mortality. Considering the unique pharmacological and pharmacokinetic properties of levosimendan, we conducted a prospective, double-blind, randomized pilot study to evaluate the effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing CABG. METHODS Thirty-two patients undergoing CABG with low left ventricular ejection fraction (LVEF ≤ 40%) were randomized to receive either a continuous infusion of levosimendan at a dose of 0.1 μg/kg/min for 24 h without a loading dose or a placebo. The primary outcome of the study was the change in the LVEF assessed with transthoracic echocardiography on the seventh postoperative day. Secondary outcomes included the physiological and clinical effects of levosimendan. RESULTS All patients tolerated preoperative infusion of levosimendan well. The LVEF improved in both groups; this increase was statistically significant in the levosimendan group (from 35.8 ± 5% preoperatively to 42.8 ± 7.8%, P = 0.001) compared with the control group (from 37.5 ± 3.4% preoperatively to 41.2 ± 8.3%, P = 0.1). The cardiac index, SvO2, pulmonary capillary wedge pressure and right ventricular stroke work index showed a similar trend, which was optimized in patients treated with levosimendan. Moreover, an increase in extravascular lung water was noticed in this group during the first 24 h after surgery. CONCLUSIONS This pilot study shows that prophylactic levosimendan infusion is safe and effective in increasing the LVEF postoperatively in patients with impaired cardiac function undergoing coronary surgery. This finding may be translated to 'optimizing' patients' status before surgery.
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MESH Headings
- Cardiac Output, Low/etiology
- Cardiotonic Agents/administration & dosage
- Coronary Artery Bypass/adverse effects
- Coronary Artery Disease/complications
- Coronary Artery Disease/diagnosis
- Coronary Artery Disease/surgery
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Finland/epidemiology
- Follow-Up Studies
- Humans
- Hydrazones/administration & dosage
- Incidence
- Infusions, Intravenous
- Male
- Middle Aged
- Pilot Projects
- Postoperative Complications/epidemiology
- Postoperative Complications/prevention & control
- Prospective Studies
- Pyridazines/administration & dosage
- Simendan
- Stroke Volume/drug effects
- Stroke Volume/physiology
- Survival Rate/trends
- Tomography, Emission-Computed, Single-Photon
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/drug effects
- Ventricular Function, Left/physiology
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88
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Palevsky PM. High-Volume Hemofiltration in Post-Cardiac Surgery Shock. A Heroic Therapy? Am J Respir Crit Care Med 2016; 192:1143-4. [PMID: 26568234 DOI: 10.1164/rccm.201508-1561ed] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Affiliation(s)
- Paul M Palevsky
- 1 Medical Service VA Pittsburgh Healthcare System Pittsburgh, Pennsylvania and.,2 Department of Medicine University of Pittsburgh School of Medicine Pittsburgh, Pennsylvania
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89
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Combes A, Bréchot N, Amour J, Cozic N, Lebreton G, Guidon C, Zogheib E, Thiranos JC, Rigal JC, Bastien O, Benhaoua H, Abry B, Ouattara A, Trouillet JL, Mallet A, Chastre J, Leprince P, Luyt CE. Early High-Volume Hemofiltration versus Standard Care for Post-Cardiac Surgery Shock. The HEROICS Study. Am J Respir Crit Care Med 2016; 192:1179-90. [PMID: 26167637 DOI: 10.1164/rccm.201503-0516oc] [Citation(s) in RCA: 92] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
RATIONALE Post-cardiac surgery shock is associated with high morbidity and mortality. By removing toxins and proinflammatory mediators and correcting metabolic acidosis, high-volume hemofiltration (HVHF) might halt the vicious circle leading to death by improving myocardial performance and reducing vasopressor dependence. OBJECTIVES To determine whether early HVHF decreases all-cause mortality 30 days after randomization. METHODS This prospective, multicenter randomized controlled trial included patients with severe shock requiring high-dose catecholamines 3-24 hours post-cardiac surgery who were randomized to early HVHF (80 ml/kg/h for 48 h), followed by standard-volume continuous venovenous hemodiafiltration (CVVHDF) until resolution of shock and recovery of renal function, or conservative standard care, with delayed CVVHDF only for persistent, severe acute kidney injury. MEASUREMENTS AND MAIN RESULTS On Day 30, 40 of 112 (36%) HVHF and 40 of 112 (36%) control subjects (odds ratio, 1.00; 95% confidence interval, 0.64-1.56; P = 1.00) had died; only 57% of the control subjects had received renal-replacement therapy. Between-group survivors' Day-60, Day-90, intensive care unit, and in-hospital mortality rates, Day-30 ventilator-free days, and renal function recovery were comparable. HVHF patients experienced faster correction of metabolic acidosis and tended to be more rapidly weaned off catecholamines but had more frequent hypophosphatemia, metabolic alkalosis, and thrombocytopenia. CONCLUSIONS For patients with post-cardiac surgery shock requiring high-dose catecholamines, the early HVHF onset for 48 hours, followed by standard volume until resolution of shock and recovery of renal function, did not lower Day-30 mortality and did not impact other important patient-centered outcomes compared with a conservative strategy with delayed CVVHDF initiation only for patients with persistent, severe acute kidney injury. Clinical trial registered with www.clinicaltrials.gov (NCT 01077349).
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Affiliation(s)
| | | | - Julien Amour
- 2 Anesthesiology and Critical Care Medicine Department
| | | | - Guillaume Lebreton
- 4 Cardiac Surgery Department, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
| | - Catherine Guidon
- 5 Anesthesiology and Critical Care Medicine Department, CHU La Timone, Marseille, France
| | - Elie Zogheib
- 6 Anesthesiology and Critical Care Medicine Department, Amiens University Hospital, INSERM U-1088, Université de Picardie Jules-Verne, Amiens, France
| | - Jean-Claude Thiranos
- 7 Anesthesiology and Critical Care Medicine Department, CHU de Strasbourg, Strasbourg, France
| | | | - Olivier Bastien
- 9 Anesthesiology and Critical Care Medicine Department, CHU de Lyon, Lyon, France
| | - Hamina Benhaoua
- 10 Anesthesiology and Critical Care Medicine Department, CHU de Toulouse, Toulouse, France
| | - Bernard Abry
- 11 Anesthesiology and Critical Care Medicine Department, Clinique Jacques Cartier, Massy, France; and
| | - Alexandre Ouattara
- 12 Department of Anesthesia and Critical Care II, CHU de Bordeaux, and Université de Bordeaux, Adaptation Cardiovasculaire à l'Ischémie, U1034, Pessac, France
| | | | | | | | - Pascal Leprince
- 4 Cardiac Surgery Department, Institute of Cardiometabolism and Nutrition, Hôpital de la Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, Université Pierre et Marie Curie-Paris 6, Paris, France
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90
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Propofol cardioprotection for on-pump aortocoronary bypass surgery in patients with type 2 diabetes mellitus (PRO-TECT II): a phase 2 randomized-controlled trial. Can J Anaesth 2015; 63:442-53. [DOI: 10.1007/s12630-015-0580-z] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/02/2014] [Revised: 09/30/2015] [Accepted: 12/22/2015] [Indexed: 01/10/2023] Open
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91
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Pilarczyk K, Boening A, Jakob H, Langebartels G, Markewitz A, Haake N, Heringlake M, Trummer G. Preoperative intra-aortic counterpulsation in high-risk patients undergoing cardiac surgery: a meta-analysis of randomized controlled trials†. Eur J Cardiothorac Surg 2015; 49:5-17. [PMID: 26245629 DOI: 10.1093/ejcts/ezv258] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2014] [Accepted: 01/12/2015] [Indexed: 01/04/2023] Open
Abstract
In contrast to the results of previous studies, recent randomized controlled trials (RCTs) failed to show a benefit of prophylactic aortic counterpulsation in high-risk patients undergoing cardiac surgery. The present analysis aims to redefine the effects of this treatment modality in the light of this new evidence. MEDLINE, EMBASE, CENTRAL/CCTR, Google Scholar and reference lists of relevant articles were searched for full-text articles of RCTs in English or German. Assessments for eligibility, relevance, study validity and data extraction were performed by two reviewers independently using prespecified criteria. The primary outcome was hospital mortality. A total of nine eligible RCTs with 1171 patients were identified: 577 patients were treated preoperatively with intra-aortic balloon pump (IABP) and 594 patients served as controls. The pooled odds ratio (OR) for hospital mortality (22 hospital deaths in the intervention arm, 54 in the control group) was 0.381 (95% CI 0.230-0.629; P < 0.001). The pooled analyses of five RCTs including only patients undergoing isolated on-pump coronary artery bypass grafting (n[IABP] = 348, n[control] = 347) also showed a statistically significant improvement in mortality for preoperative IABP implantation (fixed-effects model: OR 0.267, 95% CI 0.129-0.552, P < 0.001). The pooled OR for hospital mortality from two randomized off-pump trials was 0.556 (fixed-effects model, 95% CI 0.207-1.493, P = 0.226). Preoperative aortic counterpulsation was associated with a significant reduction in low cardiac output syndrome (LCOS) in the total population (fixed-effects model: OR 0.330, 95% CI 0.214-0.508, P < 0.001) as well as in the subgroup of CAGB patients (fixed-effects model: OR 0.113, 95% CI 0.056-0.226, P < 0.001), whereas there was no benefit in the off-pump population (fixed-effects model: OR 0.555, 95% CI 0.209-1.474, P = 0.238). Preoperative IABP implantation was associated with a reduction of intensive care unit (ICU) stay in all investigated populations with a greater effect in the total population [fixed-effects model: standard mean difference (SMD) -0.931 ± 0.198, P < 0.001] as well as in the subgroup of CAGB patients (fixed-effects model: SMD -1.240 ± 0.156, P < 0.001), compared with the off-pump group (fixed-effects model: SMD -0.723 ± 0.128, P < 0.001). Despite contradictory results from recent trials, the present study confirms the findings of previous meta-analyses that prophylactic aortic counterpulsation reduces hospital mortality, incidence of LCOS and ICU requirement in high-risk patients undergoing on-pump cardiac surgery. However, owing to small sample sizes and the lack of a clear-cut definition of high-risk patients, an adequately powered, prospective RCT is necessary to find a definite answer to the question, if certain groups of patients undergoing cardiac surgery benefit from a prophylactic IABP insertion.
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Affiliation(s)
- Kevin Pilarczyk
- Department of Thoracic and Cardiovascular Surgery, West German Heart Centre Essen, University Hospital Essen, Essen Germany
| | - Andreas Boening
- Department of Cardiovascular Surgery, Justus-Liebig University Gießen, Giessen, Germany
| | - Heinz Jakob
- Department of Thoracic and Cardiovascular Surgery, West German Heart Centre Essen, University Hospital Essen, Essen Germany
| | - Georg Langebartels
- Department of Cardiothoracic Surgery, Cologne University Heart Centre, Cologne, Germany
| | - Andreas Markewitz
- Department of Cardiovascular Surgery, Bundeswehr Central Hospital, Koblenz, Germany
| | - Nils Haake
- Department of Cardiovascular Surgery, School of Medicine, University of Schleswig-Holstein, Kiel, Germany
| | | | - Georg Trummer
- Department of Cardiovascular Surgery, Heart Center Freiburg University, Freiburg, Germany
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92
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Hyler S, Pischke SE, Halvorsen PS, Espinoza A, Bergsland J, Tønnessen TI, Fosse E, Skulstad H. Continuous monitoring of regional function by a miniaturized ultrasound transducer allows early quantification of low-grade myocardial ischemia. J Am Soc Echocardiogr 2015; 28:486-94. [PMID: 25636368 DOI: 10.1016/j.echo.2014.12.014] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2014] [Indexed: 11/18/2022]
Abstract
BACKGROUND Sensitive methods for the early detection of myocardial dysfunction are still needed, as ischemia is a leading cause of decreased ventricular function during and after heart surgery. The aim of this study was to test the hypothesis that low-grade ischemia could be detected quantitatively by a miniaturized epicardial ultrasound transducer (Ø = 3 mm), allowing continuous monitoring. METHODS In 10 pigs, transducers were positioned in the left anterior descending and circumflex coronary artery areas. Left ventricular pressure was obtained by a micromanometer. The left internal mammary artery was grafted to the left anterior descending coronary artery, which was occluded proximal to the anastomosis. Left internal mammary artery flow was stepwise reduced by 25%, 50%, and 75% for 18 min each. From the transducers, M-mode traces were obtained, allowing continuous tissue velocity traces and displacement measurements. Regional work was assessed as left ventricular pressure-displacement loop area. Tissue lactate measured from intramyocardial microdialysis was used as reference method to detect ischemia. RESULTS All steps of coronary flow reduction demonstrated reduced peak systolic velocity (P < .05) and regional work (P < .01).The decreases in peak systolic velocity and regional work were closely related to the degree of ischemia, demonstrated by their correlations with lactate (R = -0.74, P < .01, and R = -0.64, P < .01, respectively). The circumflex coronary artery area was not affected by any of the interventions. CONCLUSIONS The epicardially attached miniaturized ultrasound transducer allowed the precise detection of different levels of coronary flow reduction. The results also showed a quantitative and linear relationship among coronary flow, ischemia, and myocardial function. Thus, the ultrasound transducer has the potential to improve the monitoring of myocardial ischemia and to detect graft failure during and after heart surgery.
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Affiliation(s)
- Stefan Hyler
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Søren E Pischke
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | | | - Andreas Espinoza
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Jacob Bergsland
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway
| | - Tor Inge Tønnessen
- Department of Anaesthesiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, Oslo University, Oslo, Norway
| | - Erik Fosse
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, Faculty of Medicine, Oslo University, Oslo, Norway
| | - Helge Skulstad
- The Intervention Centre, Rikshospitalet, Oslo University Hospital, Oslo, Norway; Department of Cardiology, Rikshospitalet, Oslo University Hospital, Oslo, Norway.
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93
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Ding W, Ji Q, Shi Y, Ma R. Predictors of Low Cardiac Output Syndrome After Isolated Coronary Artery Bypass Grafting. Int Heart J 2015; 56:144-9. [DOI: 10.1536/ihj.14-231] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- WenJun Ding
- Department of Cardiovascular Surgery, Zhongshan Hospital of Fudan University, Shanghai
| | - Qiang Ji
- Department of Thoracic Cardiovascular Surgery, Tongji Hospital of Tongji University, Shanghai
| | - YunQing Shi
- Department of Cardiovascular Surgery, Zhongshan Hospital of Fudan University, Shanghai
| | - RunHua Ma
- Department of Cardiovascular Surgery, Zhongshan Hospital of Fudan University, Shanghai
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94
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Dexmedetomidine sedation after cardiac surgery decreases atrial arrhythmias. J Clin Anesth 2014; 26:634-42. [DOI: 10.1016/j.jclinane.2014.05.009] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2013] [Revised: 05/01/2014] [Accepted: 05/05/2014] [Indexed: 11/23/2022]
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95
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Harrison RW, Hasselblad V, Mehta RH, Levin R, Harrington RA, Alexander JH. Effect of Levosimendan on Survival and Adverse Events After Cardiac Surgery: A Meta-Analysis. J Cardiothorac Vasc Anesth 2013; 27:1224-32. [DOI: 10.1053/j.jvca.2013.03.027] [Citation(s) in RCA: 87] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/02/2013] [Indexed: 11/11/2022]
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96
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Ono M, Brady K, Easley RB, Brown C, Kraut M, Gottesman RF, Hogue CW. Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg 2013; 147:483-9. [PMID: 24075467 DOI: 10.1016/j.jtcvs.2013.07.069] [Citation(s) in RCA: 147] [Impact Index Per Article: 13.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2013] [Revised: 07/08/2013] [Accepted: 07/26/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVES Optimizing blood pressure using near-infrared spectroscopy monitoring has been suggested to ensure organ perfusion during cardiac surgery. Near-infrared spectroscopy is a reliable surrogate for cerebral blood flow in clinical cerebral autoregulation monitoring and might provide an earlier warning of malperfusion than indicators of cerebral ischemia. We hypothesized that blood pressure below the limits of cerebral autoregulation during cardiopulmonary bypass would be associated with major morbidity and operative mortality after cardiac surgery. METHODS Autoregulation was monitored during cardiopulmonary bypass in 450 patients undergoing coronary artery bypass grafting and/or valve surgery. A continuous, moving Pearson's correlation coefficient was calculated between the arterial pressure and low-frequency near-infrared spectroscopy signals and displayed continuously during surgery using a laptop computer. The area under the curve of the product of the duration and magnitude of blood pressure below the limits of autoregulation was compared between patients with and without major morbidity (eg, stroke, renal failure, mechanical lung ventilation >48 hours, inotrope use >24 hours, or intra-aortic balloon pump insertion) or operative mortality. RESULTS Of the 450 patients, 83 experienced major morbidity or operative mortality. The area under the curve of the product of the duration and magnitude of blood pressure below the limits of autoregulation was independently associated with major morbidity or operative mortality after cardiac surgery (odds ratio, 1.36; 95% confidence interval, 1.08-1.71; P = .008). CONCLUSIONS Blood pressure management during cardiopulmonary bypass using physiologic endpoints such as cerebral autoregulation monitoring might provide a method of optimizing organ perfusion and improving patient outcomes from cardiac surgery.
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Affiliation(s)
- Masahiro Ono
- Division of Cardiac Surgery, Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Kenneth Brady
- Department of Pediatrics and Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - R Blaine Easley
- Department of Pediatrics and Anesthesiology, Baylor College of Medicine, Texas Children's Hospital, Houston, Tex
| | - Charles Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Michael Kraut
- Department of Radiology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Rebecca F Gottesman
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Md
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Md.
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Dobson GP, Faggian G, Onorati F, Vinten-Johansen J. Hyperkalemic cardioplegia for adult and pediatric surgery: end of an era? Front Physiol 2013; 4:228. [PMID: 24009586 PMCID: PMC3755226 DOI: 10.3389/fphys.2013.00228] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 08/05/2013] [Indexed: 12/16/2022] Open
Abstract
Despite surgical proficiency and innovation driving low mortality rates in cardiac surgery, the disease severity, comorbidity rate, and operative procedural difficulty have increased. Today's cardiac surgery patient is older, has a "sicker" heart and often presents with multiple comorbidities; a scenario that was relatively rare 20 years ago. The global challenge has been to find new ways to make surgery safer for the patient and more predictable for the surgeon. A confounding factor that may influence clinical outcome is high K(+) cardioplegia. For over 40 years, potassium depolarization has been linked to transmembrane ionic imbalances, arrhythmias and conduction disturbances, vasoconstriction, coronary spasm, contractile stunning, and low output syndrome. Other than inducing rapid electrochemical arrest, high K(+) cardioplegia offers little or no inherent protection to adult or pediatric patients. This review provides a brief history of high K(+) cardioplegia, five areas of increasing concern with prolonged membrane K(+) depolarization, and the basic science and clinical data underpinning a new normokalemic, "polarizing" cardioplegia comprising adenosine and lidocaine (AL) with magnesium (Mg(2+)) (ALM™). We argue that improved cardioprotection, better outcomes, faster recoveries and lower healthcare costs are achievable and, despite the early predictions from the stent industry and cardiology, the "cath lab" may not be the place where the new wave of high-risk morbid patients are best served.
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Affiliation(s)
- Geoffrey P. Dobson
- Department of Physiology and Pharmacology, Heart and Trauma Research Laboratory, James Cook UniversityTownsville, QLD, Australia
| | - Giuseppe Faggian
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Francesco Onorati
- Division of Cardiac Surgery, University of Verona Medical SchoolVerona, Italy
| | - Jakob Vinten-Johansen
- Cardiothoracic Research Laboratory of Emory University Hospital Midtown, Carlyle Fraser Heart CenterAtlanta, GA, USA
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Current world literature. Curr Opin Cardiol 2012; 27:682-95. [PMID: 23075824 DOI: 10.1097/hco.0b013e32835a0ad8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Kirklin J. Invited commentary. Ann Thorac Surg 2011; 92:1684-5. [PMID: 22051265 DOI: 10.1016/j.athoracsur.2011.08.073] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2011] [Revised: 08/23/2011] [Accepted: 08/29/2011] [Indexed: 10/15/2022]
Affiliation(s)
- James Kirklin
- Department of Surgery, University of Alabama in Birmingham, 1530 3rd Ave S - ZRB 740, Birmingham, AL 35294-0007, USA.
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