1
|
Kayoum AA, Rivera Flores E, Reyes M, Almasarweh SI, Ojito J, Burke RP, Sasaki J. Safety of bloodless open-heart surgery on cardiopulmonary bypass in selected children: A single center experience with minimal invasive extracorporeal circulation. Perfusion 2024; 39:391-398. [PMID: 36482703 DOI: 10.1177/02676591221145623] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2023]
Abstract
INTRODUCTION Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion. METHODS Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018. RESULTS A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5-15), a weight of 32 kg (IQR, 16-55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6-14.9), and preoperative hematocrit of 40.4% (IQR, 37.2-44.3). Median CPB time was 81.5 min (IQR, 58-125), and median hematocrit coming off CPB was 26% (IQR, 23-29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001). CONCLUSIONS Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays.
Collapse
Affiliation(s)
- Anas Abdul Kayoum
- Division of Cardiology, Department of Pediatrics, Duke University Hospital, Durham, NC, USA
| | | | - Marcelle Reyes
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Saleem I Almasarweh
- Division of Cardiology, Department of Pediatrics, Children's Healthcare of Atlanta, Atlanta, GA, USA
| | - Jorge Ojito
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Redmond P Burke
- Department of Cardiology, Nicklaus Children's Hospital, Miami, FL, USA
| | - Jun Sasaki
- Department of Cardiology, Boston Children's Hospital, Boston, MA, USA
| |
Collapse
|
2
|
Münch F, Kwapil N, Teske A, Rüffer A, Dittrich S, Volk T, Purbojo A. Microplegia in paediatric hearts. Perfusion 2023; 38:1560-1564. [PMID: 36121780 PMCID: PMC10612368 DOI: 10.1177/02676591221127926] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION A basic prerequisite for a good surgical outcome in heart surgery is optimal myocardial protection. However, cardioplegia strategies used in adult cardiac surgery are not directly transferable to infant hearts. Paediatric microplegia, analogous to Calafiore cardioplegia used in adult cardiac surgery, offers the advantage of safe myocardial protection without haemodilution. The use of concentration-dependent paediatric microplegia is new in clinical implementation. MATERIAL AND METHODS Paediatric microplegia has been in clinical use in our institution since late 2014. It is applied via an 1/8 inch tube of a S5-HLM roller pump (LivaNova, Italy). As cardioplegic additive, a mixture of potassium (K) 20 mL (2 mmol/mL potassium chloride 14.9% Braun) and magnesium (Mg) 10 mL (4 mmol/mL Mg-sulphate Verla® i. v. 50%) is fixed into a syringe-pump (B. Braun, Germany). This additive is mixed with arterial patient blood from the oxygenator in different flowdependent ratios to form an effective cardioplegia. TECHNIQUE After microplegia application of initially 25 mmol/L K with 11 mmol/L Mg for 2 min, a safe cardioplegic cardiac arrest is achieved, which after release of the coronary circulation, immediately returns to a spontaneous cardiac-rhythm. In the case of prolonged aortic clamping, microplegia is repeated every 20 min with a reduction of the application dose of K by 20% and Mg by 30% (20 mmol/L K; 8.5 mmol/L Mg) and a further reduction down to a maintenance dose (15 mmol/L K; 6 mmol/L Mg) after additional 20 min. SUMMARY The microplegia adapted to the needs of paediatric myocardium is convincing due to its simple technical implementation for the perfusionist while avoiding haemodilution. However, the required intraoperative interval of microplegia of approx. 20 min demands adapted intraoperative management from the surgeon.
Collapse
Affiliation(s)
- Frank Münch
- Department of Paediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Nicola Kwapil
- Department of Paediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Andreas Teske
- Department of Paediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Andre Rüffer
- Clinic for Paediatric Cardiac Surgery and Surgery of Congenital Heart Defects, RWTH Aachen University Hospital, Aachen, Germany
| | - Sven Dittrich
- Department of Paediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Tilmann Volk
- Institute of Cellular and Molecular Physiology, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| | - Ariawan Purbojo
- Department of Paediatric Cardiac Surgery, University Hospital Erlangen, Friedrich-Alexander-University Erlangen-Nuremberg (FAU), Erlangen, Germany
| |
Collapse
|
3
|
Palanzo DA, Wise RK, Woitas KR, Ündar A, Clark JB, Myers JL. Safety and utility of modified ultrafiltration in pediatric cardiac surgery. Perfusion 2023; 38:150-155. [PMID: 34510972 DOI: 10.1177/02676591211043697] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
INTRODUCTION Modified ultrafiltration (MUF) is employed at the termination of cardiopulmonary bypass (CPB) in pediatric and neonatal patients undergoing congenital heart surgery to reduce the accumulation of total body water thus increasing the concentration of red blood cells and the other formed elements in the circulation. Modified ultrafiltration has been reported to remove circulating pro-inflammatory mediators that result in systemic inflammatory response syndrome (SIRS) postoperatively. METHODS Four hundred patients undergoing cardiac surgery requiring cardiopulmonary bypass and weighing less than or equal to 12 kg were retrospectively evaluated for the effectiveness of MUF. After the termination of CPB, blood was withdrawn through the aortic cannula and passed through a hemoconcentrator attached to the blood cardioplegia set and returned to the patient through the venous cannula. The entire CPB circuit volume in addition to the patient's circulating blood volume were concentrated until the hematocrit value displayed on the CDI cuvette within the MUF circuit reached 45% or there was no more volume to safely remove. At the same time a full unit of FFP can be infused as water is being removed, thus maintaining euvolemia. RESULTS MUF was performed in all 400 patients with no MUF-related complications. Following the conclusion of MUF, anecdotal observations included improved surgical hemostasis, improved hemodynamic parameters, decreased transfusion requirements, and decreased ventilator times. CONCLUSIONS Complete MUF enables the clinician to safely raise the post-CPB hematocrit to at least 40% while potentially removing mediators that could result in SIRS. In addition a full unit of FFP can be administered while maintaining euvolemia.
Collapse
Affiliation(s)
- David A Palanzo
- Perfusion Department, Penn State Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Robert K Wise
- Perfusion Department, Penn State Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Karl R Woitas
- Perfusion Department, Penn State Heart and Vascular Institute, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Akif Ündar
- Pediatric Cardiovascular Research Center, Departments of Pediatrics, Surgery and Biomedical Engineering, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - Joseph B Clark
- Pediatric Cardiac Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| | - John L Myers
- Pediatric Cardiac Surgery, Penn State Health Milton S. Hershey Medical Center, Penn State College of Medicine, Penn State Health Children's Hospital, Hershey, PA, USA
| |
Collapse
|
4
|
Boettcher W, O'Brien B, Photiadis J, Habazettl H, Eggert-Doktor D. Acute Kidney Injury With a Miniaturized Extracorporeal Circuit for Neonatal Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2022; 36:4045-4053. [PMID: 36008209 DOI: 10.1053/j.jvca.2022.06.036] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/12/2022] [Revised: 06/17/2022] [Accepted: 06/24/2022] [Indexed: 11/11/2022]
Abstract
OBJECTIVES The objectives of this study were to evaluate the incidence and to identify risk factors for acute kidney injury (AKI) in neonates undergoing cardiopulmonary bypass (CPB) with a miniaturized bloodless primed extracorporeal circuit. DESIGN A retrospective cohort study. SETTING A single-center, tertiary academic hospital. PARTICIPANTS Data of 462 patients were analyzed. INTERVENTIONS With a retrospective analysis of neonates undergoing CPB with bloodless priming between May 2007 and August 2019, the incidence of AKI was determined according to the neonatal Kidney Disease: Improving Global Outcomes classification. Multivariate logistic regression analyses were performed to determine risk factors for AKI. MEASUREMENTS AND MAIN RESULTS The incidence of AKI was 41.1% (190 of 462); 30.3% (n = 140) had mild stage 1, 6.5% (n = 30) reached stage 2, and 4.3% (n = 20) reached stage 3. Multivariate logistic regression showed that degree of hypothermia (p = 0.05), duration of CPB (p = 0.03), and lower baseline serum creatinine (p < 0.001) were associated independently with AKI. In the authors' patient population, patients without transfusion of donor-derived erythrocytes had a lower incidence of AKI (p = 0.003). AKI stages 2 and 3 were associated with longer duration of mechanical ventilation (p = 0.008) and increased length of stay in the intensive care unit (p = 0.03). CONCLUSIONS With a miniaturized CPB circuit and bloodless priming, the AKI incidence was well within the range consistent with previously reported studies from other institutions.
Collapse
Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany.
| | - Benjamin O'Brien
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; Department of Cardiac Anesthesiology and Intensive Care Medicine, Charité - Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery and Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany; Institute of Physiology, Charité - Universitaetsmedizin Berlin, corporate member of Freie Universität Berlin, Humboldt-Universität zu Berlin, and Berlin Institute of Health, Berlin, Germany
| | - Dirk Eggert-Doktor
- Department of Cardiac Anesthesiology and Intensive Care Medicine, German Heart Center Berlin, Berlin, Germany
| |
Collapse
|
5
|
Perioperative Pediatric Erythrocyte Transfusions: Incorporating Hemoglobin Thresholds and Physiologic Parameters in Decision-making. Anesthesiology 2022; 137:604-619. [PMID: 36264089 DOI: 10.1097/aln.0000000000004357] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
This article presents current literature and scientific evidence on hemoglobin thresholds and physiologic parameters to guide decisions regarding perioperative erythrocyte transfusions in pediatric patients based on the most up-to-date studies and expert consensus recommendations.
Collapse
|
6
|
Saleem Y, Darbari A, Sharma R, Vashisth A, Gupta A. Recent advancements in pediatric cardiopulmonary bypass technology for better outcomes of pediatric cardiac surgery. THE CARDIOTHORACIC SURGEON 2022. [DOI: 10.1186/s43057-022-00084-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
Abstract
Background
Pediatric cardiac surgery is in itself very enigmatic and individualized. Presently, there has been a slew of new developments aimed primarily toward pediatric cardiopulmonary bypass for safer, patient-centered pediatric cardiac surgery. Still, lot of technological challenges need to be resolved, and their safer application in pediatric and neonate patients requires further refinement.
Main body of the abstract
Considering various significant yet unresolved issues of pediatric cardiac bypass, an exhaustive literature search was done on various internet databases with standard keywords. There are various new recent improvements; as the first oxygenator explicitly designed for neonatal patients; pediatric oxygenators with low prime volumes and surface areas that allow flows up to 2 L/min; pediatric oxygenators with integrated arterial filters; and miniature ultrafiltration devices that allow for high rates of ultrafiltrate removal. These advancements can significantly reduce cardiopulmonary bypass circuit surface areas and prime volumes. These advancements could reduce or eliminate the requirement for homologous red blood cells during or after surgery with reduction or eliminate bypass-related hemodilution, and inflammation. Because of the immaturity of the neonatal hemostatic system, conventional coagulation tests alone are insufficient to guide neonatal hemostatic therapy. Myocardial preservation techniques, safe temperature with duration are still debatable and yet to be fully explored.
Short conclusion
This review is based on Standards for Quality Improvement Reporting Excellence guidelines to provide a framework for reporting new knowledge to find better management strategy for pediatric cardiac cases.
Collapse
|
7
|
Böttcher W, Weixler V, Redlin M, Murin P, Dehmel F, Schmitt K, Cho MY, Miera O, Sinzobahamvya N, Photiadis J. Acute Kidney Injury After Neonatal Aortic Arch Surgery: Deep Hypothermic Circulatory Arrest Versus Moderate Hypothermia With Distal Aortic Perfusion. World J Pediatr Congenit Heart Surg 2021; 12:573-580. [PMID: 34597201 DOI: 10.1177/21501351211014824] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Acute kidney injury (AKI) is a common complication observed after neonatal aortic arch repair. We studied its incidence after procedures carried out using deep hypothermic circulatory arrest (DHCA) versus moderate hypothermia with distal aortic perfusion (MHDP), usually through the common femoral artery. In both groups, continuous regional cerebral perfusion (RCP) was used during the time required for aortic arch repair. METHODS A total of 125 neonates underwent aortic arch repair. Between 2007 and 2012, DHCA with RCP was used in 51 neonates. From 2013 to 2019, MHDP with RCP was performed on 74 newborns. Operative complexity was similar in both periods. Acute kidney injury was defined as a significant elevation of serum creatinine and was classified according to the neonatal modified n-KDIGO (neonatal Kidney Disease: Improving Global Outcomes) stages 1 to 3 (Kidney Disease Improving: Global Outcomes). RESULTS Acute kidney injury was observed in a total of 68 patients (68/125: 54.4%). In the majority (44/68: 64.7%), n-KDIGO stage 1 occurred. Stage 2 (n = 14) and stage 3 (n = 10) were observed more frequently after DHCA versus MHDP: 29.4% (15/51) versus 12.2% (9/74), P = .02. At cardiopulmonary bypass end, lactate levels were significantly higher (P = .001) after DHCA: 3.4 (2.9-4.3) mmol/L compared to 2.7 (2.3-3.7) mmol/L after MHDP. Early mortality was 12% (15/125) in the entire cohort. It was 17.6% (9/51) after DHCA versus 8.1% (6/74) after MHDP, however not statistically significant (P = .16). CONCLUSION Mild (stage 1) AKI occurred frequently after neonatal aortic arch repair. The use of MHDP was associated with a significantly lower incidence of moderate (stage 2) and severe (stage 3) AKI forms.
Collapse
Affiliation(s)
- Wolfgang Böttcher
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Viktoria Weixler
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Mathias Redlin
- Department of Anesthesiology, German Heart Center Berlin, Berlin, Germany
| | - Peter Murin
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Katharina Schmitt
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Oliver Miera
- Department of Congenital Heart Disease-Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany
| | - Nicodème Sinzobahamvya
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| | - Joachim Photiadis
- Department of Congenital Heart Surgery-Pediatric Heart Surgery, German Heart Center Berlin, Berlin, Germany
| |
Collapse
|
8
|
Boos V, Bührer C, Berger F. Preoperative Anemia and Outcomes After Corrective Surgery in Neonates With Dextro-Transposition of the Great Arteries. J Cardiothorac Vasc Anesth 2021; 35:2900-2906. [PMID: 33745834 DOI: 10.1053/j.jvca.2021.02.038] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/29/2020] [Revised: 01/30/2021] [Accepted: 02/12/2021] [Indexed: 02/02/2023]
Abstract
OBJECTIVES The authors aimed to assess whether untreated preoperative anemia was associated with increased risk for adverse outcomes after the arterial switch operation in neonates with dextro-transposition of the great arteries (d-TGA). DESIGN Retrospective cohort study. SETTING Single cardiac surgery center. PARTICIPANTS Eighty-two newborns with d-TGA. INTERVENTIONS The authors categorized the cohort into the following two groups: the infants with preoperative anemia group (defined as a hematocrit <0.40 L/L) and the control group. MEASUREMENTS AND MAIN RESULTS Preoperative anemia was diagnosed in 21 (25.6%) infants. Anemic infants received intraoperative red blood cell transfusions significantly more often than controls (81.0% v 34.4%, p < 0.001). No differences were observed in the incidence of adverse events, duration of hospitalization (median 27 days v 26 days, p = 0.881), and mortality (0% v 4.9%, p = 0.566). Postnatal hematocrit was the only variable independently associated with preoperative anemia in multivariate logistic regression analysis (unit odds ratio, 0.832; 95% confidence interval, 0.743-0.931; p = 0.001). CONCLUSIONS Untreated preoperative anemia was not associated with adverse outcomes in neonates undergoing reparative surgery for d-TGA.
Collapse
Affiliation(s)
- Vinzenz Boos
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany; Department of Neonatology, Hospital Zollikerberg, Zollikerberg, Switzerland.
| | - Christoph Bührer
- Department of Neonatology, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Felix Berger
- Department of Congenital Heart Disease/Pediatric Cardiology, German Heart Center Berlin, Berlin, Germany; German Center for Cardiovascular Research (DZHK), Congenital Heart Diseases, Partner Site Berlin, Berlin, Germany
| |
Collapse
|
9
|
Desai M, Yerebakan C. Commentary: Less Bloody and Bloodless Cases. Semin Thorac Cardiovasc Surg 2020; 33:513-514. [PMID: 33171241 DOI: 10.1053/j.semtcvs.2020.11.012] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 11/05/2020] [Indexed: 11/11/2022]
Affiliation(s)
- Manan Desai
- Department of Cardiothoracic Surgery, Lucile Packard Children's Hospital, Stanford University, Palo Alto, California.
| | - Can Yerebakan
- Department of Cardiovascular Surgery, Children's National Heart Institute, Children's National Health System, The George Washington University School of Medicine and Health Sciences, Washington, District of Columbia
| |
Collapse
|
10
|
Singab H, Gamal MA, Refaey R, Al-Taher W. Effect of Retrograde Autologous Blood Priming of Cardiopulmonary Bypass on Hemodynamic Parameters and Pulmonary Mechanics in Pediatric Cardiac Surgery: A Randomized Clinical Study. Semin Thorac Cardiovasc Surg 2020; 33:505-512. [PMID: 32977015 DOI: 10.1053/j.semtcvs.2020.09.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/16/2020] [Accepted: 09/08/2020] [Indexed: 11/11/2022]
Abstract
The present study aimed to assess the impact of retrograde autologous priming (RAP) on hemodynamics and pulmonary mechanics in children subjected to cardiothoracic surgery. This prospective randomized study analyzed the clinical records of 124 children with risk adjustment in congenital heart surgery-1 left to right lesions subjected to cardiac surgery. They comprised 64 patients in RAP group and 60 patients in the conventional priming group. The preoperative, intraoperative and postoperative data of the studied patients were reported. The outcome measures included hematocrit (Hct) value, blood gases, lung mechanics parameters, transfusion needs, ICU stay, postoperative complications and mortality. Preoperatively, there were no significant differences between the studied groups regarding the demographic data, underlying lesions, laboratory data, blood gases and pulmonary mechanics parameters. Intraoperatively, RAP group patients had significantly lower amount of blood loss, less frequent need to packed red blood cells (RBC)s transfusion and better Hct values when compared with the control group. Postoperatively, RAP group patients had significantly higher Hct% at ICU arrival, significantly better pulmonary mechanics parameters and significantly shorter duration on mechanical ventilation. RAP in children older than 12 months subjected to cardiac surgery for risk adjustment in congenital heart surgery-1 left to right lesions is associated with less transfusion needs and better pulmonary mechanics.
Collapse
Affiliation(s)
- Hamdy Singab
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt.
| | - Mohamed A Gamal
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Reda Refaey
- Cardiothoracic Surgery Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| | - Waleed Al-Taher
- Anesthesia and Intensive Care Department, Ain Shams University Faculty of Medicine, Ain Shams University Hospitals, Cairo, Egypt
| |
Collapse
|
11
|
Wang L, Chen Q, Qiu YQ, Ye JX, Du JZ, Lv XC, Hou YT, Chen LW. Effects of cardiopulmonary bypass with low-priming volume on clinical outcomes in children undergoing congenital heart disease surgery. J Cardiothorac Surg 2020; 15:118. [PMID: 32460864 PMCID: PMC7251910 DOI: 10.1186/s13019-020-01151-w] [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: 02/29/2020] [Accepted: 05/10/2020] [Indexed: 11/25/2022] Open
Abstract
Background Cardiopulmonary bypass (CPB) with high-priming volume can significantly activate the inflammatory response and increse the usage of packed red blood cells (PRBCs). As risks and complications related to transfusions are increasing, many cardiac centers are focusing on reducing the priming volume of CPB. In our center, efforts have also been made to reduce the priming volume, and the effects of CPB with low-priming volume on clinical outcomes in children undergoing congenital heart disease (CHD) surgery were investigated in this study to provide referential experiences for pediatric CPB. Methods The clinical case data of 158 children undergoing CHD surgery with CPB were collected. The children were divided into the low-priming-volume group (group A, n = 79) and the traditional group (group B, n = 79) according to the priming volume. The amount of PRBCs transfused, the postoperative hematological test results and the clinical outcomes of the two groups were compared by the independent sample t-test or the chi-square test. Results The amount of PRBCs transfused during CPB and during the whole operation were significantly lower in group A than in group B (p < 0.01), but the hemoglobin (Hb) concentration was higher in group A on the first day after surgery (p < 0.01) and before hospital discharge. However, the latter showed no statistical significant difference. The lowest postoperative platelet count was higher in group A than in group B (p < 0.05). There was no statistical difference in the postoperative inflammatory markers and the main clinical outcomes between the two groups. Conclusions The usage of PRBCs in CPB with low-priming volume decreased significantly, but the postoperative Hb concentration and platelet count could still be maintained at a high level, improving the use efficiency of PRBCs. CPB with low-priming volume did not affect the postoperative recovery of patients, so it is worthy of continuous promotion and optimization.
Collapse
Affiliation(s)
- Lei Wang
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China.
| | - Qiang Chen
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Yong Qiang Qiu
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jian Xi Ye
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Jian Zhi Du
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Xiao Chai Lv
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Yan Ting Hou
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China
| | - Liang Wan Chen
- Department of Cardiac Surgery, Union Hospital of Fujian Medical University, Fuzhou, Fujian Province, China.
| |
Collapse
|
12
|
Faraoni D, Meier J, New HV, Van der Linden PJ, Hunt BJ. Patient Blood Management for Neonates and Children Undergoing Cardiac Surgery: 2019 NATA Guidelines. J Cardiothorac Vasc Anesth 2019; 33:3249-3263. [DOI: 10.1053/j.jvca.2019.03.036] [Citation(s) in RCA: 49] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 03/17/2019] [Accepted: 03/18/2019] [Indexed: 12/22/2022]
|
13
|
Machovec KA, Jooste EH. Pediatric Transfusion Algorithms: Coming to a Cardiac Operating Room Near You. J Cardiothorac Vasc Anesth 2019; 33:2017-2029. [DOI: 10.1053/j.jvca.2018.12.008] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/03/2018] [Indexed: 01/27/2023]
|
14
|
Fernandez A, Chasovskyi K. The Use of Umbilical Cord Blood for Autologous Transfusion in Neonatal Open Heart Surgery. J Cardiothorac Vasc Anesth 2019; 34:483-488. [PMID: 31151859 DOI: 10.1053/j.jvca.2019.05.007] [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: 10/08/2018] [Revised: 05/03/2019] [Accepted: 05/05/2019] [Indexed: 12/29/2022]
Abstract
In the last few decades, the use of umbilical cord blood (UCB) has received increasing attention, not only as a source of stem cells, but also as a transfusion product for the treatment of anemia in the neonatal and even the adult population. This review focuses on data reports and collection efforts related to the autologous transfusion of UCB in full-term neonates with prenatally diagnosed critical congenital heart defects. This review summarizes different aspects of UCB transfusion, including indications and contraindications; the collection procedure; storage timing; and special properties of one of its constituents, fetal hemoglobin, in the setting of hypothermic cardiopulmonary bypass.
Collapse
Affiliation(s)
- Adam Fernandez
- Perfusion Department, BC Children's Hospital, Vancouver, British Columbia, Canada
| | - Kyrylo Chasovskyi
- Perfusion Department, BC Children's Hospital, Vancouver, British Columbia, Canada.
| |
Collapse
|
15
|
Bojan M. Recent achievements and future developments in neonatal cardiopulmonary bypass. Paediatr Anaesth 2019; 29:414-425. [PMID: 30714261 DOI: 10.1111/pan.13597] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Revised: 01/11/2019] [Accepted: 01/18/2019] [Indexed: 12/21/2022]
Abstract
A primary goal of improving neonatal cardiopulmonary bypass has been making the circuit smaller and reduce the blood contacting surfaces. As bypass circuit size has decreased, bloodless surgery has become possible even in neonates. Since transfusion guidelines are difficult to construct based on existing literature, these technical advances should be taken advantage of in conjunction with an individualized transfusion scheme, based on monitoring of oxygen availability to the tissues. For the majority of neonatal heart operations, several centers have shifted toward normothermic bypass even for complex neonatal surgeries, in order to avoid the adverse effects of hypothermia. Deep hypothermic circulatory arrest is no longer a necessity but an option, and selective antegrade cerebral perfusion has become common practice; however, technical uncertainties with regard to this technique have to be addressed, based on reliable neurologic monitoring. Maintenance of patient-specific heparin concentrations during bypass is another key goal, since neonates have lower baseline antithrombin concentrations and, therefore, a higher risk for inadequate thrombin inhibition and postoperative bleeding. Due to the immaturity of their hemostatic system, the standard coagulation tests alone are inappropriate to guide hemostatic therapy in neonates. The use of indirect heparin concentration assays and global viscoelastic assays in the operating room is likely to represent the optimal strategy, and requires validation in neonates. Monitoring of global and regional indexes of oxygen availability and consumption on bypass have become possible; however, their use in neonates still has outstanding technical issues which should be addressed and hence needs further validation. Due to the immaturity of the neonatal myocardium, single-shot cold cardioplegia solutions are thought to confer the best myocardial protection; their superiority when compared to more conventional modalities, however, remains to be demonstrated.
Collapse
Affiliation(s)
- Mirela Bojan
- Congenital Cardiac Unit, Department of Anesthesiology, Marie Lannelongue Hospital, Le Plessis Robinson, France
| |
Collapse
|
16
|
Zhang C, Meng B, Wu K, Ding Y. Comparison of two cardiopulmonary bypass strategies with a miniaturized tubing system: a propensity score-based analysis. Perfusion 2019; 34:460-466. [PMID: 30739569 DOI: 10.1177/0267659118825395] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
INTRODUCTION The existing cardiopulmonary bypass tubing system has already been significantly improved in our hospital by reducing the priming volume; thus, we further employed a new cardiopulmonary bypass strategy in children based on a miniaturized cardiopulmonary bypass circuit. We aimed to compare the effectiveness of new and conventional strategies by analyzing the outcomes after congenital heart surgery. METHODS We performed a database analysis of all patients undergoing congenital heart surgery with cardiopulmonary bypass at Shenzhen Children's Hospital from 1 May 2015 to 30 June 2017. Propensity score matching was used to adjust for significant covariates, and multivariable regression models and stratified analysis were used to assess the association of cardiopulmonary bypass strategy with outcomes. RESULTS Of 925 total patients, 55.35% were in the conventional strategy group and 44.65% were in the new strategy group. After propensity score matching, there were 610 patients in total, with 305 patients in each group. In the multivariable regression models, the cardiopulmonary bypass strategy was not significantly associated with successful early extubation (p > 0.05), reintubation (p > 0.05), or nasal continuous positive airway pressure (p > 0.05) rates. The new strategy group had fewer hospital stays (p = 0.04) and intensive care unit stays (p < 0.05) compared with patients who underwent conventional strategy. The difference remained statistically significant (p < 0.05) when The Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery category was <3. CONCLUSION The implementation of a new cardiopulmonary bypass strategy, with selective ultrafiltration based on a miniaturized cardiopulmonary bypass circuit system, was safe and effective for children who underwent congenital heart surgery in a Chinese hospital. The new cardiopulmonary bypass strategy was associated with fewer hospital and intensive care unit stays.
Collapse
Affiliation(s)
- Cheng Zhang
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Baoying Meng
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Keye Wu
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| | - Yiqun Ding
- Department of Cardiac Surgery, Shenzhen Children's Hospital, Shenzhen, China
| |
Collapse
|
17
|
Sathianathan S, Nasir R, Wang S, Kunselman AR, Ündar A. In vitro evaluation of Capiox FX05 and RX05 oxygenators in neonatal cardiopulmonary bypass circuits with varying venous reservoir and vacuum‐assisted venous drainage levels. Artif Organs 2019; 44:28-39. [DOI: 10.1111/aor.13404] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2018] [Revised: 10/30/2018] [Accepted: 11/29/2018] [Indexed: 11/30/2022]
Affiliation(s)
- Shyama Sathianathan
- Department of Pediatrics Penn State Health Pediatric Cardiovascular Research Center, Penn State Health Children’s Hospital Hershey Pennsylvania
| | - Rafay Nasir
- Department of Pediatrics Penn State Health Pediatric Cardiovascular Research Center, Penn State Health Children’s Hospital Hershey Pennsylvania
| | - Shigang Wang
- Department of Pediatrics Penn State Health Pediatric Cardiovascular Research Center, Penn State Health Children’s Hospital Hershey Pennsylvania
| | - Allen R. Kunselman
- Department of Public Health and Sciences Penn State Health Children’s Hospital Hershey Pennsylvania
| | - Akif Ündar
- Department of Pediatrics Penn State Health Pediatric Cardiovascular Research Center, Penn State Health Children’s Hospital Hershey Pennsylvania
- Department of Surgery and Bioengineering Penn State Health Children’s Hospital Hershey Pennsylvania
| |
Collapse
|
18
|
Bloodless priming of the cardiopulmonary bypass circuit: determinants of successful transfusion-free operation in neonates and infants with a maximum body weight of 7 kg. Cardiol Young 2018; 28:1141-1147. [PMID: 30033907 DOI: 10.1017/s1047951118001154] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
We currently perform open-heart procedures using bloodless priming of cardiopulmonary bypass circuits regardless of a patient's body weight. This study presents results of this blood-saving approach in neonates and infants with a body weight of up to 7 kg. It tests with multivariate analysis factors that affect perioperative transfusion. A total of 498 open-heart procedures were carried out in the period 2014-2016 and were analysed. Priming volume ranged from 73 ml for patients weighing up to 2.5 kg to 110 ml for those weighing over 5 kg. Transfusion threshold during cardiopulmonary bypass was 8 g/dl of haemoglobin concentration. Transfusion factors were first analysed individually. Variables with a p-value lower than 0.2 underwent logistic regression. Extracorporeal circulation was conducted without transfusion of blood in 335 procedures - that is, 67% of cases. Transfusion-free operation was achieved in 136 patients (27%) and was more frequently observed after arterial switch operation and ventricular septal defect repair (12/18=66.7%). It was never observed after Norwood procedure (0/33=0%). Lower mortality score (p=0.001), anaesthesia provided by a certain physician (p=0.006), first chest entry (p=0.013), and higher haemoglobin concentration before going on bypass (p=0.013) supported transfusion-free operation. Early postoperative mortality was 4.4% (22/498). It was lower than expected (6.4%: 32/498). In conclusion, by adjusting the circuit, cardiopulmonary bypass could be conducted without donor blood in majority of patients, regardless of body weight. Transfusion-free open-heart surgery in neonates and infants requires team cooperation. It was more often achieved in procedures with lower mortality score.
Collapse
|
19
|
Costa ACBA, Parham DR, Ashley JE, Nguyen KH. A Table Mounted Cardiopulmonary Bypass System for Pediatric Cardiac Surgery. Ann Thorac Surg 2018; 106:e163-e165. [PMID: 29660358 DOI: 10.1016/j.athoracsur.2018.03.027] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 03/06/2018] [Accepted: 03/11/2018] [Indexed: 10/17/2022]
Abstract
Systemic inflammatory response and hemodilution are prominent factors associated with cardiopulmonary bypass and result in increased morbidity and mortality in children. Miniaturized systems have evolved to decrease such effects and restrict use of blood products, especially in the neonatal population. We have developed a table mounted cardiopulmonary bypass system that allows closer proximity of the system to the patient with consequent decrease in priming volumes, hemodilution, and its associated effects, and contributes to development into an ideally bloodless surgical approach.
Collapse
Affiliation(s)
- Ana Claudia B A Costa
- Department of Cardiovascular Surgery, Icahn School of Medicine at Mount Sinai, Mount Sinai Hospital, New York, New York
| | - Darren R Parham
- Department of Cardiothoracic Surgery, Maimonides Medical Center, Brooklyn, New York
| | - Justin E Ashley
- Department of Cardiothoracic and Vascular Surgery, Montefiore Medical Center, New York, New York
| | - Khanh H Nguyen
- Division of Pediatric Cardiac Surgery, Maria Fareri Children's Hospital, Westchester Medical Center, Valhalla, New York.
| |
Collapse
|
20
|
Sturmer D, Beaty C, Clingan S, Jenkins E, Peters W, Si MS. Recent innovations in perfusion and cardiopulmonary bypass for neonatal and infant cardiac surgery. Transl Pediatr 2018; 7:139-150. [PMID: 29770295 PMCID: PMC5938255 DOI: 10.21037/tp.2018.03.05] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
The development and refinement of cardiopulmonary bypass (CPB) has made the repair of complex congenital heart defects possible in neonates and infants. In the past, the primary goal for these procedures was patient survival. Now that substantial survival rates have been achieved for even the most complex of repairs in these patients, focus has been given to the reduction of morbidity. Although a necessity for these complex neonatal and infant heart defect repairs, CPB can also be an important source of perioperative complications. Recent innovations have been developed to mitigate these risks and is the topic of this review. Specifically, we will discuss improvements in minimizing blood transfusions, CPB circuit design, monitoring, perfusion techniques, temperature management, and myocardial protection, and then conclude with a brief discussion of how further systematic improvements can be made in these areas.
Collapse
Affiliation(s)
- David Sturmer
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Claude Beaty
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Sean Clingan
- Deprtment of Perfusion, Cincinnati Children's Hospital Medical Center, Cincinnati, OH, USA
| | - Eric Jenkins
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Whitney Peters
- Department of Perfusion, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| | - Ming-Sing Si
- Department of Cardiac Surgery, University of Michigan C.S. Mott Children's Hospital, Ann Arbor, MI, USA
| |
Collapse
|
21
|
Boettcher W, Redlin M, Dehmel F, Graefe K, Cho MY, Habazettl H, Kukucka M. Asanguineous priming of miniaturized paediatric cardiopulmonary bypass circuits for congenital heart surgery: independent predictors associated with transfusion requirements and effects on postoperative morbidity. Eur J Cardiothorac Surg 2018; 53:1075-1081. [DOI: 10.1093/ejcts/ezx479] [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: 07/10/2017] [Accepted: 11/28/2017] [Indexed: 11/14/2022] Open
Affiliation(s)
- Wolfgang Boettcher
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Matthias Redlin
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Katharina Graefe
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Physiology, Charité—Universitätsmedizin Berlin, Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin Institute of Health, Berlin, Germany
| | - Marian Kukucka
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| |
Collapse
|
22
|
Redlin M, Boettcher W, Dehmel F, Cho MY, Kukucka M, Habazettl H. Accuracy of predicted haemoglobin concentration on cardiopulmonary bypass in paediatric cardiac surgery: effect of different formulae for estimating patient blood volume. Perfusion 2017; 32:639-644. [DOI: 10.1177/0267659117714861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Introduction: When applying a blood-conserving approach in paediatric cardiac surgery with the aim of reducing the transfusion of homologous blood products, the decision to use blood or blood-free priming of the cardiopulmonary bypass (CPB) circuit is often based on the predicted haemoglobin concentration (Hb) as derived from the pre-CPB Hb, the prime volume and the estimated blood volume. We assessed the accuracy of this approach and whether it may be improved by using more sophisticated methods of estimating the blood volume. Patients and Methods: Data from 522 paediatric cardiac surgery patients treated with CPB with blood-free priming in a 2-year period from May 2013 to May 2015 were collected. Inclusion criteria were body weight <15 kg and available Hb data immediately prior to and after the onset of CPB. The Hb on CPB was predicted according to Fick’s principle from the pre-CPB Hb, the prime volume and the patient blood volume. Linear regression analyses and Bland-Altman plots were used to assess the accuracy of the Hb prediction. Different methods to estimate the blood volume were assessed and compared. Results: The initial Hb on CPB correlated well with the predicted Hb (R2=0.87, p<0.001). A Bland-Altman plot revealed little bias at 0.07 g/dL and an area of agreement from -1.35 to 1.48 g/dL. More sophisticated methods of estimating blood volume from lean body mass did not improve the Hb prediction, but rather increased bias. Conclusion: Hb prediction is reasonably accurate, with the best result obtained with the simplest method of estimating the blood volume at 80 mL/kg body weight. When deciding for or against blood-free priming, caution is necessary when the predicted Hb lies in a range of ± 2 g/dL around the transfusion trigger.
Collapse
Affiliation(s)
- Matthias Redlin
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Wolfgang Boettcher
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Frank Dehmel
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Mi-Young Cho
- Department of Congenital and Pediatric Heart Surgery, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Marian Kukucka
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
| | - Helmut Habazettl
- Department of Anesthesiology, Deutsches Herzzentrum Berlin, Berlin, Germany
- Institute of Physiology, Charité, University Medicine Berlin, Berlin, Germany
| |
Collapse
|