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Hussain AM, Younes MA. Early outcomes of experience warm surgery in children undergoing complete repair of tetralogy of Fallot in developing countries. BMC Pediatr 2024; 24:499. [PMID: 39097678 PMCID: PMC11297559 DOI: 10.1186/s12887-024-04976-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/14/2024] [Accepted: 07/26/2024] [Indexed: 08/05/2024] Open
Abstract
OBJECTIVES While significant evidence supports the benefits of normothermic cardiopulmonary bypass (NCPB) over hypothermic techniques, many institutions in developing countries, including ours, continue to employ hypothermic methods. This study aimed to assess the early postoperative outcomes of normothermic cardiopulmonary bypass (NCPB) for complete surgical repair via the Tetralogy of Fallot (TOF) within our national context. METHODS We conducted this study in the Pediatric Cardiac Intensive Care Unit (PCICU) at the University Children's Hospital. One hundred patients who underwent complete TOF repair were enrolled and categorized into two groups: the normothermic group (n = 50, temperature 35-37 °C) and the moderate hypothermic group (n = 50, temperature 28-32 °C). We evaluated mortality, morbidity, and postoperative complications in the PCICU as outcome measures. RESULTS The demographic characteristics were similar between the two groups. However, the cardiopulmonary bypass (CPB) time and aortic cross-clamp (ACC) time were notably longer in the hypothermic group. The study recorded seven deaths, yielding an overall mortality rate of 7%. No significant differences were observed between the two groups concerning mortality, morbidity, or postoperative complications in the PCICU. CONCLUSIONS Our findings suggest that normothermic procedures, while not demonstrably effective, are safe for pediatric cardiac surgery. Further research is warranted to substantiate and endorse the adoption of this technique.
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Affiliation(s)
- Alaa Mohamad Hussain
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
| | - Mohammad Ali Younes
- University Children's Hospital, Damascus University, Damascus, Syrian Arab Republic.
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Skeffington KL, Mohamed Ahmed E, Rapetto F, Chanoit G, Bond AR, Vardeu A, Ghorbel MT, Suleiman MS, Caputo M. The effect of cardioplegic supplementation with sildenafil on cardiac energetics in a piglet model of cardiopulmonary bypass and cardioplegic arrest with warm or cold cardioplegia. Front Cardiovasc Med 2023; 10:1194645. [PMID: 37351284 PMCID: PMC10282544 DOI: 10.3389/fcvm.2023.1194645] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2023] [Accepted: 05/17/2023] [Indexed: 06/24/2023] Open
Abstract
Cardioplegic cardioprotection strategies used during paediatric open-heart surgery remain suboptimal. Sildenafil, a phosphodiesterase 5 (PDE-5) inhibitor, has been shown to be cardioprotective against ischemia/reperfusion injury in a variety of experimental models and this study therefore tested the efficacy of supplementation of cardioplegia with sildenafil in a piglet model of cardiopulmonary bypass and arrest, using both cold and warm cardioplegia protocols. Piglets were anaesthetized and placed on coronary pulmonary bypass (CPB), the aorta cross-clamped and the hearts arrested for 60 min with cardioplegia with or without sildenafil (10 nM). Twenty minutes after removal of cross clamp (reperfusion), attempts were made to wean the pigs from CPB. Termination was carried out after 60 min reperfusion. Throughout the protocol blood and left ventricular tissue samples were taken for analysis of selected metabolites (using HPLC) and troponin I. In both the cold and warm cardioplegia protocols there was evidence that sildenafil supplementation resulted in faster recovery of ATP levels, improved energy charge (a measure of metabolic flux) and altered release of hypoxanthine and inosine, two purine catabolites. There was no effect on troponin release within the studied short timeframe. In conclusion, sildenafil supplementation of cardioplegia resulted in improved cardiac energetics in a translational animal model of paediatric CPB surgery.
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Affiliation(s)
- Katie L. Skeffington
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | | | - Filippo Rapetto
- Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Guillaume Chanoit
- Langford Vets, University of Bristol, Langford, Bristol, United Kingdom
| | - Andrew R. Bond
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Antonella Vardeu
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Mohamed T. Ghorbel
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - M-Saadeh Suleiman
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
| | - Massimo Caputo
- Bristol Heart Institute, University of Bristol, Research Floor Level 7, Bristol Royal Infirmary, Bristol, United Kingdom
- Department of Cardiac Surgery, Bristol Royal Infirmary, Bristol, United Kingdom
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Keizman E, Mishaly D, Ram E, Urtaev S, Tejman-Yarden S, Tirosh Wagner T, Serraf AE. Normothermic Versus Hypothermic Norwood Procedure. World J Pediatr Congenit Heart Surg 2023; 14:125-132. [PMID: 36537725 DOI: 10.1177/21501351221140330] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Either deep hypothermia with circulatory arrest or hypothermic perfusion with antegrade selective cerebral perfusion is used during the Norwood procedure for hypoplastic left heart syndrome. Normothermic perfusion has been described for pediatric patients. The aim of this study was to compare the early outcomes of patients undergoing the Norwood procedure with antegrade selective cerebral perfusion under hypothermia with the procedure under normothermia. METHODS From 2005 to 2020, 117 consecutive patients with hypoplastic left heart syndrome underwent the Norwood procedure: 68 (58.2%) under hypothermia and 49 (41.8%) under normothermia. Antegrade selective cerebral perfusion flow was adjusted to maintain right radial arterial pressure above 50 mm Hg, and a flow rate of 40 to 50 mL kg-1 min-1. Baseline characteristics, operative data, and postoperative outcomes including lactate recovery time were compared. RESULTS The baseline characteristics and cardiovascular diagnosis were similar in both groups. The normothermic group had a significantly shorter bypass time (in minutes) of 90.31 (±31.60) versus 123.63 (±25.33), a cross-clamp time of 45.24 (±16.35) versus 81.93 (±16.34), and an antegrade selective cerebral perfusion time of 25.61 (±13.84) versus 47.30 (±14.35) (P < .001). There were no statistically significant differences in the immediate postoperative course, or in terms of in-hospital mortality, which totaled 9 (18.4%) in the normothermic group, and 10 (14.9%) in the hypothermic group (P = .81). CONCLUSION The normothermic Norwood procedure with selective cerebral perfusion is feasible and safe in terms of in-hospital mortality and short-term outcomes. It is comparable to the standard hypothermic Norwood with selective cerebral perfusion.
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Affiliation(s)
- Eitan Keizman
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - David Mishaly
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Eilon Ram
- Department of Cardiac Surgery, The Leviev Cardiothoracic and Vascular Center, Sheba Medical Center, affiliated to the Sackler School of Medicine, Tel Aviv University, Ramat Gan, Israel
| | - Soslan Urtaev
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Shai Tejman-Yarden
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Tal Tirosh Wagner
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
| | - Alain E Serraf
- The Edmond J. Safra International Congenital Heart Center, Sheba Medical Center, Ramat Gan, Israel
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Vanreusel I, Vermeulen D, Goovaerts I, Stoop T, Ectors B, Cornelis J, Hens W, de Bliek E, Heuten H, Van Craenenbroeck EM, Van Berendoncks A, Segers VFM, Briedé JJ. Circulating Reactive Oxygen Species in Adults with Congenital Heart Disease. Antioxidants (Basel) 2022; 11:antiox11122369. [PMID: 36552576 PMCID: PMC9774177 DOI: 10.3390/antiox11122369] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2022] [Revised: 11/24/2022] [Accepted: 11/25/2022] [Indexed: 12/05/2022] Open
Abstract
Oxidative stress is an important pathophysiological mechanism in the development of numerous cardiovascular disorders, but few studies have examined the levels of oxidative stress in adults with congenital heart disease (CHD). The objective of this study was to investigate oxidative stress levels in adults with CHD and the association with inflammation, exercise capacity and endothelial function. To this end, 36 adults with different types of CHD and 36 age- and gender-matched healthy controls were enrolled. Blood cell counts, hs-CRP, NT-proBNP, fasting glucose, cholesterol levels, iron saturation and folic acid concentrations were determined in venous blood samples. Levels of superoxide anion radical in whole blood were determined using electron paramagnetic resonance spectroscopy in combination with the spin probe CMH. Physical activity was assessed with the IPAQ-SF questionnaire. Vascular function assessment (EndoPAT) and cardiopulmonary exercise testing were performed in the patient group. Superoxide anion radical levels were not statistically significantly different between adults with CHD and the matched controls. Moreover, oxidative stress did not correlate with inflammation, or with endothelial function or cardiorespiratory fitness in CHD; however, a significant negative correlation with iron saturation was observed. Overall, whole blood superoxide anion radical levels in adults with CHD were not elevated, but iron levels seem to play a more important role in oxidative stress mechanisms in CHD than in healthy controls. More research will be needed to improve our understanding of the underlying pathophysiology of CHD.
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Affiliation(s)
- Inne Vanreusel
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
- Correspondence: ; Tel.: +32-3-821-38-47
| | - Dorien Vermeulen
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Inge Goovaerts
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Tibor Stoop
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Bert Ectors
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Jacky Cornelis
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Wendy Hens
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Cardiac Rehabilitation Centre, Antwerp University Hospital, 2650 Edegem, Belgium
- Department of Rehabilitation Sciences and Physiotherapy, Faculty of Medicine and Health Sciences, MOVANT Research Group, University of Antwerp, 2000 Antwerp, Belgium
| | - Erwin de Bliek
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
- Cardiac Rehabilitation Centre, Antwerp University Hospital, 2650 Edegem, Belgium
| | - Hilde Heuten
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Emeline M. Van Craenenbroeck
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - An Van Berendoncks
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Vincent F. M. Segers
- Department of Cardiology, Antwerp University Hospital, 2650 Edegem, Belgium
- Research Group Cardiovascular Diseases, GENCOR, University of Antwerp, 2000 Antwerp, Belgium
| | - Jacob J. Briedé
- Department of Toxicogenomics, School of Oncology and Developmental Biology (GROW), Maastricht University, 6211 MD Maastricht, The Netherlands
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Iacobazzi D, Alvino VV, Caputo M, Madeddu P. Accelerated Cardiac Aging in Patients With Congenital Heart Disease. Front Cardiovasc Med 2022; 9:892861. [PMID: 35694664 PMCID: PMC9177956 DOI: 10.3389/fcvm.2022.892861] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 04/11/2022] [Indexed: 01/03/2023] Open
Abstract
An increasing number of patients with congenital heart disease (CHD) survive into adulthood but develop long-term complications including heart failure (HF). Cellular senescence, classically defined as stable cell cycle arrest, is implicated in biological processes such as embryogenesis, wound healing, and aging. Senescent cells have a complex senescence-associated secretory phenotype (SASP), involving a range of pro-inflammatory factors with important paracrine and autocrine effects on cell and tissue biology. While senescence has been mainly considered as a cause of diseases in the adulthood, it may be also implicated in some of the poor outcomes seen in patients with complex CHD. We propose that patients with CHD suffer from multiple repeated stress from an early stage of the life, which wear out homeostatic mechanisms and cause premature cardiac aging, with this term referring to the time-related irreversible deterioration of the organ physiological functions and integrity. In this review article, we gathered evidence from the literature indicating that growing up with CHD leads to abnormal inflammatory response, loss of proteostasis, and precocious age in cardiac cells. Novel research on this topic may inspire new therapies preventing HF in adult CHD patients.
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Affiliation(s)
| | | | | | - Paolo Madeddu
- Bristol Medical School, Faculty of Health Sciences, University of Bristol, Bristol, United Kingdom
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Liu H, Hu YJ, Zheng SQ, Chen T, Zeng ZH, Wu DD, Zhao S, Zeng B, Liu ZG, Shao YF. Effect of perfusate oxygenation on inflammatory response in congenital heart disease children from low versus high altitude. J Thorac Cardiovasc Surg 2021; 161:2180-2190. [DOI: 10.1016/j.jtcvs.2020.05.108] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/01/2019] [Revised: 05/13/2020] [Accepted: 05/31/2020] [Indexed: 10/24/2022]
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Xiong T, Pu L, Ma YF, Zhu YL, Cui X, Li H, Zhan X, Li YX. Safety of Normothermic Cardiopulmonary Bypass in Pediatric Cardiac Surgery: A System Review and Meta-Analysis. Front Pediatr 2021; 9:757551. [PMID: 34970516 PMCID: PMC8712704 DOI: 10.3389/fped.2021.757551] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2021] [Accepted: 11/24/2021] [Indexed: 01/14/2023] Open
Abstract
Objectives: Hypothermic cardiopulmonary bypass (HCPB) has been used successfully in cardiac surgery for more than half a century, although adverse effects have been reported with its use. Many studies on temperature management during CPB published to date have shown that normothermic CPB (NCPB) provides more benefits to children undergoing cardiac surgery. The present meta-analysis investigated the effect of NCPB on clinical outcomes based on results of randomized controlled trials and observational studies on pediatric cardiac surgery. Methods: Databases such as PubMed, EMBASE, Cochrane Central Register of Controlled Trials, and Clinical Trials.gov were searched from inception to May 2021 to identify relevant studies published in English. Results: The present meta-analysis included 13 studies characterizing a total of 837 pediatric patients. The random effects model exhibited that the NCPB group had reduced revision for postoperative bleeding [odds ratio (OR): 0.11; 95% confidence interval (CI): 0.01-0.89; I 2 = 0%, P = 0.04], serum lactate 2-4 h after CPB (mean difference: -0.60; 95% CI: -1.09 to -0.11; I 2 = 82%, P = 0.02), serum creatinemia 24 h after CPB (mean difference: -2.73; 95% CI: -5.06 to -0.39; I 2 = 83%, P = 0.02), serum creatinemia 48 h after CPB (mean difference: -2.08; 95% CI: -2.78 to -1.39; I 2 = 0%, P < 0.05), CPB time (mean difference: -19.10, 95% CI: -32.03 to -6.18; I 2 = 96%, P = 0.04), and major adverse events (OR: 0.37; 95% CI: 0.15-0.93; Z = 2.12, P = 0.03) after simple congenital surgery compared with the HCPB group. Conclusion: NCPB is as safe as HCPB in pediatric congenital heart surgery. Moreover, NCPB provides more advantages than HCPB in simple congenital heart surgery.
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Affiliation(s)
- Tao Xiong
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Lei Pu
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China.,Cardiovascular Surgery, Institution of Yunnan, Kunming, China
| | - Yuan-Feng Ma
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Yun-Long Zhu
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Xu Cui
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China.,Cardiovascular Surgery, Institution of Yunnan, Kunming, China
| | - Hua Li
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China.,Cardiovascular Surgery, Institution of Yunnan, Kunming, China
| | - Xu Zhan
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China.,Cardiovascular Surgery, Institution of Yunnan, Kunming, China
| | - Ya-Xiong Li
- Department of Cardiac Surgery, Kunming Yan'an Hospital, Affiliated Hospital of Kunming Medical University, Kunming, China.,Cardiovascular Surgery, Institution of Yunnan, Kunming, China
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Valente AS, Lustosa GP, Mota LAM, Lima A, Mesquita FAD, Gondim A, Rodrigues FA, Pompeu RG, Branco KC. Comparative Analysis of Myocardial Protection with HTK Solution and Hypothermic Hyperkalemic Blood Solution in the Correction of Acyanogenic Congenital Cardiopathies - A Randomized Study. Braz J Cardiovasc Surg 2019; 34:271-278. [PMID: 31310464 PMCID: PMC6629237 DOI: 10.21470/1678-9741-2018-0243] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
Abstract
OBJECTIVE The goal of the present study was to compare the myocardial protection obtained with histidine-tryptophan-ketoglutarate (HTK) cardioplegic solution (Custodiol®) and with intermittent hypothermic blood solution. METHODS Two homogenous groups of 25 children with acyanotic congenital heart disease who underwent total correction with mean aortic clamping time of 60 minutes were evaluated in this randomized study. Troponin and creatine kinase-MB curves, vasoactive-inotropic score, and left ventricular function were obtained by echocardiogram in each group. The values were correlated and presented through graphs and tables after adequate statistical treatment. RESULTS It was observed that values of all the studied variables varied over time, but there was no difference between the groups. CONCLUSION We conclude that in patients with acyanotic congenital cardiopathies submitted to total surgical correction, mean aortic clamping time around one hour, and cardiopulmonary bypass with moderate hypothermia, the HTK crystalloid cardioplegic solution offers the same myocardial protection as the cold-blood hyperkalemic cardioplegic solution analyzed, according to the variables considered in our study model.
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Affiliation(s)
- Acrisio Sales Valente
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil.,Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Gustavo Porto Lustosa
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Lia Alves Martins Mota
- Centro Universitário Unichristus Fortaleza Ceará Brazil Centro Universitário Unichristus, Fortaleza, Ceará, Brazil
| | - Adriano Lima
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fernando Antônio de Mesquita
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Aloísio Gondim
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Fábio Alércio Rodrigues
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Surgery Fortaleza Ceará Brazil Department of Surgery, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Ronald Guedes Pompeu
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
| | - Klébia Castelo Branco
- Hospital de Messejana Dr. Carlos Alberto Studart Gomes Department of Congenital Heart Disease Fortaleza Ceará Brazil Department of Congenital Heart Disease, Hospital de Messejana Dr. Carlos Alberto Studart Gomes, Fortaleza, Ceará, Brazil
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Hill GD, Ghanayem NS, Hraska V, Jacobsen RM, Mitchell ME, Woods RK, Ginde S. Variation in the use of Fontan fenestration in the current surgical era. PROGRESS IN PEDIATRIC CARDIOLOGY 2019. [DOI: 10.1016/j.ppedcard.2018.08.007] [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: 10/28/2022]
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10
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Raffaeli G, Ghirardello S, Passera S, Mosca F, Cavallaro G. Oxidative Stress and Neonatal Respiratory Extracorporeal Membrane Oxygenation. Front Physiol 2018; 9:1739. [PMID: 30564143 PMCID: PMC6288438 DOI: 10.3389/fphys.2018.01739] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2018] [Accepted: 11/19/2018] [Indexed: 12/16/2022] Open
Abstract
Oxidative stress is a frequent condition in critically ill patients, especially if exposed to extracorporeal circulation, and it is associated with worse outcomes and increased mortality. The inflammation triggered by the contact of blood with a non-endogenous surface, the use of high volumes of packed red blood cells and platelets transfusion, the risk of hyperoxia and the impairment of antioxidation systems contribute to the increase of reactive oxygen species and the imbalance of the redox system. This is responsible for the increased production of superoxide anion, hydrogen peroxide, hydroxyl radicals, and peroxynitrite resulting in increased lipid peroxidation, protein oxidation, and DNA damage. The understanding of the pathophysiologic mechanisms leading to redox imbalance would pave the way for the future development of preventive approaches. This review provides an overview of the clinical impact of the oxidative stress during neonatal extracorporeal support and concludes with a brief perspective on the current antioxidant strategies, with the aim to focus on the potential oxidative stress-mediated cell damage that has been implicated in both short and long-term outcomes.
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Affiliation(s)
- Genny Raffaeli
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Stefano Ghirardello
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Sofia Passera
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Fabio Mosca
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Clinical Sciences and Community Health, Università degli Studi di Milano, Milan, Italy
| | - Giacomo Cavallaro
- NICU, Fondazione IRCCS Ca’ Granda Ospedale Maggiore Policlinico, Milan, Italy
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11
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Caputo M, Pike K, Baos S, Sheehan K, Selway K, Ellis L, Stoica S, Parry A, Clayton G, Culliford L, Angelini GD, Pandey R, Rogers CA. Normothermic versus hypothermic cardiopulmonary bypass in low-risk paediatric heart surgery: a randomised controlled trial. Heart 2018; 105:455-464. [PMID: 30322847 PMCID: PMC6580777 DOI: 10.1136/heartjnl-2018-313567] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/08/2018] [Revised: 07/16/2018] [Accepted: 08/15/2018] [Indexed: 11/03/2022] Open
Abstract
OBJECTIVE To compare normothermic (35°C-36°C) versus hypothermic (28°C) cardiopulmonary bypass (CPB) in paediatric patients undergoing open heart surgery to test the hypothesis that normothermic CPB perfusion maintains the functional integrity of major organ systems leading to faster recovery. METHODS Two single-centre, randomised controlled trials (known as Thermic-1 and Thermic-2, respectively) were carried out to compare the effectiveness and acceptability of normothermic versus hypothermic CPB in children with congenital heart disease undergoing open heart surgery. In both studies, the co-primary clinical outcomes were duration of inotropic support, intubation time and postoperative hospital stay. RESULTS In total, 200 participants were recruited; 59 to the Thermic-1 study and 141 to the Thermic-2 study. 98 patients received normothermic CPB and 102 patients received hypothermic CPB. There were no significant differences between the treatment groups for any of the co-primary outcomes: inotrope duration HR=1.01, 95% CI (0.72 to 1.41); intubation time HR=1.14, 95% CI (0.86 to 1.51); postoperative hospital stay HR=1.06, 95% CI (0.80 to 1.40). Differences favouring normothermia were found in urea nitrogen at 2 days geometric mean ratio (GMR)=0.86 95% CI (0.77 to 0.97); serum creatinine at 3 days GMR=0.89, 95% CI (0.81 to 0.98); urinary albumin at 48 hours GMR=0.32, 95% CI (0.14 to 0.74) and neutrophil gelatinase-associated lipocalin at 4 hours GMR=0.47, 95% CI (0.22 to 1.02), but not at other postoperative time points. CONCLUSIONS Normothermic CPB is as safe and effective as hypothermic CPB and can be routinely adopted as a perfusion strategy in low-risk infants and children undergoing open heart surgery. TRIAL REGISTRATION NUMBER ISRCTN93129502.
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Affiliation(s)
- Massimo Caputo
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Katie Pike
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Sarah Baos
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Karen Sheehan
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Kathleen Selway
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Lucy Ellis
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Serban Stoica
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Andrew Parry
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gemma Clayton
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | - Lucy Culliford
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
| | | | - Ragini Pandey
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Chris A Rogers
- Clinical Trials and Evaluation Unit, Bristol Trials Centre, University of Bristol, Bristol, UK
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Raees MA, Bichell DP. Direct Splanchnic Perfusion Safely Avoids Deep Hypothermia. Semin Thorac Cardiovasc Surg Pediatr Card Surg Annu 2018; 21:28-32. [PMID: 29425522 DOI: 10.1053/j.pcsu.2017.11.003] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 11/03/2017] [Indexed: 11/11/2022]
Abstract
Deep hypothermia for the operative correction of congenital cardiac lesions protects hypoperfused organs, mostly because of its effect on lowering metabolic demand and oxygen requirement. Deleterious cerebral and extracranial side effects of deep hypothermia itself calls for a reexamination of the therapeutic value of hypothermia, and has led to the development of alternative perfusion strategies. Here we describe the potential advantages of milder hypothermia over deep hypothermia and our method of a practical and reproducible implementation of multisite perfusion under mild hypothermia (32°C).
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Affiliation(s)
- Muhammad Aanish Raees
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, TN, USA..
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, TN, USA
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13
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Corno AF, Bostock C, Chiles SD, Wright J, Tala MTJ, Mimic B, Cvetkovic M. Comparison of Early Outcomes for Normothermic and Hypothermic Cardiopulmonary Bypass in Children Undergoing Congenital Heart Surgery. Front Pediatr 2018; 6:219. [PMID: 30175089 PMCID: PMC6108179 DOI: 10.3389/fped.2018.00219] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 07/17/2018] [Indexed: 11/13/2022] Open
Abstract
Objective: Comparison of early outcomes of normothermic cardiopulmonary bypass (N-CPB, ≥35°C) with hypothermic cardiopulmonary bypass (H-CPB, 28-34°C) for congenital heart defects. Methods: Data from 99 patients <2 years operated with N-CPB (n = 48) or H-CPB (n = 51) were retrospectively reviewed: aortic X-clamping and CPB duration, vasoactive inotropic score (VIS), arterial lactate, pH and base excess, urine output, extubation, PICU stay, transfusion requirements, chest drain losses, costs of transfusions, and costs of PICU stay. Results: The two groups were homogeneous for diagnosis, risk factors, surgery and demographic variables: N-CPB age 7.7 ± 6.1 months, weight 6.2 ± 2.4 kg, and H-CPB age 6.6 ± 6.5 months, weight 6.1 ± 2.4 kg. There were no hospital deaths in either group. VIS in N-CPB was lower than H-CPB on PICU arrival (9.7 ± 5.9 vs. 13.4 ± 7.9, P < 0.005), after 4 h (7.0 ± 5.2 vs. 11.1 ± 7.3, P < 0.001) and 24 h (2.8 ± 3.6 vs. 5.6 ± 5.6, P < 0.003); arterial pH was better at PICU arrival (7.33 ± 0.09 vs. 7.30 ± 0.09, P = 0.046) after 4 h (7.35 ± 0.07 vs. 7.32 ± 0.07, P = 0.022) and after 24 h (7.37 ± 0.05 vs. 7.35 ± 0.05, P = 0.01). Extubation was earlier in N-CPB than in H-CPB (22 ± 27 vs. 48 ± 57 h, P = 0.003) as PICU discharge (61 ± 46 h vs. 87 ± 69 h, P = 0.021). Transfusion requirements in operating room were lower in N-CPB vs. H-CPB for RBC, FFP, cryoprecipitate, and platelets, while during the first 24 h in PICU were lower only for cryoprecipitate and platelets. Chest drain losses (mL/kg) on PICU arrival, after 4 and 24 h were lower with N-CPB vs. H-CPB (respectively 1.5 ± 1.4 vs. 2.5 ± 2.7, P = 0.013, 7.8 ± 6.0 vs. 10.9 ± 8.7, P = 0.025, and 23.0 ± 12.0 vs. 27.9 ± 15.2, P = 0.043). Tranexamic acid infusion was required in 7/48 (14.6%) patients with N-CPB vs. 18/51(= 35.3%) in H-CPB (P = 0.009). The average total costs/patient of blood and blood products (RBC, FFP, cryoprecipitate, platelets) were lower in N-CPB vs. H-CPB for both the first 24 h after surgery (£204 ± 169 vs. £306 ± 254, P = 0.011) as well as during the total duration of PICU stay (£239 ± 193 vs. £427 ± 337, P = 0.001). The average cost/patient/day of stay in PICU was lower in N-CPB than in H-CPB (£4,067 ± 3,067 vs. £5,800 ± 4,600, P = 0.021). Conclusions: N-CPB may reduce inotropic and respiratory support, shorten PICU stay, and decrease peri-operative transfusion requirements, with subsequent costs reduction, compared to H-CPB. Future studies are needed to validate and support wider use of N-CPB.
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Affiliation(s)
- Antonio F Corno
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom.,Cardiovascular Research Center, University of Leicester, Leicester, United Kingdom
| | - Claire Bostock
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Simon D Chiles
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Joanna Wright
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Maria-Teresa Jn Tala
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Branko Mimic
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
| | - Mirjana Cvetkovic
- East Midlands Congenital Heart Centre, University Hospitals of Leicester, Leicester, United Kingdom
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14
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Raees MA, Morgan CD, Pinto VL, Westrick AC, Shannon CN, Christian KG, Mettler BA, Bichell DP. Neonatal Aortic Arch Reconstruction With Direct Splanchnic Perfusion Avoids Deep Hypothermia. Ann Thorac Surg 2017; 104:2054-2063. [PMID: 28709662 DOI: 10.1016/j.athoracsur.2017.04.037] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2016] [Revised: 04/12/2017] [Accepted: 04/17/2017] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neonatal aortic arch reconstruction, typically performed with deep hypothermia and selective cerebral perfusion, leaves splanchnic organ protection dependent on hypothermia alone. A simplified method of direct in-field descending aortic perfusion during neonatal arch reconstruction permits the avoidance of deep hypothermia. We hypothesize that direct splanchnic perfusion at mild hypothermia provides improved or equivalent safety compared with deep hypothermia and may contribute to postoperative extracardiac organ recovery. METHODS Included were 138 biventricular patients aged younger than 90 days undergoing aortic arch reconstruction with cardiopulmonary bypass. Patients were grouped according to perfusion method A (selective cerebral perfusion with deep hyperthermia at 18° to 20°C) or method B (selective cerebral perfusion and splanchnic perfusion at 30° to 32°C). Patient characteristics and perioperative clinical and serologic data were analyzed. Significance was assigned for p of less than 0.05. RESULTS Of the 138 survivors, 63 underwent method A and 75 underwent method B. The median age at operation was 8.5 days (range, 6 to 15 days), and median weight was 3.2 kg (range, 2.8 to 3.73 kg), with no significant differences between groups. Cardiopulmonary bypass times were comparable between the two perfusion methods (p = 0.255) as were the ascending aortic cross-clamp times (p = 0.737). The postoperative glomerular filtration rate was significantly different between our groups (p = 0.028 to 0.044), with method B achieving a higher glomerular filtration rate. No significant differences were seen in ventilator time, postoperative length of stay, fractional increase of postoperative serum creatinine over preoperative serum creatinine, and postoperative lactate. CONCLUSIONS A simplified method of direct splanchnic perfusion during neonatal aortic arch reconstruction avoids the use of deep hypothermia and provides renal protection at least as effective as deep hypothermia.
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Affiliation(s)
- Muhammad Aanish Raees
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, Tennessee
| | | | - Venessa L Pinto
- Critical Care Section, Department of Pediatrics, Baylor College of Medicine, Houston, Texas
| | - Ashly C Westrick
- Department of Neurological Surgery, Vanderbilt School of Medicine, Children's Hospital, Nashville, Tennessee
| | - Chevis N Shannon
- Department of Neurological Surgery, Vanderbilt School of Medicine, Children's Hospital, Nashville, Tennessee
| | - Karla G Christian
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, Tennessee
| | - Bret A Mettler
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, Tennessee
| | - David P Bichell
- Division of Pediatric Cardiac Surgery, Vanderbilt University Medical Center, Children's Hospital, Nashville, Tennessee.
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15
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Dittrich S. Patienten nach biventrikulärer Korrektur eines angeborenen Herzfehlers. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2016. [DOI: 10.1007/s00398-016-0107-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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Durandy Y. Rationale for Implementation of Warm Cardiac Surgery in Pediatrics. Front Pediatr 2016; 4:43. [PMID: 27200324 PMCID: PMC4858514 DOI: 10.3389/fped.2016.00043] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 04/21/2016] [Indexed: 02/03/2023] Open
Abstract
Cardiac surgery was developed thanks to the introduction of hypothermia and cardiopulmonary bypass in the early 1950s. The deep hypothermia protective effect has been essential to circulatory arrest complex cases repair. During the early times of open-heart surgery, a major concern was to decrease mortality and to improve short-term outcomes. Both mortality and morbidity dramatically decreased over a few decades. As a consequence, the drawbacks of deep hypothermia, with or without circulatory arrest, became more and more apparent. The limitation of hypothermia was particularly evident for the brain and regional perfusion was introduced as a response to this problem. Despite a gain in popularity, the results of regional perfusion were not fully convincing. In the 1990s, warm surgery was introduced in adults and proved to be safe and reliable. This option eliminates the deleterious effect of ischemia-reperfusion injuries through a continuous, systemic coronary perfusion with warm oxygenated blood. Intermittent warm blood cardioplegia was introduced later, with impressive results. We were convinced by the easiness, safety, and efficiency of warm surgery and shifted to warm pediatric surgery in a two-step program. This article outlines the limitations of hypothermic protection and the basic reasons that led us to implement pediatric warm surgery. After tens of thousands of cases performed across several centers, this reproducible technique proved a valuable alternative to hypothermic surgery.
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Affiliation(s)
- Yves Durandy
- Perfusion Department, CCML, Le Plessis Robinson, France
- Intensive Care Department, CCML, Le Plessis Robinson, France
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17
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Cardiopulmonary bypass in the pediatric population. Best Pract Res Clin Anaesthesiol 2015; 29:241-56. [DOI: 10.1016/j.bpa.2015.03.006] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Revised: 02/24/2015] [Accepted: 03/20/2015] [Indexed: 11/23/2022]
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Baos S, Sheehan K, Culliford L, Pike K, Ellis L, Parry AJ, Stoica S, Ghorbel MT, Caputo M, Rogers CA. Normothermic versus hypothermic cardiopulmonary bypass in children undergoing open heart surgery (thermic-2): study protocol for a randomized controlled trial. JMIR Res Protoc 2015; 4:e59. [PMID: 26007621 PMCID: PMC4460263 DOI: 10.2196/resprot.4338] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 03/04/2015] [Indexed: 11/13/2022] Open
Abstract
Background During open heart surgery, patients are connected to a heart-lung bypass machine that pumps blood around the body (“perfusion”) while the heart is stopped. Typically the blood is cooled during this procedure (“hypothermia”) and warmed to normal body temperature once the operation has been completed. The main rationale for “whole body cooling” is to protect organs such as the brain, kidneys, lungs, and heart from injury during bypass by reducing the body’s metabolic rate and decreasing oxygen consumption. However, hypothermic perfusion also has disadvantages that can contribute toward an extended postoperative hospital stay. Research in adults and small randomized controlled trials in children suggest some benefits to keeping the blood at normal body temperature throughout surgery (“normothermia”). However, the two techniques have not been extensively compared in children. Objective The Thermic-2 study will test the hypothesis that the whole body inflammatory response to the nonphysiological bypass and its detrimental effects on different organ functions may be attenuated by maintaining the body at 35°C-37°C (normothermic) rather than 28°C (hypothermic) during pediatric complex open heart surgery. Methods This is a single-center, randomized controlled trial comparing the effectiveness and acceptability of normothermic versus hypothermic bypass in 141 children with congenital heart disease undergoing open heart surgery. Children having scheduled surgery to repair a heart defect not requiring deep hypothermic circulatory arrest represent the target study population. The co-primary clinical outcomes are duration of inotropic support, intubation time, and postoperative hospital stay. Secondary outcomes are in-hospital mortality and morbidity, blood loss and transfusion requirements, pre- and post-operative echocardiographic findings, routine blood gas and blood test results, renal function, cerebral function, regional oxygen saturation of blood in the cerebral cortex, assessment of genomic expression changes in cardiac tissue biopsies, and neuropsychological development. Results A total of 141 patients have been successfully randomized over 2 years and 10 months and are now being followed-up for 1 year. Results will be published in 2015. Conclusions We believe this to be the first large pragmatic study comparing clinical outcomes during normothermic versus hypothermic bypass in complex open heart surgery in children. It is expected that this work will provide important information to improve strategies of cardiopulmonary bypass perfusion and therefore decrease the inevitable organ damage that occurs during nonphysiological body perfusion. Trial Registration ISRCTN Registry: ISRCTN93129502, http://www.isrctn.com/ISRCTN93129502 (Archived by WebCitation at http://www.webcitation.org/6Yf5VSyyG).
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Affiliation(s)
- Sarah Baos
- Clinical Trials and Evaluation Unit, School of Clinical Sciences, University of Bristol, Bristol, United Kingdom
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19
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Fiorentino F, Angelini GD, Suleiman MS, Rahman A, Anderson J, Bryan AJ, Culliford LA, Moscarelli M, Punjabi PP, Reeves BC. Investigating the effect of remote ischaemic preconditioning on biomarkers of stress and injury-related signalling in patients having isolated coronary artery bypass grafting or aortic valve replacement using cardiopulmonary bypass: study protocol for a randomized controlled trial. Trials 2015; 16:181. [PMID: 25899533 PMCID: PMC4425928 DOI: 10.1186/s13063-015-0696-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2014] [Accepted: 03/30/2015] [Indexed: 01/14/2023] Open
Abstract
Background Ischaemia-reperfusion injury occurs during heart surgery that uses cardiopulmonary bypass (CPB) and cardioplegic arrest. It is hypothesised that remote ischaemic preconditioning (RIPC) protects the heart against such injury. Despite the numerous studies investigating the protective effects of RIPC, there is still uncertainty about the interpretation of the findings as well as conflicting results between studies. The objective of this trial is to investigate the cardioprotective effect of RIPC in patients having coronary artery bypass grafting (CABG) or aortic valve replacement surgery. This will be achieved by estimating the effect of the intervention in the two groups of pathologies and by investigating the signalling mechanisms that may underpin the cardioprotective effect. Methods/Design A two-centre randomised controlled trial will be used to investigate the effects of RIPC in two pathologies: patients having isolated CABG and those having aortic valve replacement surgery (AVR) with CPB. Participants will be randomised to RIPC or control (sham RIPC), stratified by surgical stratum. The intervention will be delivered by a research nurse. Data will be collected by a research nurse blinded to the intervention. The patient and the theatre staff are also blinded to the allocation. Markers of myocardial injury and inflammation will be measured in myocardial biopsies and in blood samples at different times. Discussion This trial is designed to investigate whether RIPC will reduce myocardial injury and inflammation following heart surgery and whether there is a difference in effect between participants having CABG or AVR. This trial is a unique opportunity to study the mechanisms associated with RIPC using human myocardial tissue and blood, and to relate these to the extent of myocardial injury/protection. Trial registration Current Controlled Trials ISRCTN33084113 (25 March 2013). Electronic supplementary material The online version of this article (doi:10.1186/s13063-015-0696-z) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Francesca Fiorentino
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Gianni D Angelini
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK. .,Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - M-Saadeh Suleiman
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Alima Rahman
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Jon Anderson
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Alan J Bryan
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Lucy A Culliford
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
| | - Marco Moscarelli
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Prakash P Punjabi
- National Heart and Lung Institute, Cardiothoracic Surgery Department, Imperial College London, Du Cane Road, W12 0NN, London, UK.
| | - Barnaby C Reeves
- Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Marlborough Street, BS2 8HW, Bristol, UK.
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Xiong Y, Sun Y, Ji B, Liu J, Wang G, Zheng Z. Systematic Review and Meta-Analysis of benefits and risks between normothermia and hypothermia during cardiopulmonary bypass in pediatric cardiac surgery. Paediatr Anaesth 2015; 25:135-42. [PMID: 25331483 DOI: 10.1111/pan.12560] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/26/2014] [Indexed: 11/29/2022]
Abstract
BACKGROUND The controversy over the benefits between normothermic and hypothermic cardiopulmonary bypass (CPB) for children is still uncertain. The purpose of this systematic review and meta-analysis is to investigate the benefits and risks of normothermia comparing with hypothermia in pediatric cardiac surgery by randomized controlled trials. METHODS Pubmed, Embase, and the Cochrane Central Register of Controlled Trials were searched for studies reported in English up to September 28, 2013. Eligible studies were those in which investigators enrolled pediatric patients, who had cardiac surgery, randomized them to normothermic or hypothermic CPB. We prespecified the use of random-effects models to calculate risk ratios and 95% CIs for binary variables, weighted mean difference (WMD) or standard mean difference and 95% CIs for continuous variables. We assessed heterogeneity using I(2). When heterogeneity was absent (I(2) = 0%), we used fixed-effects models. The endpoints were serum lactate, serum creatinine, duration of clamp, and duration of CPB in pediatrics who had cardiac surgery in normothermic CPB compared with those in hypothermic CPB. RESULTS The initial search strategy identified 3910 citations, of which 10 trials compared pediatrics and seven trails were eligible. These seven trials included 419 participants from seven countries. The serum lactate and the serum creatinine had three time points. The outcomes had no different between normothermic group and hypothermic group. Duration of clamp (WMD = -10.793, 95% CI -28.89, 7.304; P = 0.242; I(2) = 86.6%; 204 patients, three trials) and duration of CPB (WMD = -41.780, 95% CI -89.523, 5.963; P = 0.086; I(2) = 95.6%; 199 patients, three trials) also had no significant differences between two groups. CONCLUSION Normothermic CPB is as safe as hypothermic CPB in children requiring correction of simple congenital cardiac defects.
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Affiliation(s)
- Yaoyao Xiong
- Department of Cardiopulmonary Bypass, Cardiovascular Institute & Fuwai Heart Hospital, PUMC & CAMS, Beijing, China; Department of Cardiopulmonary Bypass, The Second XiangYa Hospital of Central South University, ChangSha, China
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Shamsuddin AM, Nikman AM, Ali S, Zain MRM, Wong AR, Corno AF. Normothermia for pediatric and congenital heart surgery: an expanded horizon. Front Pediatr 2015; 3:23. [PMID: 25973411 PMCID: PMC4411990 DOI: 10.3389/fped.2015.00023] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2015] [Accepted: 03/14/2015] [Indexed: 12/01/2022] Open
Abstract
Cardiopulmonary bypass (CPB) in pediatric cardiac surgery is generally performed with hypothermia, flow reduction and hemodilution. From October 2013 to December 2014, 55 patients, median age 6 years (range 2 months to 52 years), median weight 18.5 kg (range 3.2-57 kg), underwent surgery with normothermic high flow CPB in a new unit. There were no early or late deaths. Fifty patients (90.9%) were extubated within 3 h, 3 (5.5%) within 24 h, and 2 (3.6%) within 48 h. Twenty-four patients (43.6%) did not require inotropic support, 31 (56.4%) received dopamine or dobutamine: 21 ≤5 mcg/kg/min, 8 5-10 mcg/kg/min, and 2 >10 mcg/kg/min. Two patients (6.5%) required noradrenaline 0.05-0.1 mcg/kg/min. On arrival to ICU and after 3 and 6 h and 8:00 a.m. the next morning, mean lactate levels were 1.9 ± 09, 2.0 ± 1.2, 1.6 ± 0.8, and 1.4 ± 0.7 mmol/L (0.6-5.2 mmol/L), respectively. From arrival to ICU to 8:00 a.m. the next morning mean urine output was 3.8 ± 1.5 mL/kg/h (0.7-7.6 mL/kg/h), and mean chest drainage was 0.6 ± 0.5 mL/kg/h (0.1-2.3 mL/kg/h). Mean ICU and hospital stay were 2.7 ± 1.4 days (2-8 days) and 7.2 ± 2.2 days (4-15 days), respectively. In conclusion, normothermic high flow CPB allows pediatric and congenital heart surgery with favorable outcomes even in a new unit. The immediate post-operative period is characterized by low requirement for inotropic and respiratory support, low lactate production, adequate urine output, minimal drainage from the chest drains, short ICU, and hospital stay.
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Affiliation(s)
- Ahmad Mahir Shamsuddin
- Pediatric and Congenital Cardiac Surgery Unit, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Ahmad Mohd Nikman
- Department of Anesthesia, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Saedah Ali
- Department of Anesthesia, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Mohd Rizal Mohd Zain
- Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
| | - Abdul Rahim Wong
- Pediatric Cardiology, Hospital Raja Perempuan Zainab II , Kota Bharu, Kelantan , Malaysia
| | - Antonio Francesco Corno
- Pediatric and Congenital Cardiac Surgery Unit, Department of Surgery, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia ; Department of Pediatrics, School of Medical Sciences, Universiti Sains Malaysia , Kubang Kerian, Kelantan , Malaysia
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Stevanovic A, Coburn M, Menon A, Rossaint R, Heyland D, Schälte G, Werker T, Wonisch W, Kiehntopf M, Goetzenich A, Rex S, Stoppe C. The importance of intraoperative selenium blood levels on organ dysfunction in patients undergoing off-pump cardiac surgery: a randomised controlled trial. PLoS One 2014; 9:e104222. [PMID: 25118980 PMCID: PMC4132095 DOI: 10.1371/journal.pone.0104222] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2014] [Accepted: 06/21/2014] [Indexed: 12/14/2022] Open
Abstract
INTRODUCTION Cardiac surgery is accompanied by an increase of oxidative stress, a significantly reduced antioxidant (AOX) capacity, postoperative inflammation, all of which may promote the development of organ dysfunction and an increase in mortality. Selenium is an essential co-factor of various antioxidant enzymes. We hypothesized a less pronounced decrease of circulating selenium levels in patients undergoing off-pump coronary artery bypass (OPCAB) surgery due to less intraoperative oxidative stress. METHODS In this prospective randomised, interventional trial, 40 patients scheduled for elective coronary artery bypass grafting were randomly assigned to undergo either on-pump or OPCAB-surgery, if both techniques were feasible for the single patient. Clinical data, myocardial damage assessed by myocard specific creatine kinase isoenzyme (CK-MB), circulating whole blood levels of selenium, oxidative stress assessed by asymmetric dimethylarginine (ADMA) levels, antioxidant capacity determined by glutathionperoxidase (GPx) levels and perioperative inflammation represented by interleukin-6 (IL-6) levels were measured at predefined perioperative time points. RESULTS At end of surgery, both groups showed a comparable decrease of circulating selenium concentrations. Likewise, levels of oxidative stress and IL-6 were comparable in both groups. Selenium levels correlated with antioxidant capacity (GPx: r = 0.720; p<0.001) and showed a negative correlation to myocardial damage (CK-MB: r = -0.571, p<0.001). Low postoperative selenium levels had a high predictive value for the occurrence of any postoperative complication. CONCLUSIONS OPCAB surgery is not associated with less oxidative stress and a better preservation of the circulating selenium pool than on-pump surgery. Low postoperative selenium levels are predictive for the development of complications. TRIAL REGISTRATION ClinicalTrials.gov NCT01409057.
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Affiliation(s)
- Ana Stevanovic
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Mark Coburn
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Ares Menon
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital, RWTH Aachen, Aachen, Germany
| | - Rolf Rossaint
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Daren Heyland
- Kingston General Hospital, Kingston, Ontario, Canada
| | - Gereon Schälte
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Thilo Werker
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
| | - Willibald Wonisch
- Institute of Physiological Chemistry, Centre for Physiological Medicine, Medical University of Graz, Graz, Austria
- Clinical Institute of Medical and Chemical Laboratory Diagnostics, Medical University of Graz, Graz, Austria
| | - Michael Kiehntopf
- Institute of Clinical Chemistry, Friedrich-Schiller University, Jena, Germany
| | - Andreas Goetzenich
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital, RWTH Aachen, Aachen, Germany
| | - Steffen Rex
- Department of Anaesthesiology and Department of Cardiovascular Sciences, University Hospitals Leuven, KU Leuven, Belgium
| | - Christian Stoppe
- Department of Anaesthesiology, University Hospital of the RWTH Aachen, Aachen, Germany
- Department of Thoracic, Cardiac and Vascular Surgery, University Hospital, RWTH Aachen, Aachen, Germany
- Institute of Biochemistry and Molecular Cell Biology, RWTH Aachen University, Aachen, Germany
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Intestinal epithelial apoptosis initiates gut mucosal injury during extracorporeal membrane oxygenation in the newborn piglet. J Transl Med 2014; 94:150-60. [PMID: 24365747 PMCID: PMC3946757 DOI: 10.1038/labinvest.2013.149] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/09/2013] [Revised: 11/08/2013] [Accepted: 11/09/2013] [Indexed: 01/24/2023] Open
Abstract
Neonates and young infants exposed to extracorporeal circulation during extracorporeal membrane oxygenation (ECMO) and cardiopulmonary bypass are at risk of developing a systemic inflammatory response syndrome with multi-organ dysfunction. We used a piglet model of ECMO to investigate the hypothesis that epithelial apoptosis is an early event that precedes villous damage during ECMO-related bowel injury. Healthy 3-week-old piglets were subjected to ECMO for up to 8 h. Epithelial apoptosis was measured in histopathological analysis, nuclear imaging, and terminal deoxynucleotidyl transferase dUTP nick end labeling. Plasma intestinal fatty acid-binding protein (I-FABP) levels were measured by enzyme immunoassay. Intestinal mast cells were isolated by fluorescence-assisted cell sorting. Cleaved caspase-8, caspase-9, phospho-p38 MAPK, and fas ligand expression were investigated by immunohistochemistry, western blots, and reverse transcriptase-quantitative PCR. Piglet ECMO was associated with increased gut epithelial apoptosis. Extensive apoptotic changes were noted on villus tips and in scattered crypt cells after 2 h of ECMO. After 8 h, the villi were denuded and apoptotic changes were evident in a majority of crypt cells. Increased circulating I-FABP levels, a marker of gut epithelial injury, showed that epithelial injury occurred during ECMO. We detected increased cleaved caspase-8, but not cleaved caspase-9, in epithelial cells indicating that the extrinsic apoptotic pathway was active. ECMO was associated with increased fas ligand expression in intestinal mast cells, which was induced through activation of the p38 mitogen-activated protein kinase. We conclude that epithelial apoptosis is an early event that initiates gut mucosal injury in a piglet model of ECMO.
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Lundemoen S, Kvalheim VL, Mongstad A, Andersen KS, Grong K, Husby P. Microvascular fluid exchange during pulsatile cardiopulmonary bypass perfusion with the combined use of a nonpulsatile pump and intra-aortic balloon pump. J Thorac Cardiovasc Surg 2013; 146:1275-82. [DOI: 10.1016/j.jtcvs.2013.06.002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2012] [Revised: 04/29/2013] [Accepted: 06/14/2013] [Indexed: 11/29/2022]
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Hammel JM, Deptula JJ, Siecke R, Abdullah I, Duncan KF. Descending Aortic and Innominate Artery Cannulation for Aortic Arch Repair With Mildly Hypothermic Continuous Cardiopulmonary Bypass in Infants and Children. World J Pediatr Congenit Heart Surg 2013; 4:418-21. [DOI: 10.1177/2150135113492346] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
A technique is described for exposure of the descending aorta, allowing separate arterial cannulation for perfusion of the upper and lower body during reconstruction of the aortic arch, maintaining continuous full-flow cardiopulmonary bypass to the entire body. This single technique is applicable to all aortic arch pathologies and allows an unhurried aortic reconstruction in an unobstructed field.
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Affiliation(s)
- James M. Hammel
- Department of Surgery, Section of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Children’s Hospital and Medical Center, Omaha, NE, USA
| | | | | | - Ibrahim Abdullah
- Department of Surgery, Section of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Children’s Hospital and Medical Center, Omaha, NE, USA
| | - Kim F. Duncan
- Department of Surgery, Section of Cardiothoracic Surgery, University of Nebraska Medical Center, Omaha, NE, USA
- Children’s Hospital and Medical Center, Omaha, NE, USA
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Hall R. Identification of Inflammatory Mediators and Their Modulation by Strategies for the Management of the Systemic Inflammatory Response During Cardiac Surgery. J Cardiothorac Vasc Anesth 2013; 27:983-1033. [DOI: 10.1053/j.jvca.2012.09.013] [Citation(s) in RCA: 56] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2012] [Indexed: 12/21/2022]
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Tirilomis T, Zwiehoff JM, Waldmann-Beushausen R, Schneider S, Schoendube FA. The effect of cardiopulmonary bypass and hypothermic circulatory arrest on hepatic histology in newborn animals: an experimental study. Artif Organs 2013; 37:E35-9. [PMID: 23305585 DOI: 10.1111/j.1525-1594.2012.01577.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Still little is known about the effect of cardiac surgery on neonatal hepatic tissue. We examined the effect of cardiopulmonary bypass (CPB) and the effect of deep hypothermic circulatory arrest (DHCA) on neonatal hepatic tissue. Liver biopsies of neonatal piglets were taken after CPB (n = 4), after DHCA (n = 5), and after surgery without CPB (non-CPB; n = 3). Additionally, findings were compared to those of control piglets (n = 9). The liver specimens were fixed, stained with hematoxylin and eosin, and scored regarding inflammatory reaction, hepatocellular edema, and apoptosis. Inflammation score of treated groups was higher than in control; CPB 2.5 ± 0.5, DHCA 1.6 ± 0.4, non-CPB 1.2 ± 0.6, control 0.4 ± 0.3 (P < 0.001 CPB and DHCA vs. control; P < 0.05 non-CPB vs. control). Hepatic cell edema was more evident after DHCA (score 2.0 ± 0.4 vs. 0.2 ± 0.3 in control and 0.6 ± 0.5 after CPB; P < 0.001 and P < 0.05, respectively). The highest apoptotic cell count was in the non-CPB group (22.3 ± 6.3 vs. 11.4 ± 3.6 in control and 8.9 ± 5.4 after CPB; P < 0.05). The present study showed that (i) surgical trauma induces hepatic cell apoptosis; (ii) CPB increases hepatic inflammatory reaction; and (iii) DHCA amplifies hepatic cell edema.
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Affiliation(s)
- Theodor Tirilomis
- Department for Thoracic, Cardiac, and Vascular Surgery, University of Goettingen, Goettingen, Germany.
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Bojan M, Peperstraete H, Lilot M, Tourneur L, Vouhé P, Pouard P. Cold Histidine-Tryptophan-Ketoglutarate Solution and Repeated Oxygenated Warm Blood Cardioplegia in Neonates With Arterial Switch Operation. Ann Thorac Surg 2013; 95:1390-6. [DOI: 10.1016/j.athoracsur.2012.12.025] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/04/2012] [Revised: 12/09/2012] [Accepted: 12/11/2012] [Indexed: 11/30/2022]
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Wollersheim S, Fedarava K, Huebler M, Schneiderhan-Marra N, Berger F, Miera O, Schmitt KR. Establishment of a coculture model for studying inflammation after pediatric cardiopulmonary bypass: from bench to bedside. J Interferon Cytokine Res 2012; 32:269-76. [PMID: 22540942 DOI: 10.1089/jir.2011.0096] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Cardiopulmonary bypass (CPB) has been known to induce an inflammatory response that is influenced by various factors. Hypothermia is supposed to reduce inflammation after CPB. We developed an in vitro coculture model for CPB and compared the effects of hypothermia on the inflammatory response in the coculture model with results from a clinical prospective randomized trial. The coculture model consisted of endothelial cells and monocytes. Cells were stimulated with tumor necrosis factor (TNF)-α and exposed to deep hypothermia (20°C) or normothermia (37°C). In the clinical trial, 20 patients undergoing CPB for ventricular septum defect receive either normothermic (37°C) or mild hypothermic (32°C) CPB. We observed a significant interleukin (IL)-6 and IL-8 release in the coculture model 2 and 24 h after the experimental start. In the clinical trial, cytokines were significantly increased directly after weaning from CPB and remained elevated until 24 h. IL-8 and IL-6 secretions were similar in the hypothermic and normothermic group of the coculture model and the patients after 24 h. These results demonstrate that the inflammatory reaction observed in our coculture model is comparable with the cytokine increase in the blood of children undergoing CPB. Our coculture model could be useful for studies on the mechanisms of CPB-induced inflammation.
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Affiliation(s)
- Sonja Wollersheim
- Department of Congenital Heart Disease/Pediatric Cardiology, Deutsches Herzzentrum Berlin, Berlin, Germany
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Caputo M, Patel N, Angelini GD, de Siena P, Stoica S, Parry AJ, Rogers CA. Effect of normothermic cardiopulmonary bypass on renal injury in pediatric cardiac surgery: A randomized controlled trial. J Thorac Cardiovasc Surg 2011; 142:1114-21, 1121.e1-2. [DOI: 10.1016/j.jtcvs.2011.08.008] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2011] [Revised: 07/13/2011] [Accepted: 08/04/2011] [Indexed: 11/29/2022]
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Ali Aydemir N, Harmandar B, Karaci AR, Erdem A, Yurtseven N, Sasmazel A, Yekeler I. Randomized comparison between mild and moderate hypothermic cardiopulmonary bypass for neonatal arterial switch operation. Eur J Cardiothorac Surg 2011; 41:581-6. [PMID: 22011772 DOI: 10.1093/ejcts/ezr002] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES To compare neonates receiving arterial switch operation (ASO) either with mild or moderate hypothermic cardiopulmonary bypass. METHODS Forty neonates undergoing ASO were randomized to receive either mild (Mi > 32 °C, n = 20) or moderate (Mo > 26 °C, n = 20) hypothermic cardiopulmonary bypass (CPB) between April 2007 and June 2010. All patients were diagnosed with simple transposition of the great arteries. Mean age (Mi: 8.32 ± 4.5 days, Mo: 7.54 ± 5.0 days, P = 0.21) and body weight were similar in both groups (Mi: 3.64 ± 0.91 kg, Mo: 3.73 ± 0.84 kg, P = 0.14). Follow-up was 3.1 ± 2.5 years for all patients. RESULTS Lowest perioperative rectal temperature was 33.5 ± 1.4 °C (Mi) versus 28.2 ± 2.1 °C (Mo) (P < 0.001). All patients safely weaned from CPB required lower doses of dopamine (Mi: 5.1 ± 2.4 µg/kg min, Mo: 6.5 ± 2.1 µ/kg min, P = 0.04), dobutamine (Mi: 7.2 ± 2.5 µg/kg min, Mo: 8.6 ± 2.4 µ/kg min, P = 0.04) and adrenalin (Mi: 0.02 ± 0.02 µg/kg min, Mo: 0.05 ± 0.03 µ/kg min, P = 0.03) in mild hypothermia group. Intraoperative blood transfusion (Mi: 190 ± 58 ml, Mo: 230 ± 24 ml, P = 0.03) and postoperative lactate levels (Mi: 2.7 ± 0.9 mmol/l, Mo: 3.1 ± 2.2 mmol/l, P = 0.02) were lower under mild hypothermia. Secondary chest closure was performed in 30% (Mi) versus 35% (Mo) (P = 0.65). Duration of inotropic support (Mi: 7 (4-11) days, Mo: 11 (7-15) days, P = 0.03), time to extubation (Mi: 108 (88-128) h, Mo: 128 (102-210) h, P = 0.04), lengths of intensive care unit (ICU) stay (Mi: 9 (5-14) days, Mo: 12 (10-18) days, P = 0.04) and hospital stay (Mi: 19 (10-29) days, Mo: 23 (15-37) days, P = 0.04) were significantly shorter under mild hypothermia. Two-year freedom from reoperation was 100% for both the groups. CONCLUSIONS The ASO under mild hypothermia seemed to be beneficial for pulmonary recovery, need for inotropic support and length of ICU and hospital stay. No worse early- or intermediate-term effects of mild hypothermia were found.
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Affiliation(s)
- Numan Ali Aydemir
- Department of Pediatric Cardiac Surgery, Dr. Siyami Ersek Thoracic and Cardiovascular Training and Research Hospital, Istanbul, Turkey
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Ly M, Roubertie F, Belli E, Grollmuss O, Bui MT, Roussin R, Lebret E, Capderou A, Serraf A. Continuous Cerebral Perfusion for Aortic Arch Repair: Hypothermia Versus Normothermia. Ann Thorac Surg 2011; 92:942-8; discussion 948. [PMID: 21704296 DOI: 10.1016/j.athoracsur.2011.03.006] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2010] [Revised: 02/28/2011] [Accepted: 03/07/2011] [Indexed: 11/29/2022]
Affiliation(s)
- Mohamed Ly
- Department of Congenital Heart Surgery, Marie Lannelongue Hospital, University Paris-Sud, Le Plessis-Robinson, France.
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Stocker CF, Shekerdemian LS, Horton SB, Lee KJ, Eyres R, D’Udekem Y, Brizard CP. The influence of bypass temperature on the systemic inflammatory response and organ injury after pediatric open surgery: A randomized trial. J Thorac Cardiovasc Surg 2011; 142:174-80. [DOI: 10.1016/j.jtcvs.2011.01.059] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/06/2009] [Revised: 10/22/2010] [Accepted: 01/24/2011] [Indexed: 10/18/2022]
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Abstract
Cold pediatric cardiac surgery has been a dogma for 50 years. However, the beneficial effects of cold perfusion are counterbalanced by the drawbacks of hypothermia. Thus, we propose a major paradigm shift from hypothermic surgery to warm perfusion and intermittent warm blood cardioplegia. This approach gives satisfactory results even with prolonged aortic crossclamp times. The major advantages are reduced time to extubation and shorter intensive care unit stay. Warm pediatric surgery is an anecdotal phenomenon no more; over 10,000 procedures have been carried out in Europe. All types of cardiopathy have been treated, including arterial switch, total pulmonary anomalous venous return, interruption of the aortic arch, and hypoplastic left heart syndrome. Once surgeons decide to shift from hypothermia to normothermia, they never decide to shift back to hypothermia. This fact is evidence of the satisfactory clinical outcome obtained with this technique. The technique and the composition of microplegia is identical in all European centers, the only variable factor being the interval between microplegia injections, which varies from 10 to 25 min. We hope that the increasing interest in pediatric warm surgery will hearten new candidates.
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Affiliation(s)
- Yves Durandy
- Jacques Cartier Private Hospital, Massy, France.
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Normothermic CPB in congenital heart disease—an experience of 653 cases. Indian J Thorac Cardiovasc Surg 2010. [DOI: 10.1007/s12055-010-0048-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022] Open
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Ranucci M, Carlucci C, Isgrò G, Brozzi S, Boncilli A, Costa E, Frigiola A. Hypothermic cardiopulmonary bypass as a determinant of late thrombocytopenia following cardiac operations in pediatric patients. Acta Anaesthesiol Scand 2009; 53:1060-7. [PMID: 19496765 DOI: 10.1111/j.1399-6576.2009.02010.x] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Abstract
BACKGROUND Thrombocytopenia after cardiac operations is a common event in both adult and pediatric patients. Late thrombocytopenia (LTCP) is a less common event that is still without a well-recognized cause. This study explores the role of heparin-induced thrombocytopenia (HIT) and other factors (complexity of the operation, temperature management, and drug use) in determining LTCP. METHODS We conducted an observational study of 63 consecutive patients aged <36 months operated with or without cardiopulmonary bypass (CPB). LTCP was defined as a platelet count <100,000 cells/microl or <50% of the pre-operative count at any point in time between post-operative days 5 and 10. A diagnostic test for heparin-platelet factor 4 (PF4) antibodies was performed in patients with LTCP. Other pre- and post-operative factors were investigated for their association with LTCP. RESULTS LTCP occurred in 15 (24%) patients. No patient had positive heparin-PF4 antibodies. The lowest temperature on CPB was an independent predictor of LTCP, with a cut-off value at 29 degrees C (sensitivity 80%, specificity 70%). Other factors associated with LTCP were prolonged post-operative use of unfractionated heparin and milrinone. LTCP was associated with increased post-operative morbidity. CONCLUSION LTCP was related to a combination of factors (operation severity, degree of hypothermia during CPB, prolonged use of unfractionated heparin, and milrinone). The individual contribution of each factor seems difficult to establish. However, the degree of hypothermia during CPB and drug-associated effects were identified. HIT could be excluded in all cases.
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Affiliation(s)
- M Ranucci
- Department of Cardiothoracic-vascular Anesthesia and Intensive Care, IRCCS Policlinico S.Donato, Milan, Italy.
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Caputo M, Mokhtari A, Rogers CA, Panayiotou N, Chen Q, Ghorbel MT, Angelini GD, Parry AJ. The effects of normoxic versus hyperoxic cardiopulmonary bypass on oxidative stress and inflammatory response in cyanotic pediatric patients undergoing open cardiac surgery: a randomized controlled trial. J Thorac Cardiovasc Surg 2009; 138:206-14. [PMID: 19577081 DOI: 10.1016/j.jtcvs.2008.12.028] [Citation(s) in RCA: 60] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2008] [Revised: 11/21/2008] [Accepted: 12/25/2008] [Indexed: 11/17/2022]
Abstract
OBJECTIVES This study investigates the effects of controlled reoxygenation cardiopulmonary bypass on oxidative stress, inflammatory response, and organ function in children undergoing repair of cyanotic congenital heart defects. METHODS Sixty-seven cyanotic patients (median age 15 months, interquartile range 6-49 months) undergoing corrective cardiac surgery were randomized to receive either controlled normoxic (50-0 mm Hg; n = 35) or hyperoxic (150-180 mm Hg; n = 32) cardiopulmonary bypass. Troponin I and 8-isoprostane, C3a, interleukins 6, 8, and 10, cortisol, protein S100, and alpha-glutamate transferase were measured preoperatively and 10 and 30 minutes after starting bypass, on removal of the aortic crossclamp, and 12 and 24 hours thereafter. RESULTS Overall, troponin I and 8-isoprostane levels were lower in the controlled normoxic group (-29%, 95% CI -48% to -3%, P = .03, and -26%, 95% CI -44% to -2%, P = .03, respectively). Protein S100 release was also lower in the normoxic group 10 minutes after starting bypass (-26%, 95% CI -40% to -9%, P = .005) and 10 minutes after aortic crossclamp removal (-23%, 95% CI -38% to -3%, P = .02, respectively), but similar at other time points in the two groups (P >or= .17). The alpha-glutamate transferase release was significantly lower in the normoxic group 10 minutes after aortic crossclamp removal (-28%, 95% CI -44% to -9%, P = .006, respectively) but was similar at other times (P >or= .11). Release of C3a, interleukins 6, 8, and 10, and cortisol was similar in the two groups throughout (P >or= .15). CONCLUSION Controlled reoxygenation on starting cardiopulmonary bypass is associated with reduced myocardial damage, oxidative stress, and cerebral and hepatic injury compared with hyperoxic bypass and similar whole body inflammatory and stress response in cyanotic children undergoing open cardiac surgery.
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Durandy YD, Younes M, Mahut B. Pediatric warm open heart surgery and prolonged cross-clamp time. Ann Thorac Surg 2009; 86:1941-7. [PMID: 19022013 DOI: 10.1016/j.athoracsur.2008.08.004] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 08/01/2008] [Accepted: 08/04/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND The safety of normothermic pediatric cardiac surgery remains controversial. This study evaluated the performance of normothermic cardiopulmonary bypass (CPB) associated with intermittent warm blood cardioplegia during prolonged aortic cross-clamp time (CCT). METHODS This retrospective study included 234 consecutive patients weighing less than 10 kg operated under CPB from August 2006 to November 2007. Patients were divided into two groups: group 1 contained 38 patients with CCT exceeding 90 minutes, and group 2 had 196 patients with shorter CCT. Classic factors were used to analyze outcomes, and outcomes were compared with those from the Society of Thoracic Surgeons-European Association for Cardio-Thoracic Surgery database. RESULTS Results, expressed as values for group 1 vs those for group 2, were mortality rate, 5.3% vs 2%; length of hospital stay exceeding 21 days, 5% vs 0.5%; delayed chest closure, 21% vs 2.6%; epinephrine infusion, 45% vs 11%; organ failure, 13% vs 2%; reoperation due to bleeding, 3% vs 0.5%; heart block, 3% vs 1%; time to extubation, in hours, 64 +/- 94 vs 19 +/- 48; plasma lactate concentrations after bypass, 2.6 vs 1.9 mmol/L; length of stay in intensive care, in hours, 100 +/- 105 vs 52 +/- 48. CONCLUSIONS Despite expected differences between the two groups, our results were within the range of values described in the literature. This led us to conclude that warm pediatric cardiac surgery with a long CCT is safe. A large, multicenter, randomized prospective study comparing normothermic and hypothermic pediatric cardiac surgery is underway.
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Affiliation(s)
- Yves D Durandy
- Department of Perfusion and Intensive Care, Institut Hospitalier Jacques Cartier, Massy, France
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Levionnois O, Kronen P. Development of post-pump syndrome in a sheep after mitral valve stenting. Lab Anim 2008; 42:505-10. [DOI: 10.1258/la.2007.007041] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Abstract
Summary A one-year-old healthy sheep received an implant stenting the mural (‘posterior’) leaflet of the mitral valve. The experiment was authorized by the Cantonal Ethical Committee. The surgery was performed on the open, beating heart during cardiopulmonary bypass (CPB). Management of anaesthesia was based on isoflurane with mechanical intermittent positive pressure ventilation (IPPV) of the lungs, combined with intercostal nerve blocks and intravenous fentanyl and lidocaine. Marked cardiovascular depression occurred towards the end of CPB time and required high doses of dopamine, dobutamine, lidocaine and ephedrine to allow for weaning off the CPB pump. Moreover, severe pulmonary dysfunction developed when IPPV was re-initiated after CPB. Hypoxaemia persisted throughout the recovery from general anaesthesia. Multiple organ failure developed gradually during the three postoperative days, leading to euthanasia of the animal. As described in this case, marked lung injury associated with some degree of failure of other vital organs may occur in sheep after CPB. Intraoperative cardiorespiratory complications when weaning-off may indicate the development of ‘post-pump syndrome’.
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Affiliation(s)
- Olivier Levionnois
- Vetsuisse Faculty, University of Berne, Section of Anaesthesiology, Berne, Switzerland
| | - Peter Kronen
- Veterinary Anaesthesia Services International, Winthertur, Switzerland
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Abstract
OBJECTIVE Some centres have proposed creating the bidirectional cavopulmonary anastomosis without cardiopulmonary bypass, while others continue to use deep hypothermic circulatory arrest. The purpose of this review is to evaluate the results of using continuous cardiopulmonary bypass with moderate hypothermia, perhaps the most commonly used of the three techniques for this procedure. METHODS Between 1990 and 2005, 114 patients, having a mean age of 1.58 years, with a median age of 8 months, and ranging from 3 months to 16 years, underwent creation of either a unilateral cavopulmonary anastomosis, in 94 cases, or bilateral anastomoses in 20 cases. All had continuous cardiopulmonary bypass with moderate hypothermia at 32 degrees Celsius, with 24 also having aortic cross-clamping with cardioplegia for simultaneous intracardiac procedures. Interrupted absorbable sutures were used to create the anastomosis in 105 patients. RESULTS Perioperative mortality was 5%, with 6 of the patients dying. The mean period of cardiopulmonary bypass for an isolated anastomosis was 91 minutes, with a range from 44 to 160 minutes. In 10 patients (8.8%), it was necessary to place a graft to augment the anastomosis. The average postoperative length of stay was 7.9 days for those undergoing an isolated unilateral anastomosis, and 16.4 days for patients undergoing combined cardiac operations. We have now created the Fontan circulation in 79 of the patients, at an average interval from the bidirectional cavopulmonary anastomosis of 2.1 plus or minus 1.14 years. In 76 patients, we performed postoperative angiograms, and none revealed any stenoses. CONCLUSIONS The bidirectional cavopulmonary anastomosis can be performed successfully with continuous cardiopulmonary bypass and moderate hypothermia with a beating heart, avoiding circulatory arrest. The use of interrupted and absorbable sutures was not associated with any late anastomotic stenosis.
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Effect of perfusion temperature on the inflammatory response during pediatric cardiac surgery. Ann Thorac Surg 2008; 85:611-7. [PMID: 18222275 DOI: 10.1016/j.athoracsur.2007.10.062] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2007] [Revised: 10/16/2007] [Accepted: 10/17/2007] [Indexed: 11/23/2022]
Abstract
BACKGROUND Cardiopulmonary bypass (CPB) triggers the whole body inflammatory response, and it has been suggested that the degree of hypothermia may influence these responses. The aim of this prospective study was to compare the inflammatory response in children undergoing CPB for repair of congenital heart defects, randomized to mild or moderate hypothermia. METHODS We measured inflammatory markers in blood samples of thirty children with body weight less than 10 kg undergoing open heart surgery randomized to surgery at either mild (32 degrees C) or moderate (25 degrees C) hypothermia. Blood was sampled after induction of anesthesia, at skin closure, 2 hours, 24 hours, and 48 hours postoperatively. RESULTS Except for an enhanced interleukin-8 response in the moderate hypothermia group, there were no differences in levels of inflammatory mediators between those with mild and those with moderate hypothermia. In contrast to the modest influence of the degree of hypothermia, long CPB time and long aortic cross-clamp time were accompanied by enhanced inflammation involving raised levels of interleukin-8 and myeloperoxidase, as well as increased leukocyte counts. CONCLUSIONS Only minor differences in cytokine levels were detected between those with moderate and those with mild hypothermia during CPB. Ischemic aortic cross-clamp time and time on CBP should be as short as possible to avoid an excessive inflammatory response and possibly adverse clinical effects.
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Enkhbaatar P, Traber L, Traber D, Herndon D. Whole-body hypothermia: Another option in smoke inhalation management?*. Crit Care Med 2006; 34:1280-1. [PMID: 16550094 DOI: 10.1097/01.ccm.0000208152.58639.5e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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