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Zhang S, Chou YT, Zhang J, Chen J, Xiong Y, Lu J, Chen C, Xu Y, Liu Y. Experience in applied veno-arterial extracorporeal membrane oxygenation to support catheter ablation of malignant ventricular tachycardia. IJC HEART & VASCULATURE 2023; 49:101283. [PMID: 37908623 PMCID: PMC10613908 DOI: 10.1016/j.ijcha.2023.101283] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/26/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 11/02/2023]
Abstract
Background An electrical storm due to malignant ventricular tachycardia (VT) is a life-threatening condition that requires catheter ablation (CA). Most VT arrhythmias evolve over time after acute myocardial infarction, coronary artery bypass grafting, or chronic heart failure. Clinically, only radiofrequency ablation can identify and block all arrhythmia origin points. The procedure necessitates continuous VT induction in patients, resulting in hemodynamic instability; therefore, extracorporeal membrane oxygenation (ECMO) support is required. Earlier studies have reported substantial mortality rates; however, our results are significantly more favorable. In this study, we combined the minimally invasive extracorporeal circulation (MiECC) approach with ECMO to preserve an appropriate ECMO flow rate, thus reducing intraoperative left heart afterload. We report 21 cases illustrating the usefulness of modified veno-arterial (VA)-ECMO in this scenario. Methods Data of 21 patients supported by the modified VA-ECMO system (MiECC approach combined with the ECMO system) during VT CA in the Wuhan Asia Heart Hospital between June 2020 and July 2021 were reviewed retrospectively. Results Successful ablation was achieved in 20 out of 21 patients (95%). The median time for ECMO implantation was 206 min. Only two patients experienced complications post-treatment. All patients made complete recovery and were discharged. All patients were alive at the 1-year-follow-up. Conclusions Our modified VA-ECMO system helped restore systemic circulation in patients experiencing an electrical storm, thus achieving greater electrical stability during VT CA. Pre-insertion of VA-ECMO can achieve even better results.
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Affiliation(s)
| | - Yueh-ting Chou
- Wuhan Asia Heart Hospital, Wuhan, China
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | | | - Jin Chen
- Wuhan Asia Heart Hospital, Wuhan, China
| | | | - Juan Lu
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Chao Chen
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Yue Xu
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Yan Liu
- Wuhan Asia Heart Hospital, Wuhan, China
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Cheng T, Barve R, Cheng YWM, Ravendren A, Ahmed A, Toh S, Goulden CJ, Harky A. Conventional versus miniaturized cardiopulmonary bypass: A systematic review and meta-analysis. JTCVS OPEN 2021; 8:418-441. [PMID: 36004169 PMCID: PMC9390465 DOI: 10.1016/j.xjon.2021.09.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/24/2021] [Indexed: 11/05/2022]
Abstract
Objective A meta-analysis of randomized controlled trials was performed to compare the effects of miniaturized extracorporeal circulation (MECC) and conventional extracorporeal circulation (CECC) on morbidity and mortality rates after cardiac surgery. Methods A comprehensive literature search was conducted using Ovid, PubMed, Medline, EMBASE, and the Cochrane databases. Randomized controlled trials from the year 2000 with n > 40 patients were considered. Key search terms included variations of “mini,” “cardiopulmonary,” “bypass,” “extracorporeal,” “perfusion,” and “circuit.” Studies were assessed for bias using the Cochrane Risk of Bias tool. The primary outcomes were postoperative mortality and stroke. Secondary outcomes included arrhythmia, myocardial infarction, renal failure, blood loss, and a composite outcome comprised of mortality, stroke, myocardial infarction and renal failure. Duration of intensive care unit, and hospital stay was also recorded. Results The 42 studies eligible for this study included a total of 2154 patients who underwent CECC and 2196 patients who underwent MECC. There were no significant differences in any preoperative or demographic characteristics. Compared with CECC, MECC did not reduce the incidence of mortality, stroke, myocardial infarction, and renal failure but did significantly decrease the composite of these outcomes (odds ratio, 0.64; 95% confidence interval [CI], 0.50-0.81; P = .0002). MECC was also associated with reductions in arrhythmia (odds ratio, 0.67; 95% CI, 0.54-0.83; P = .0003), blood loss (mean difference [MD], –96.37 mL; 95% CI, –152.70 to –40.05 mL; P = .0008), hospital stay (MD, –0.70 days; 95% CI, –1.21 to –0.20 days; P = .006), and intensive care unit stay (MD, –2.27 hours; 95% CI, –3.03 to –1.50 hours; P < .001). Conclusions MECC demonstrates clinical benefits compared with CECC. Further studies are required to perform a cost–utility analysis and to assess the long-term outcomes of MECC. These should use standardized definitions of endpoints such as mortality and renal failure to reduce inconsistency in outcome reporting.
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Abstract
Minimally invasive extracorporeal circulation (MiECC) technology is characterized by improved biocompatibility due to closed-loop design, minimized priming, and markedly reduced artificial surface. Despite well-evidenced clinical advantages in coronary surgery, MiECC penetration in complex open-heart surgery is low. Concerns have been raised by surgeons and perfusionist regarding safety of perfusion in situations when the heart is opened and air is entering the closed system. Moreover, issues of blood and volume management are deemed impractical without having a reservoir. In the evolution of MiECC safety aspects as well as means of air and volume management have been addressed. The integration of active air removal devices, and the possibility of venting and volume buffering made MiECC suitable for valvular or even more complex surgery. However, typical clinical benefits found with MiECC in coronary artery bypass grafting (CABG) surgery, in particular blood sparing effects, were not reproducible. Air handling and blood management remain the main issues of MiECC in non-coronary surgery. With the introduction of modular (type IV) MiECC systems containing a second, accessory circuit for immediate conversion to open cardiopulmonary bypass (CPB), the last obstacles seem to be cleared away. The first reports using this latest development in MiECC technology sound promising. It is now up to the cardiac surgical community to adopt this technology and produce data helping to answer the question whether MiECC is the best perfusion strategy for all comer's cardiac surgery.
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Affiliation(s)
- Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Günter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
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El-Essawi A, Breitenbach I, Haupt B, Brouwer R, Morjan M, Harringer W. Aortic valve replacement with or without myocardial revascularization in octogenarians. Can minimally invasive extracorporeal circuits improve the outcome? Perfusion 2018; 34:217-224. [PMID: 30394847 DOI: 10.1177/0267659118811048] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVE The positive impact of minimally invasive extracorporeal circuits (MiECC) on patient outcome is expected to be most evident in patients with limited physiologic reserves. Nevertheless, most studies have limited their use to low-risk patients undergoing myocardial revascularization. As such, there is little evidence to their benefit outside this patient population. We, therefore, set out to explore their potential benefit in octogenarians undergoing aortic valve replacement (AVR) with or without concomitant myocardial revascularization. METHODS Based on the type of the utilized ECC, we performed a retrospective propensity score-matched comparison among all octogenarians (n = 218) who received a primary AVR with or without concomitant coronary artery bypass grafting in our institution between 2003 and 2010. RESULTS A MiECC was utilized in 32% of the patients. The propensity score matching yielded 52 matched pairs. The 30-day postoperative mortality (2% vs. 10%; p=0.2), the incidence of low cardiac output (0% vs. 6%; p=0.2) and the Intensive Care Unit (ICU) stay (2.5 ± 2.6 vs. 3.8 ± 4.7 days; p=0.06) were all in favour of the MiECC group, but failed to reach statistical significance while the 90-day postoperative mortality did (2% vs. 16%; p=0.02). CONCLUSION MiECCs have a positive influence on the outcome of octogenarians undergoing AVR with or without concomitant coronary artery bypass grafting. Their use should, therefore, be extended beyond isolated coronary artery bypass graft (CABG) surgery.
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Affiliation(s)
- Aschraf El-Essawi
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Ingo Breitenbach
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Benjamin Haupt
- 2 Academy of Perfusion, German Heart Centre Berlin, Berlin, Germany
| | - Rene Brouwer
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Mohammed Morjan
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
| | - Wolfgang Harringer
- 1 Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Braunschweig, Germany
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Complex Recanalization of Chronic Total Occluison Supported by Minimal Extracorporeal Circulation in a Patient with an Aortic Valve Bioprothesis in Extraanatomic Position. Case Rep Cardiol 2018; 2018:4975412. [PMID: 29850264 PMCID: PMC5907480 DOI: 10.1155/2018/4975412] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/12/2018] [Revised: 02/26/2018] [Accepted: 03/20/2018] [Indexed: 11/26/2022] Open
Abstract
Percutaneous coronary intervention (PCI) of chronic total occlusion (CTO) still remains a major challenge in interventional cardiology. This case describes a complex PCI of the left main coronary artery and of a CTO of the right coronary artery using a minimal extracorporeal circulation system (MECC) in a patient with an aortic valve bioprothesis in extraanatomic position. It illustrates that complex recanalization strategies can be solved combining it with mechanical circulatory support technologies.
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Gygax E, Kaeser HU, Stalder M, Gahl B, Rieben R, Carrel T, Erdoes G. Type II Minimal-Invasive Extracorporeal Circuit for Aortic Valve Replacement: A Randomized Controlled Trial. Artif Organs 2018; 42:620-629. [PMID: 29435996 DOI: 10.1111/aor.13093] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Revised: 11/08/2017] [Accepted: 11/10/2017] [Indexed: 12/11/2022]
Abstract
Extracorporeal circulation triggers systemic inflammatory response and coagulation disorders which may lead to unfavorable clinical outcome. A type II minimally-invasive extracorporeal circuit (MiECC) is a closed system with markedly reduced artificial surface as compared to conventional extracorporeal circuits (CECC). The aim of this study was to investigate and compare inflammatory responses, complement activation and selected clinical end-points in isolated surgical aortic valve replacement (SAVR) performed with a type II MiECC circuit or a CECC. Fifty patients were prospectively randomized to MiECC or CECC perfusion regimen. Complement activation (sC5b-9), inflammation (IL-6, TNF-α, sCD40-ligand) and activation of the coagulation system (D-dimer, TAT-complex) were determined before operation, at 2 hours and 24 hours after surgery. Clinical end-points included perfusion time, transfusion of allogeneic blood products, postoperative bleeding, sepsis, new onset of atrial fibrillation, stroke and in-hospital mortality. Patient characteristics and baseline plasma markers were similar in both groups. Levels for sC5b-9, TNF-α, sCD40 ligand, TAT-complex and D-dimers were not significantly different between MiECC and CECC at 2 hours and 24 hours after surgery. The IL-6 plasma concentration was lower in the CECC group at 24 hours (P = 0.026, vs. MiECC). Comparisons of the baseline level to values at 2 hours and 24 hours, adjusted for the type of oxygenator and hemoglobin, showed a significantly lower sC5b-9 in MiECC at 2 hours (P = 0.013), but no difference at 24 hours (P=0.990). Compared with CECC, MiECC patients had a shorter perfusion time (P = 0.037) and less transfusion requirements (P = 0.04). In this selected cohort of SAVR patients, the type II MiECC was not inferior to CECC in terms of inflammatory response and complement activation. Thus, MiECC might be an alternative perfusion strategy to conventional.
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Affiliation(s)
- Erich Gygax
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Hans-Ulrich Kaeser
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Mario Stalder
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Brigitta Gahl
- Clinical Trials Unit, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Robert Rieben
- Department for Biomedical Research, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Thierry Carrel
- Department of Cardiovascular Surgery, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Therapy, Inselspital, University Hospital Bern, University of Bern, Bern, Switzerland
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Blaudszun G, Butchart A, Klein AA. Blood conservation in cardiac surgery. Transfus Med 2017; 28:168-180. [DOI: 10.1111/tme.12475] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Revised: 08/27/2017] [Accepted: 08/28/2017] [Indexed: 12/30/2022]
Affiliation(s)
- G. Blaudszun
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
| | - A. Butchart
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
| | - A. A. Klein
- Department of Anaesthesia and Intensive Care; Papworth Hospital NHS Foundation Trust; Cambridge UK
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Wang C, Hua K, Yin L, Wang Y, Li W. A Meta-Analysis of Miniaturized Versus Conventional Extracorporeal Circulation in Valve Surgery. Ann Thorac Surg 2016; 102:2099-2108. [PMID: 27590682 DOI: 10.1016/j.athoracsur.2016.05.118] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 05/17/2016] [Accepted: 05/30/2016] [Indexed: 11/18/2022]
Abstract
The effects of miniaturized extracorporeal circulation in patients operated on for heart valve surgery are still inconsistent. We performed a meta-analysis of eight studies involving 1,011 patients to evaluate the comprehensive effects of miniaturized extracorporeal circulation. The results suggested its application significantly reduced the length of stay in the intensive care unit and total hospital stay after heart valve surgery, but no significant effects on reducing postoperative morbidity and mortality were observed. Further studies with long-term follow-up are needed to confirm our results.
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Affiliation(s)
- Chuangshi Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Kun Hua
- Beijing Anzhen Hospital, Capital Medical University, Beijing, China
| | - Lu Yin
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Yang Wang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China
| | - Wei Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Disease, Peking Union Medical College and Chinese Academy of Medical Sciences, Beijing, China.
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Abstract
INTRODUCTION Cardiopulmonary bypass has undoubtedly been the cornerstone in the rapid development of cardiac surgery, allowing even the performance of procedures beyond the scope of cardiothoracic surgery. Its use however, is associated with significant complications that arise from the mechanical effects of the circuit on circulating blood components as well as the contact of blood with non-endothelial surfaces. Miniature cardiopulmonary bypass systems have been developed in an attempt to minimize these complications. Areas covered: Herein clinical outcomes from the most recent studies in adult cardiac surgery are discussed. The main benefits of miniaturisation as well as potential areas of further application are described. Expert commentary: Data is critically appraised in the context of current guidelines. Finally the need for further basic science in addition to large multi-centre randomized controlled trial data is highlighted.
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Affiliation(s)
- Ioannis Dimarakis
- a Department of Cardiothoracic Surgery , Wythenshawe Hospital , Manchester , UK
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Baumbach H, Rustenbach CJ, Ahad S, Nagib R, Albert M, Ratge D, Franke UF. Minimally Invasive Extracorporeal Bypass in Minimally Invasive Heart Valve Operations: A Prospective Randomized Trial. Ann Thorac Surg 2016; 102:93-100. [DOI: 10.1016/j.athoracsur.2016.01.043] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2015] [Revised: 01/05/2016] [Accepted: 01/11/2016] [Indexed: 10/21/2022]
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Basciani R, Kröninger F, Gygax E, Jenni H, Reineke D, Stucki M, Hagenbuch N, Carrel T, Eberle B, Erdoes G. Cerebral Microembolization During Aortic Valve Replacement Using Minimally Invasive or Conventional Extracorporeal Circulation: A Randomized Trial. Artif Organs 2016; 40:E280-E291. [DOI: 10.1111/aor.12744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Reto Basciani
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Felix Kröninger
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Erich Gygax
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - David Reineke
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Monika Stucki
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | | | - Thierry Carrel
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
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What We have Learned about Minimized Extracorporeal Circulation versus Conventional Extracorporeal Circulation: An Updated Meta-Analysis. Int J Artif Organs 2015; 38:444-53. [PMID: 26349528 DOI: 10.5301/ijao.5000427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 12/29/2022]
Abstract
Introduction The benefits of minimized extracorporeal circulation (MECC) compared with conventional extracorporeal circulation (CECC) are still in debate. Methods PubMed, EMBASE and the Cochrane Library were searched until November 10, 2014. After quality assessment, we chose a fixed-effects model when the trials showed low heterogeneity, otherwise a random-effects model was used. We performed univariate meta-regression and sensitivity analysis to search for the potential sources of heterogeneity. Cumulative meta-analysis was performed to access the evolution of outcome over time. Results 41 RCTs enrolling 3744 patients were included after independent article review by 2 authors. MECC significantly reduced atrial fibrillation (RR, 0.76; 95% CI, 0.66 to 0.89; P<0.001; I2 = 0%), and myocardial infarction (RR, 0.43; 95% CI, 0.26 to 0.71; P = 0.001; I2 = 0%). In addition, the results regarding chest tube drainage, transfusion rate, blood loss, red blood cell transfusion volume, and platelet count favored MECC as well. Conclusions MECC diminished morbidity of cardiovascular complications postoperatively, conserved blood cells, and reduced allogeneic blood transfusion.
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Ploppa A, Haeberle L, Schmid E, Nohe B. Left Ventricular Thrombus During Cardiopulmonary Bypass as the Primary Manifestation of Heparin-Induced Thrombocytopenia. J Cardiothorac Vasc Anesth 2013; 27:744-8. [DOI: 10.1053/j.jvca.2011.11.001] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/30/2011] [Indexed: 01/11/2023]
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Scrascia G, Guida P, Rotunno C, de Luca Tupputi Schinosa L, Paparella D. Anti-inflammatory strategies to reduce acute kidney injury in cardiac surgery patients: a meta-analysis of randomized controlled trials. Artif Organs 2013; 38:101-12. [PMID: 23876045 DOI: 10.1111/aor.12127] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Acute kidney injury (AKI) after cardiac operations is a serious complication associated with postoperative mortality. Multiple factors contribute to AKI development, principally ischemia-reperfusion injury and inflammatory response. It is well proven that glucocorticoid administration, leukocyte filter application, and miniaturized extracorporeal circuits (MECC) modulate inflammatory response. We conducted a systematic review of randomized controlled trials (RCTs) in which one of these inflammatory system modulation strategies was used, with the aim to evaluate the effects on postoperative AKI. MEDLINE and Cochrane Library were screened through November 2011 for RCTs in which an inflammatory system modulation strategy was adopted. Included were trials that reported data about postoperative renal outcomes. Because AKI was defined by different criteria, including biochemical determinations, urine output, or dialysis requirement, we unified renal outcome as worsening renal function (WRF). We identified 14 trials for steroids administration (931 patients, WRF incidence [treatment vs. placebo]: 2.7% vs. 2.4%; OR: 1.13; 95% CI: 0.53-2.43; P = 0.79), 9 trials for MECC (947 patients, WRF incidence: 2.4% vs. 0.9%; OR: 0.47; 95% CI: 0.18-1.25; P = 0.13), 6 trials for leukocyte filters (374 patients, WRF incidence: 1.1% vs. 7.5%; OR: 0.18; 95% CI: 0.05-0.64; P = 0.008). Only leukocyte filters effectively reduced WRF incidence. Not all cardiopulmonary bypass-related anti-inflammatory strategies analyzed reduced renal damage after cardiac operations. In adult patients, probably other factors are predominant on inflammation in determining AKI, and only leukocyte filters were effective. Large multicenter RCTs are needed in order to better evaluate the role of inflammation in AKI development after cardiac operations.
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Affiliation(s)
- Giuseppe Scrascia
- Department of Emergency and Organ Transplant, Division of Cardiac Surgery, University of Bari "Aldo Moro, Bari, Italy
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Momin AU, Sharabiani MTA, Kidher E, Najefi A, Mulholland JW, Reeves BC, Angelini GD, Anderson JR. Feasibility and safety of minimized cardiopulmonary bypass in major aortic surgery. Interact Cardiovasc Thorac Surg 2013; 17:659-63. [PMID: 23814138 DOI: 10.1093/icvts/ivt285] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Conventional cardiopulmonary bypass causes haemodilution and is a trigger of systemic inflammatory reactions, coagulopathy and organ failure. Miniaturized cardiopulmonary bypass has been proposed as a way to reduce these deleterious effects of conventional cardiopulmonary bypass and to promote a more physiological state. The use of miniaturized cardiopulmonary bypass has been reported in low-risk patients undergoing valve and coronary artery bypass graft (CABG) surgery. However, little is known about its application in major aortic surgery. METHODS From February 2007 to September 2010, 49 patients underwent major aortic surgery using the Hammersmith miniaturized cardiopulmonary bypass (ECCO, Sorin). Data were extracted from medical records to characterize preoperative comorbidities (EuroSCORE), perioperative complications and the use of blood products. The same data were collected and described for 328 consecutive patients having similar surgery with conventional cardiopulmonary bypass at the Bristol Heart Institute, our twinned centre, during the same period. RESULTS The miniaturized cardiopulmonary bypass group had a median EuroSCORE of 8 [inter-quartile range (IQR): 5-11], 13% had preoperative renal dysfunction and 20% of operations were classified as emergency or salvage. Thirty-day mortalities were 6.4; and 69, 67 and 74% had ≥ 1 unit of red cells, fresh frozen plasma (FFP) and platelets transfused, respectively. Eight percent of patients experienced a renal complication, and 8% a neurological complication. The conventional cardiopulmonary bypass group was similar, with a EuroSCORE of 8 (IQR: 6-10); 30-day mortalities were 9.4; and 68, 62 and 74% had ≥ 1 unit of red cells, FFP and platelets transfused, respectively. The proportions experiencing renal and neurological complications were 14 and 5%. CONCLUSIONS Our experience suggests that miniaturized cardiopulmonary bypass is safe and feasible for use in major aortic cardiac surgery. A randomized trial is needed to evaluate miniaturized cardiopulmonary bypass formally.
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Affiliation(s)
- Aziz U Momin
- Department of Cardiac Surgery, Imperial College London, Hammersmith Hospital, London, UK
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Momin A, Sharabiani M, Mulholland J, Yarham G, Reeves B, Anderson J, Angelini G. Miniaturized cardiopulmonary bypass: the Hammersmith technique. J Cardiothorac Surg 2013; 8:143. [PMID: 23731623 PMCID: PMC3674973 DOI: 10.1186/1749-8090-8-143] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2013] [Accepted: 05/27/2013] [Indexed: 11/16/2022] Open
Abstract
Background Conventional Cardiopulmonary Bypass (cCPB) is a trigger of systemic inflammatory reactions, hemodilution, coagulopathy, and organ failure. Miniaturised Cardiopulmonary Bypass (mCPB) has the potential to reduce these deleterious effects. Here, we describe our standardised ‘Hammersmith’ mCPB technique, used in all types of adult cardiac operations including major aortic surgery. Methods The use of mCPB remains limited by the diversity of technologies which range from extremely complex, micro systems to ones very similar to cCPB. Our approach is designed around the principle of balancing the benefits of miniaturisation; reducing foreign surface area while maintaining patient safety. Results From January 2010 to March 2011, a single surgeon performed 184 consecutive operations (Euro score Logistic 8.4+/-9.9): 61 aortic valve replacements, 78 CABGs, 25 aortic valve replacement and CABG and 17 other procedures (major aortic surgery, re-do operations or double/triple valve replacements). Our clinical experience suggests that: i. Venous drainage is optimally maintained using kinetic energy. ii. Venous collapse pressure depends on the patient’s anatomy and cannula size, but most importantly on the negative pressure generated by venous drainage. iii. The patient-prime interaction is optimised with antegrade and retrograde autologous priming, which mixes the blood and prime away from the tissues and results in a reduced oncotic destabilization. iv. mCPB is a safe and reproducible technique Conclusion The Hammersmith mCPB is a “next generation” system which uses standard commercially available components. It aims to maintain safety margin and the benefit of miniaturised system whilst reducing the human factor demands.
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Affiliation(s)
- Aziz Momin
- Cardiac Surgery and Clinical Perfusion, Imperial College London, London, UK
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Anastasiadis K, Antonitsis P, Haidich AB, Argiriadou H, Deliopoulos A, Papakonstantinou C. Use of minimal extracorporeal circulation improves outcome after heart surgery; a systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2013; 164:158-69. [DOI: 10.1016/j.ijcard.2012.01.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 12/30/2011] [Accepted: 01/10/2012] [Indexed: 11/15/2022]
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Liu Y, Tao L, Wang X, Cui H, Chen X, Ji B. Beneficial effects of using a minimal extracorporeal circulation system during coronary artery bypass grafting. Perfusion 2011; 27:83-9. [PMID: 21987667 DOI: 10.1177/0267659111424636] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Background: In this study, we assessed clinical results by using a minimal extracorporeal circuit (MECC) and compared it to a conventional cardiopulmonary bypass (CPB) system in patients undergoing coronary artery bypass grafting (CABG) procedures. Methods and Materials: From August to October 2006, forty consecutive patients undergoing isolated CABG procedures were randomly assigned to either a miniaturized closed circuit CPB with the Maquet-Cardiopulmonary MECC system (Group M, n=20) or to a conventional CPB system (Group C, n=20). Clinical outcomes were observed before, during and after the operation. Besides evaluating the perioperative clinical data, serial blood venous samples were obtained after induction, 30 minutes after CPB initiation, 2h, 6h, 12h, and 24h post-CPB. The focus of our study was on myocardial damage (cTnI), neutrophil and platelet counts, activated partial thromboplastin time (aPTT) and free hemoglobin. Results: Both the transfusion of packed red blood cells and fresh frozen plasma were significantly lower in Group M compared to Group C ( p<0.05). The levels of cTnI were lower in Group M at 2h, 6h and 12h post-CPB than in Group C ( p<0.01). The values of aPTT in Group M recovered to normal levels after surgery, but were prolonged in Group C at early post-CPB and were statistically longer than Group M at 2h, 6h, and 12h post-CPB ( p<0.05). The concentrations of free hemoglobin in Group C were higher than in Group M during and post-CPB, and there was a statistical difference at 2h post-CPB ( p<0.05). Conclusion: In conclusion, the MECC system is a safe alternative for patients who undertake extracorporeal circulation (ECC) for CABG surgery. Lower transfusion requirements and less damage to red cells may further promote the use of MECC systems, especially in higher risk patients.
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Affiliation(s)
- Y Liu
- Department of Cardiopulmonary Bypass, Wuhan Asia Heart Hospital, Wuhan 430022, Peoples R China
| | - L Tao
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan 430022, Peoples R China
| | - X Wang
- Department of Cardiopulmonary Bypass, Chinese Acad Med Sci, Peking Union Med Coll, Fuwai Hosp & Cardiovasc Inst, Beijing 100037, Peoples R China
| | - H Cui
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan 430022, Peoples R China
| | - X Chen
- Department of Cardiac Surgery, Wuhan Asia Heart Hospital, Wuhan 430022, Peoples R China
| | - B Ji
- Department of Cardiopulmonary Bypass, Chinese Acad Med Sci, Peking Union Med Coll, Fuwai Hosp & Cardiovasc Inst, Beijing 100037, Peoples R China
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Ranucci M, Aronson S, Dietrich W, Dyke CM, Hofmann A, Karkouti K, Levi M, Murphy GJ, Sellke FW, Shore-Lesserson L, von Heymann C. Patient blood management during cardiac surgery: Do we have enough evidence for clinical practice? J Thorac Cardiovasc Surg 2011; 142:249.e1-32. [DOI: 10.1016/j.jtcvs.2011.04.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/24/2011] [Revised: 02/09/2011] [Accepted: 04/08/2011] [Indexed: 12/13/2022]
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Rimpiläinen R, Hautala N, Koskenkari J, Rimpiläinen J, Ohtonen P, Mustonen P, Surcel HM, Savolainen ER, Mosorin M, Ala-Kokko T, Juvonen T. Comparison of the use of minimized cardiopulmonary bypass with conventional techniques on the incidence of retinal microemboli during aortic valve replacement surgery. Perfusion 2011; 26:479-86. [PMID: 21727175 DOI: 10.1177/0267659111415564] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Minimized cardiopulmonary bypass (MCPB) circuits have been shown to reduce cerebral and retinal microembolisation during coronary artery bypass graft (CABG) surgery compared to conventional CPB (CCPB) circuits. Our aim was to evaluate whether the reduction of microembolisation is sustained in aortic valve surgery, as well as to evaluate the effects of MCPB on inflammatory, endothelial, and platelet activation markers. MATERIAL AND METHODS Patients were randomized to undergo aortic valve replacement (AVR), with or without CABG, with MPCB (n=20) or CCPB (n=20). After anaesthesia induction and termination of CPB, standardized digital retinal fluorescein angiography images were obtained on both eyes and analyzed in a blinded fashion. Blood samples were collected at eight time points until the third postoperative day. RESULTS Fewer patients in the MCPB group showed evidence of microembolic perfusion defects on postperfusion retinal fluorescein angiographs compared to the CCPB group (37% vs. 63%, absolute difference 26%, 95% CI -5% -51%, P = 0.194). Polymorphonuclear leukocyte (PMN) elastase and von Willebrand factor release were statistically significantly reduced in the MCPB group, but there were no significant differences in other markers of inflammation, coagulation or endothelial activation. A significantly higher three-fold increase in the amount of shed blood was collected to the cell saver with a higher rate of intraoperative platelet transfusion in the MCPB group compared to CCPB. CONCLUSIONS The use of MCPB was associated statistically insignificantly with less retinal microemboli compared to CCPB. MCPB was complicated by excess bleeding and need for transfusion. The feasibility of MCPB techniques in valve surgery requires further studies.
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Affiliation(s)
- R Rimpiläinen
- Department of Anesthesiology and Surgery, Division of Anesthesiology and Intensive Care, Oulu University Hospital, Oulu, Finland.
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 874] [Impact Index Per Article: 67.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Do Miniaturized Extracorporeal Circuits Confer Significant Clinical Benefit Without Compromising Safety? A Meta-Analysis of Randomized Controlled Trials. ASAIO J 2011; 57:141-51. [DOI: 10.1097/mat.0b013e318209d63b] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Anastasiadis K, Chalvatzoulis O, Antonitsis P, Deliopoulos A, Argiriadou H, Karapanagiotidis G, Kambouroglou D, Papakonstantinou C. Use of Minimized Extracorporeal Circulation System in Noncoronary and Valve Cardiac Surgical Procedures-A Case Series. Artif Organs 2011; 35:960-3. [DOI: 10.1111/j.1525-1594.2010.01183.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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25
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Yilmaz A, Sjatskig J, van Boven WJ, Waanders FG, Kelder JC, Sonker U, Kloppenburg GT. Combined coronary artery bypass grafting and aortic valve replacement with minimal extracorporeal closed circuit circulation versus standard cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2010; 11:754-7. [DOI: 10.1510/icvts.2010.241943] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Abstract
Since 2005, we have used a novel technique based on the closed cardiopulmonary bypass system without cardiotomy suction (minimal cardiopulmonary bypass [mini-CPB]) for aortic valve replacement (AVR). In this study, we investigated the clinical advantages of this approach. We prospectively studied 32 patients who underwent isolated AVR using the mini-CPB (group M, n = 13) or conventional CPB (group C, n = 19). We compared the hemodilution ratio, serum interleukin (IL)-6 and IL-8 levels, and blood transfusion volume between the two groups. The characteristics, duration of CPB, and aortic cross-clamping time did not differ between the two groups. The hemodilution ratio was significantly lower in group M just after starting CPB (M vs. C: 14% +/- 2% vs. 25% +/- 3%, p = 0.0009). IL-6 levels increased significantly after surgery in both groups, but the postoperative levels were significantly lower in group M at 6 (84.9 +/- 24.9 pg/ml vs. 152 +/- 78 pg/ml, p = 0.042) and 12 (72.7 +/- 36.1 pg/ml vs. 123 +/- 49.6 pg/ml, p = 0.029) hours after CPB. There were no differences in IL-8 or blood transfusion volume after CPB. Mini-CPB offers an alternative to conventional CPB for AVR and has some advantages regarding hemodilution and serum IL-6 levels. However, it is unlikely to become the standard approach for AVR because there are no marked clinical advantages of mini-CPB.
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27
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Zangrillo A, Garozzo FA, Biondi-Zoccai G, Pappalardo F, Monaco F, Crivellari M, Bignami E, Nuzzi M, Landoni G. Miniaturized cardiopulmonary bypass improves short-term outcome in cardiac surgery: A meta-analysis of randomized controlled studies. J Thorac Cardiovasc Surg 2010; 139:1162-9. [PMID: 19775708 DOI: 10.1016/j.jtcvs.2009.07.048] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 06/19/2009] [Accepted: 07/16/2009] [Indexed: 02/08/2023]
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Svitek V, Lonsky V, Mandak J, Krejsek J, Kolackova M, Brzek V, Kubicek J, Volt M, Bartos M, Harrer J. No clear clinical benefit of using mini-invasive extracorporeal circulation in coronary artery bypass grafting in low-risk patients. Perfusion 2010; 24:389-95. [DOI: 10.1177/0267659109359437] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Background: Current research is engaged in innovative technologies of extracorporeal circulation (ECC) systems in an effort to eliminate negative effetcs. Some studies have shown that, due to the complexity of technical settings of mini-ECC, they invoke a weaker immune response compared to classic ECC. The clinical benefits of using these systems have not been clearly proven yet. Methods: A group of 54 patients who were indicated for elective coronary surgery were randomised into two groups — Group A (patients operated on using classic ECC - open modification) and Group B (patients operated on using mini-ECC). The concentrations of IL-6, PMN elastase and MCP-1 in both groups were monitored per- and postoperatively, along with the postoperative clinical course. Results: The groups did not differ in the basic pre- and peroperative characteristics. We recorded a lower priming for mini-ECC (p < 0.001) and significantly reduced hemodilution during ECC. There were no differences in the clinical outcome in either group. Serum concentrations of monitored markers of immune reaction towards ECC showed higher activity during standard ECC. Conclusion: New technologies used in mini-systems have proven to lower activation of the immune system, which can be monitored using kinetics of proinflammatory mediators. In spite of these comparable laboratory results, we did not find differences in short-term clinical results when comparing both these groups of low-risk patients.
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Affiliation(s)
- Vladimir Svitek
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic,
| | - Vladimir Lonsky
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic, Department of Cardiac Surgery of Palacky University Faculty of Medicine and Dentistry and University Hospital in Olomouc, Czech Republic
| | - Jiri Mandak
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Jan Krejsek
- Department of Clinical Immunology and Allergology of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Martina Kolackova
- Department of Clinical Immunology and Allergology of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Vladimir Brzek
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Jaroslav Kubicek
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Martin Volt
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic, Department of Cardiac Surgery of Palacky University Faculty of Medicine and Dentistry and University Hospital in Olomouc, Czech Republic
| | - Michael Bartos
- Department of Anesthesiology, Resuscitation and Intensive Care of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
| | - Jan Harrer
- Department of Cardiac Surgery of Charles University in Prague, Faculty of Medicine in Hradec Kralove and University Hospital in Hradec Kralove, Czech Republic
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Rahe-Meyer N, Solomon C, Tokuno ML, Winterhalter M, Shrestha M, Hahn A, Tanaka K. Comparative Assessment of Coagulation Changes Induced by Two Different Types of Heart-Lung Machine. Artif Organs 2010; 34:3-12. [DOI: 10.1111/j.1525-1594.2009.00792.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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30
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Panday GF, Fischer S, Bauer A, Metz D, Schubel J, Shouki NE, Eberle T, Hausmann H. Minimal extracorporeal circulation and off-pump compared to conventional cardiopulmonary bypass in coronary surgery☆. Interact Cardiovasc Thorac Surg 2009; 9:832-6. [DOI: 10.1510/icvts.2009.206466] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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Fernandes P, MacDonald J, Cleland A, Mayer R, Fox S, Kiaii B. The use of a mini bypass circuit for minimally invasive mitral valve surgery. Perfusion 2009; 24:163-8. [DOI: 10.1177/0267659109346662] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: The purpose of the study is to clinically evaluate minimally invasive mitral valve surgeries (MIMVS) using a mini bypass circuit. The challenge to perfusion is to keep pace with MIMVS, with demonstrated improvements in perfusion-related technologies. Methods: From October 28, 2005 to September 10, 2008, we retrospectively evaluated thirty-four elective cases which used the mini-circuit (Medtronic Resting Heart System®), with respect to safety, efficacy, cannulation technique, blood usage, resultant hemoglobin, length of ICU and hospital stay, and complications. Conclusion: The Medtronic Resting Heart System® alleviates many factors, such as high shear stress, turbulence, air to blood interface and decreased oncotic pressure caused by hemodilution, providing more efficient perfusion to our MIMVS patients. We demonstrate, with minor circuit modifications and attention to venous air issues, that this mini-circuit can be used safely and effectively, while being associated with improvements in patient outcomes.
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Affiliation(s)
- P. Fernandes
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada,
| | - J. MacDonald
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
| | - A. Cleland
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
| | - R. Mayer
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
| | - S. Fox
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
| | - B. Kiaii
- London Health Sciences Centre, Clinical Perfusion Services, Division of Cardiac Surgery, University of Western Ontario, London, Ontario, Canada
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Valtonen M, Vähäsilta T, Kaila-Keinänen T, Kuttila K. New mini-extracorporeal circulation system (ECC.O) is a safe technique in coronary surgery. SCAND CARDIOVASC J 2009; 41:345-50. [PMID: 17852793 DOI: 10.1080/14017430701446933] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Cardiopulmonary bypass (CPB) is known to cause the systemic inflammatory reaction after cardiac surgery. New coated and closed loop circuit systems may reduce this inflammation response and improve the surgical outcome. This study was designed to evaluate the safety and efficacy of the mini-extracorporeal circulation system (ECC.O) in CABG patients. DESIGN Forty patients undergoing elective coronary surgery were randomized into two groups, the ECC.O group and the standard CPB group. Routine hemodynamic monitoring and biochemical measurements were registered according to the hospital practice. RESULTS The clinical outcome of the patients was similar in both groups. There were no significant differences between the groups in the duration of intubation following surgery, the length of intensive care unit-stay or the total hospital stay. The haemoglobin level was significantly higher (p=0.0069) during and after the perfusion in the ECC.O group. CONCLUSIONS The ECC.O system can be safely used in CABG patients and it maintains haemoglobin level better than conventional CPB.
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Affiliation(s)
- Mika Valtonen
- Department of Anaesthesia and Intensive Care, Turku University Hospital, Finland.
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Colli A, Fernandez C, Delgado L, Romero B, Camara ML, Ruyra X. Aortic valve replacement with minimal extracorporeal circulation versus standard cardiopulmonary bypass. Interact Cardiovasc Thorac Surg 2009; 9:583-7. [PMID: 19574264 DOI: 10.1510/icvts.2009.202804] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
The purpose of this study was to evaluate the safety and the clinical outcomes of aortic valve replacement (AVR) performed with minimally invasive extracorporeal circulation (miniECC) technique vs. standard cardiopulmonary bypass (CPB). From February 2006 to December 2007 a total of 181 isolated AVR were performed, of these 53 patients were operated using minimal extracorporeal circulation system and 128 patients were operated using the standard CPB. Demographic characteristics and operative data were similar in both groups except for EuroSCORE (P<0.0001). Operative mortality (<30 days) was 3.8% for miniECC group and 4.7% for CPB group (P=ns). Patients in both groups showed similar postoperative chest tube drainage (432+/-325 ml vs. 460+/-331 ml, P=ns). The percentage of transfused patients was similar in both groups (37.7% vs. 43.8%, P=0.45). The number of transfused blood bank products was higher in patients with a body surface area >1.7 m(2) and who underwent traditional CPB in respect to miniECC system. Postoperatively renal injury, atrial fibrillation episodes, neurologic event rate, ICU and hospital stay length were similar in both groups. The miniECC is suitable for AVR providing good clinical results but the present results should not identify the miniECC system to be superior to the conventional CPB.
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Affiliation(s)
- Andrea Colli
- Department of Cardiac Surgery, Hospital Universitari Germans Trias i Pujols, Ctra. Canyet Sn, 08916 Badalona, Barcelona, Spain.
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Kutschka I, Skorpil J, El Essawi A, Hajek T, Harringer W. Beneficial effects of modern perfusion concepts in aortic valve and aortic root surgery. Perfusion 2009; 24:37-44. [DOI: 10.1177/0267659109106727] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimized perfusion circuits (MPC) were found to reduce side effects of standard extracorporeal circulation (ECC). We evaluated the safety and efficacy of the ROCsafe™ MPC for aortic valve and aortic root surgery. One hundred and seventy patients were randomized for surgery using either MPC [n = 85, 30 female/55 male, mean age: 69.8 ± 11.8 years; aortic valve replacement (AVR): n = 40; AVR + coronary artery bypass graft (CABG): n = 31; David operation: n = 3; aortic root replacement (ARR): n = 11] or ECC [n = 85, 29 female/56 male, mean age: 67.7 ± 9.5 years; AVR: n = 39; AVR+CABG: n = 35, David operation: n = 2; ARR: n = 9]. Neurological status, length of ICU stay, C-reactive protein (CRP), blood count, transfusion requirements and bleeding volume were analyzed. The MPC system provided ultrasound-controlled de-airing. A small roller pump and a flexible reservoir were used for left ventricular venting. As a control, we used a standard ECC with cardiotomy suction and hard-shell reservoir. Cross-clamp time (MPC: 76.5 ± 29.5; ECC: 79.0 ± 34.0 min) and bypass time (MPC: 103.0 ± 37.9; ECC: 106.9 ± 44.9 min) were comparable between groups. Transfusion requirements (red blood cells: MPC: 1.5 ± 1.5 vs. ECC: 2.2 ± 2.1 units [p = 0.05], frozen plasma: MPC: 1.2 ± 1.8 vs. ECC: 1.9 ± 2.4 units [p = 0.03]), postoperative bleeding (MPC: 521 ± 283 vs. ECC: 615 ± 326 ml/24 h, p = 0.09) were lower using MPC. ICU stay was shorter with MPC (1.6 ± 1.6 days) compared to ECC (2.4 ± 2.8 days, p = 0.001). One stroke occurred in each group. The ROCsafe™ MPC provides safe circulatory support for a wide range of aortic valve surgeries. Transfusion requirements, postoperative bleeding and length of ICU stay were markedly reduced compared to standard extracorporeal perfusion.
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Affiliation(s)
- I Kutschka
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany; Department of Cardiothoracic, Transplant and Vascular Surgery, Hannover Medical School, Hannover, Germany
| | - J Skorpil
- Department of Thoracic and Cardiovascular Surgery, Pilsner University Hospital Pilsen, Pilsen, Czech Republic
| | - A El Essawi
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
| | - T Hajek
- Department of Thoracic and Cardiovascular Surgery, Pilsner University Hospital Pilsen, Pilsen, Czech Republic
| | - W Harringer
- Department of Thoracic and Cardiovascular Surgery, Klinikum Braunschweig, Germany
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Colangelo N, Moriggia S, Kieser T, De Simone F, Vescovo A, Palumbo L, Denti P, Guidotti A, Blasio A, Maisano F, Alfieri O. A cardioplegia circuit with versatility: the 'ReVerse' system. How to do it. Perfusion 2009; 23:205-7. [PMID: 19181751 DOI: 10.1177/0267659108101498] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Various methods of cardioplegia administration have been used in cardiac surgery: crystalloid, blood and mixed crystalloid/blood. Each of these types of cardioplegia administration typically needs a different circuit. This may correspond to an increase in cost and the time needed to change the circuit if required. When various modifications are performed on the circuit, this also increases the risk of contamination. In order to simplify the management of differing cardioplegia circuits, we devised one circuit for all solutions in all situations by adding one modification. The ReVerse cardioplegia circuit system is a description of a two-pump cardioplegia circuit which is adaptable to either blood or crystalloid cardioplegia. The change from one mode to another requires a manoeuvre of two clamps, allowing the blood solution to travel through shunt tubing into the apposite pumphead. In our experience the versatility of this circuit is a fast, safe method to administrate all types of cardioplegia solution, saving the space taken up by storing multiple circuits.
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Affiliation(s)
- N Colangelo
- Department of Cardiac Surgery and Cardiovascular Perfusion, San Raffaele Vita e Salute University Hospital, Milan, Italy.
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Myocardial revascularization with miniaturized extracorporeal circulation versus off pump: Evaluation of systemic and myocardial inflammatory response in a prospective randomized study. J Thorac Cardiovasc Surg 2009; 137:1206-12. [DOI: 10.1016/j.jtcvs.2008.09.074] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/26/2008] [Revised: 09/06/2008] [Accepted: 09/19/2008] [Indexed: 11/20/2022]
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Dimarakis I, Stefanou D, Yarham G, Mulholland J, Anderson J. Total miniaturized cardiopulmonary bypass: the next step in minimally invasive aortic valve replacement. Perfusion 2009; 23:275-8. [PMID: 19346265 DOI: 10.1177/0267659109103991] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Minimally invasive aortic valve replacement has been established in many centres over the last decade. Although numerous modifications have been described to date, these solely involve variations of the utilized operative incision. Total miniaturized cardiopulmonary bypass (tMCPB) offers the theoretical potential of reducing even further the overall procedural "invasiveness". We describe our initial experience of an application of MCPB for aortic valve replacement through a minimal incision.
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Affiliation(s)
- I Dimarakis
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK.
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Puehler T, Haneya A, Philipp A, Wiebe K, Keyser A, Rupprecht L, Hirt S, Kobuch R, Diez C, Hilker M, Schmid C. Minimal extracorporeal circulation: an alternative for on-pump and off-pump coronary revascularization. Ann Thorac Surg 2009; 87:766-72. [PMID: 19231386 DOI: 10.1016/j.athoracsur.2008.11.050] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 11/12/2008] [Accepted: 11/17/2008] [Indexed: 10/21/2022]
Abstract
BACKGROUND Coronary artery bypass surgery employing minimal extracorporeal circulation (MECC) was compared with standard extracorporeal circulation (ECC) and off-pump coronary artery bypass graft surgery (OPCABG) with regard to the perioperative course. METHODS From January 2004 to December 2007, 1,674 patients (n = 558 MECC, n = 558 ECC, n = 558 OPCABG) who underwent coronary bypass surgery were studied. The primary end point was in-hospital mortality; secondary end points were perioperative variables, intensive care, and in-hospital course. RESULTS Demographic data, comorbidity, and the European System for Cardiac Operative Risk Evaluation score (MECC 3.0%, ECC 3.5%, OPCABG 3.2%) were similar among the groups, but in-hospital mortality for elective and urgent/emergent patients was lower in the MECC and OPCABG groups (MECC 3.2%, OPCABG 3.7%, ECC 6.9%; p < 0.05). The number of distal anastomoses was lowest in the OPCABG group, but comparable for MECC and ECC patients. Postoperative ventilation time, release of creatinine kinase, catecholamine therapy, drainage loss, and transfusion requirements were lower in the MECC and OPCABG groups, whereas stay in the intensive care unit was shorter only in the latter (p < 0.05). CONCLUSIONS Minimal extracorporeal circulation is an easy and safe procedure for coronary artery bypass graft surgery. In selected patients, the advantages of MECC equal those of OPCABG. MECC should be considered as an alternative to OPCABG and standard ECC procedures.
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Affiliation(s)
- Thomas Puehler
- Department of Cardiothoracic Surgery, University Hospital Regensburg, Regensburg, Germany.
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Yilmaz A, Rehman A, Sonker U, Kloppenburg GT. Minimal Access Aortic Valve Replacement Using a Minimal Extracorporeal Circulatory System. Ann Thorac Surg 2009; 87:720-5. [DOI: 10.1016/j.athoracsur.2008.12.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2008] [Revised: 11/27/2008] [Accepted: 12/01/2008] [Indexed: 11/25/2022]
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Coronary artery bypass grafting with a minimized cardiopulmonary bypass circuit: A prospective, randomized trial. J Thorac Cardiovasc Surg 2009; 137:481-5. [DOI: 10.1016/j.jtcvs.2008.08.057] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2008] [Revised: 08/04/2008] [Accepted: 08/27/2008] [Indexed: 11/17/2022]
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Lehmann A. Ecallantide (DX-88), a plasma kallikrein inhibitor for the treatment of hereditary angioedema and the prevention of blood loss in on-pump cardiothoracic surgery. Expert Opin Biol Ther 2008; 8:1187-99. [DOI: 10.1517/14712598.8.8.1187] [Citation(s) in RCA: 56] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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The Use of the Mini-Cardiopulmonary Bypass Circuit in Robotic Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2008; 3:16-8. [DOI: 10.1097/01.imi.0000312975.89468.8f] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background Computer enabled robotic mitral valve repair cases have longer cross-clamp and perfusion times because of the more technically difficult procedure. To modify some of the well-documented side effects of standard cardiopulmonary bypass (CPB), we used a new mini-circuit on three robotic mitral cases. Methods Three patients having mitral valve repair (triangular resection of P2 and annuloplasty ring) using the daVinci Robot (Intuitive Surgical, Sunnyvale, CA) had circulatory support using a modified Resting Heart System (Medtronic, Inc., Fridley, MN), a vertically oriented space saving CPB configuration incorporating a high efficiency miniaturized oxygenator, centrifugal pump, shortened heparin coated tubing and an air evacuation system with a closed circuit. Results All patients had successful mitral repair (echo = 0 to trace residual leakage) under a cross-clamp time of 161 ± 54 minutes and perfusion time of 229 ± 31 minutes. No blood was given during CPB and 0.7 ± 1.2 red cell units after the CPB run and 0.7 ± 1.2 units during the postoperative course. Conclusion Miniaturized bypass circuit reducing the level of necessary anticoagulation, hemodilation, and blood trauma can be used despite the increased perfusion time necessary for robotic mitral surgery.
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Emery RW, Raikar GV, Murphy B, Rohan A, Nielsen K. The Use of the Mini-Cardiopulmonary Bypass Circuit in Robotic Mitral Valve Surgery. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2008. [DOI: 10.1177/155698450800300104] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Robert W. Emery
- Divisions of Cardiovascular Surgery, Regions and St. Joseph's Hospitals, St. Paul, Minnesota
| | - Goya V. Raikar
- Divisions of Cardiovascular Surgery, Regions and St. Joseph's Hospitals, St. Paul, Minnesota
| | - Barbara Murphy
- Divisions of Cardiovascular Surgery, Regions and St. Joseph's Hospitals, St. Paul, Minnesota
| | - Anton Rohan
- Divisions of Cardiovascular Surgery, Regions and St. Joseph's Hospitals, St. Paul, Minnesota
| | - Kris Nielsen
- Divisions of Cardiovascular Surgery, Regions and St. Joseph's Hospitals, St. Paul, Minnesota
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Snircova J, Jares M, Maly M, Straka Z, Spegar J, Vanek T. Postoperative Blood Loss in Coronary Surgery No Real Impact of Fibrinolysis Detected by Thromboelastography and D-Dimers. A Prospective, Randomized Study. Int Heart J 2008; 49:25-38. [DOI: 10.1536/ihj.49.25] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/18/2022]
Affiliation(s)
- Jana Snircova
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Kralovske Vinohrady University Hospital
| | - Martin Jares
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Kralovske Vinohrady University Hospital
| | - Marek Maly
- Department of Biostatistics and Informatics, National Institute of Public Health
| | - Zbynek Straka
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Kralovske Vinohrady University Hospital
| | - Jan Spegar
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Kralovske Vinohrady University Hospital
| | - Tomas Vanek
- Department of Cardiac Surgery, Third Faculty of Medicine, Charles University in Prague, Kralovske Vinohrady University Hospital
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Habib RH, Zacharias A, Schwann TA. Minimally Invasive Closed Circuit Versus Standard Cardiopulmonary Bypass: Is It Renoprotective? Ann Thorac Surg 2007; 84:1426-7. [PMID: 17889031 DOI: 10.1016/j.athoracsur.2007.04.093] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2007] [Revised: 03/05/2007] [Accepted: 04/23/2007] [Indexed: 10/22/2022]
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