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Elmahrouk AF, Shihata MS, Al-Radi OO, Arafat AA, Altowaity M, Alshaikh BA, Galal MN, Bogis AA, Al Omar HY, Assiri WJ, Jamjoom AA. Custodiol versus blood cardioplegia in pediatric cardiac surgery: a randomized controlled trial. Eur J Med Res 2023; 28:404. [PMID: 37798628 PMCID: PMC10552411 DOI: 10.1186/s40001-023-01372-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2023] [Accepted: 09/17/2023] [Indexed: 10/07/2023] Open
Abstract
BACKGROUND Blood-based cardioplegia is the standard myocardial protection strategy in pediatric cardiac surgery. Custadiol (histidine-tryptophan-ketoglutarate), an alternative, may have some advantages but is potentially less effective at myocardial protection. This study aimed to test whether custadiol is not inferior to blood-based cardioplegia in pediatric cardiac surgery. METHODS The study was designed as a randomized controlled trial with a blinded outcome assessment. All pediatric patients undergoing cardiac surgery with cardiopulmonary bypass and cardioplegia, including neonates, were eligible. Emergency surgery was excluded. The primary outcome was a composite of death within 30 days, an ICU stay longer than 5 days, or arrhythmia requiring intervention. Secondary endpoints included total hospital stay, inotropic score, cardiac troponin levels, ventricular function, and extended survival postdischarge. The sample size was determined a priori for a noninferiority design with an expected primary outcome of 40% and a clinical significance difference of 20%. RESULTS Between January 2018 and January 2021, 226 patients, divided into the Custodiol cardioplegia (CC) group (n = 107) and the blood cardioplegia (BC) group (n = 119), completed the study protocol. There was no difference in the composite endpoint between the CC and BC groups, 65 (60.75%) vs. 71 (59.66%), respectively (P = 0.87). The total length of stay in the hospital was 14 (Q2-Q3: 10-19) days in the CC group vs. 13 (10-21) days in the BC group (P = 0.85). The inotropic score was not significantly different between the CC and BC groups, 5 (2.6-7.45) vs. 5 (2.6-7.5), respectively (P = 0.82). The cardiac troponin level and ventricular function did not differ significantly between the two groups (P = 0.34 and P = 0.85, respectively). The median duration of follow-up was 32.75 (Q2-Q3: 18.73-41.53) months, and there was no difference in survival between the two groups (log-rank P = 0.55). CONCLUSIONS Custodial cardioplegia is not inferior to blood cardioplegia for myocardial protection in pediatric patients. Trial registration The trial was registered in Clinicaltrials.gov, and the ClinicalTrials.gov Identifier number is NCT03082716 Date: 17/03/2017.
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Affiliation(s)
- Ahmed F Elmahrouk
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia.
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt.
| | - Mohammad S Shihata
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Osman O Al-Radi
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
- Department of Surgery, Cardiac Surgery Section, King Abdulaziz University, Jeddah, Saudi Arabia
| | - Amr A Arafat
- Cardiothoracic Surgery Department, Tanta University, Tanta, Egypt
| | - Musleh Altowaity
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Bayan A Alshaikh
- Cardiac Surgery Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Mohamed N Galal
- Pediatric Cardiac Surgery Department, King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia
| | - Abdulbadee A Bogis
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
| | - Haneen Y Al Omar
- Research Centre, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Wesal J Assiri
- Department of Nursing, King Faisal Specialist Hospital and Research Centre, Jeddah, Saudi Arabia
| | - Ahmed A Jamjoom
- Cardiothoracic Surgery Department, King Faisal Specialist Hospital and Research Centre,, MBC J-16, P.O. Box: 40047, 21499, Jeddah, Saudi Arabia
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2
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Stoica S, Smartt HJM, Heys R, Sheehan K, Walker-Smith T, Parry A, Beringer R, Ttofi I, Evans R, Dabner L, Ghorbel MT, Lansdowne W, Reeves BC, Angelini GD, Rogers CA, Caputo M. Warm versus cold blood cardioplegia in paediatric congenital heart surgery: a randomized trial. Eur J Cardiothorac Surg 2023; 63:ezad041. [PMID: 36799559 PMCID: PMC10097434 DOI: 10.1093/ejcts/ezad041] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/20/2022] [Revised: 12/06/2022] [Indexed: 02/18/2023] Open
Abstract
OBJECTIVES Intermittent cold blood cardioplegia is commonly used in children, whereas intermittent warm blood cardioplegia is widely used in adults. We aimed to compare clinical and biochemical outcomes with these 2 methods. METHODS A single-centre, randomized controlled trial was conducted to compare the effectiveness of warm (≥34°C) versus cold (4-6°C) antegrade cardioplegia in children. The primary outcome was cardiac troponin T over the 1st 48 postoperative hours. Intensive care teams were blinded to group allocation. Outcomes were compared by intention-to-treat using linear mixed-effects, logistic or Cox regression. RESULTS 97 participants with median age of 1.2 years were randomized (49 to warm, 48 to cold cardioplegia); 59 participants (61%) had a risk-adjusted congenital heart surgery score of 3 or above. There were no deaths and 92 participants were followed to 3-months. Troponin release was similar in both groups [geometric mean ratio 1.07; 95% confidence interval (CI) 0.79-1.44; P = 0.66], as were other cardiac function measures (echocardiography, arterial and venous blood gases, vasoactive-inotrope score, arrhythmias). Intensive care stay was on average 14.6 h longer in the warm group (hazard ratio 0.52; 95% CI 0.34-0.79; P = 0.003), with a trend towards longer overall hospital stays (hazard ratio 0.66; 95% CI 0.43-1.02; P = 0.060) compared with the cold group. This could be related to more unplanned reoperations on bypass in the warm group compared to cold group (3 vs 1). CONCLUSIONS Warm blood cardioplegia is a safe and reproducible technique but does not provide superior myocardial protection in paediatric heart surgery.
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Affiliation(s)
- Serban Stoica
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Helena J M Smartt
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rachael Heys
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Karen Sheehan
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Terrie Walker-Smith
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Andrew Parry
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Richard Beringer
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Iakovos Ttofi
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Rebecca Evans
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Lucy Dabner
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | | | - William Lansdowne
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
| | - Barnaby C Reeves
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Gianni D Angelini
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
| | - Chris A Rogers
- Bristol Trials Centre, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol and Weston NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children, University Hospitals Bristol and Weston NHS Foundation Trust, Bristol, UK
- Bristol Heart Institute, University of Bristol, Bristol, UK
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3
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Feldmann M, Bataillard C, Ehrler M, Ullrich C, Knirsch W, Gosteli-Peter MA, Held U, Latal B. Cognitive and Executive Function in Congenital Heart Disease: A Meta-analysis. Pediatrics 2021; 148:peds.2021-050875. [PMID: 34561266 DOI: 10.1542/peds.2021-050875] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 07/26/2021] [Indexed: 11/24/2022] Open
Abstract
CONTEXT Cognitive function and executive function (EF) impairments contribute to the long-term burden of congenital heart disease (CHD). However, the degree and profile of impairments are insufficiently described. OBJECTIVE To systematically review and meta-analyze the evidence on cognitive function and EF outcomes in school-aged children operated for CHD and identify the risk factors for an unfavorable outcome. DATA SOURCES Cochrane, Embase, Medline, and PsycINFO. STUDY SELECTION Original peer-reviewed studies reporting cognitive or EF outcome in 5- to 17-year old children with CHD after cardiopulmonary bypass surgery. DATA EXTRACTION Results of IQ and EF assessments were extracted, and estimates were transformed to means and SE. Standardized mean differences were calculated for comparison with healthy controls. RESULTS Among 74 studies (3645 children with CHD) reporting total IQ, the summary estimate was 96.03 (95% confidence interval: 94.91 to 97.14). Hypoplastic left heart syndrome and univentricular CHD cohorts performed significantly worse than atrial and ventricular septum defect cohorts (P = .0003; P = .027). An older age at assessment was associated with lower IQ scores in cohorts with transposition of the great arteries (P = .014). Among 13 studies (774 children with CHD) reporting EF compared with controls, the standardized mean difference was -0.56 (95% confidence interval: -0.65 to -0.46) with no predilection for a specific EF domain or age effect. LIMITATIONS Heterogeneity between studies was large. CONCLUSIONS Intellectual impairments in CHD are frequent, with severity and trajectory depending on the CHD subtype. EF performance is poorer in children with CHD without a specific EF profile. The heterogeneity in studied populations and applied assessments is large. A uniform testing guideline is urgently needed.
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Affiliation(s)
- Maria Feldmann
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Célina Bataillard
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Melanie Ehrler
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Cinzia Ullrich
- Child Development Centre and Children's Research Centre.,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
| | - Walter Knirsch
- Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland.,Pediatric Cardiology, Pediatric Heart Center, and
| | | | - Ulrike Held
- Department of Biostatistics, Epidemiology, Biostatistics, and Prevention Institute, University of Zurich, Zurich, Switzerland
| | - Beatrice Latal
- Child Development Centre and Children's Research Centre .,Children's Research Centre, University Children's Hospital Zurich, Zurich, Switzerland
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Zhang J, Deng L, Wang X, Song F, Hou H, Qiu Y. Effect of Forced-Air Warming Blanket on Perioperative Hypothermia in Elderly Patients Undergoing Laparoscopic Radical Resection of Colorectal Cancer. Ther Hypothermia Temp Manag 2021; 12:68-73. [PMID: 34232804 DOI: 10.1089/ther.2021.0010] [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: 11/13/2022] Open
Abstract
The study aimed to evaluate the effect of forced-air warming blanket combined with conventional thermal insulation measures on inadvertent perioperative hypothermia (IPH) in elderly patients undergoing laparoscopic radical resection of colorectal cancer. A total of 70 elderly patients undergoing laparoscopic radical resection of colorectal cancer with general anesthesia were included, and divided into conventional warming treatment (CT) group or forced-air warming treatment (FT) group. In the FT group, based on the conventional warming strategy, patients received prewarming with the forced-air warming blanket (38°C) for ≥20 minutes before induction of anesthesia, and received this treatment continuously during operation. The core body temperature, recovery time from anesthesia, extubating time, and length of stay in the postanesthesia care unit were recorded. The incidence of IPH and postoperative shivering was observed. The incidence of IPH was significantly lower, and average minimum body temperature during the operation was significantly higher in the FT group than that in the CT group (5.7% vs. 22.8% and 36.23°C vs. 35.89°C, respectively). The intraoperative body temperature decreased less (0.32°C vs. 0.69°C), the recovery time from anesthesia was faster (12.8 minutes vs. 17.1 minutes), and the incidence of postoperative shivering was less (2.8% vs. 28.6%) in the FT group than the CT group. In elderly patients undergoing laparoscopic radical resection of colorectal cancer, use of forced-air warming blankets combined with conventional warming measures is more effective to maintain normal body temperature during the perioperative period and reduce the incidence of IPH.
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Affiliation(s)
- Junxia Zhang
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Liqin Deng
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Xiaomei Wang
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Fengxiang Song
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Haitao Hou
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yuxue Qiu
- Department of Anesthesiology, General Hospital of Ningxia Medical University, Yinchuan, China
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5
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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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6
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Zhang P, Liu J, Tong Y, Guo S, Bai L, Jin Y, Feng Z, Zhao J, Li Y. Investigation of myocardial protection during pediatric CPB: Practical experience in 100 Chinese hospitals. Perfusion 2020; 37:5-13. [PMID: 33345699 DOI: 10.1177/0267659120983107] [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: 11/17/2022]
Abstract
Many measures have been proposed for myocardial protection in pediatric congenital heart surgeries, but little data is available for China. This study investigates myocardial protection strategies in pediatric cardiopulmonary bypass (CPB) throughout China. Online questionnaires were delivered to 100 hospitals in 27 provinces. The number of yearly on-pump pediatric cardiovascular surgeries in these hospitals varied greatly. About 91.0% of respondents believe that each surgery should have at least two perfusionists, while only 64.0% of hospitals actually met this requirement. For pediatric patients, crystalloid cardioplegia was more prevalent than blood-based cardioplegia. Histidine-tryptophan-ketoglutarate solution and St. Thomas crystalloid solution were dominant among crystalloid cardioplegia. Del Nido cardioplegia and St. Thomas blood-based cardioplegia ranked the top two in the popularity of blood-based cardioplegia. Dosages varied among different kinds of cardioplegia. In the choice of different cardioplegia, perfusionists mainly focused on myocardial protective effect and cost. Hypothermia of cardioplegia solution was maintained by ice buckets in 3/4 of the hospitals in this survey. In conclusion, the essence of myocardial protection management during pediatric CPB was cardiac arrest induced by cardioplegia under systemic hypothermia. However, there is no uniform standard for the type of cardioplegia, or dosages. Therefore, well-designed multicenter randomized controlled trials are warranted to provide tangible evidence for myocardial protection of cardioplegia in pediatric CPB.
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Affiliation(s)
- Peiyao Zhang
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Jinping Liu
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yuanyuan Tong
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Shengwen Guo
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Liting Bai
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yu Jin
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Zhengyi Feng
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Ju Zhao
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
| | - Yixuan Li
- State Key Laboratory of Cardiovascular Disease, Department of Cardiopulmonary Bypass, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, China
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Heys R, Stoica S, Angelini G, Beringer R, Evans R, Ghorbel M, Lansdowne W, Parry A, Pieles G, Reeves B, Rogers C, Saxena R, Sheehan K, Smith S, Walker-Smith T, Tulloh RM, Caputo M. Intermittent antegrade warm-blood versus cold-blood cardioplegia in children undergoing open heart surgery: a protocol for a randomised controlled study (Thermic-3). BMJ Open 2020; 10:e036974. [PMID: 33055113 PMCID: PMC7559029 DOI: 10.1136/bmjopen-2020-036974] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
INTRODUCTION Surgical repair of congenital heart defects often requires the use of cardiopulmonary bypass (CPB) and cardioplegic arrest. Cardioplegia is used during cardiac surgery requiring CPB to keep the heart still and to reduce myocardial damage as a result of ischaemia-reperfusion injury. Cold cardioplegia is the prevalent method of myocardial protection in paediatric patients; however, warm cardioplegia is used as part of usual care throughout the UK in adults. We aim to provide evidence to support the use of warm versus cold blood cardioplegia on clinical and biochemical outcomes during and after paediatric congenital heart surgery. METHODS AND ANALYSIS We are conducting a single-centre randomised controlled trial in paediatric patients undergoing operations requiring CPB and cardioplegic arrest at the Bristol Royal Hospital for Children. We will randomise participants in a 1:1 ratio to receive either 'cold-blood cardioplegia' or 'warm-blood cardioplegia'. The primary outcome will be the difference between groups with respect to Troponin T levels over the first 48 postoperative hours. Secondary outcomes will include measures of cardiac function; renal function; cerebral function; arrythmias during and postoperative hours; postoperative blood loss in the first 12 hours; vasoactive-inotrope score in the first 48 hours; intubation time; chest and wound infections; time from return from theatre until fit for discharge; length of postoperative hospital stay; all-cause mortality to 3 months postoperative; myocardial injury at the molecular and cellular level. ETHICS AND DISSEMINATION This trial has been approved by the London - Central Research Ethics Committee. Findings will be disseminated to the academic community through peer-reviewed publications and presentation at national and international meetings. Patients will be informed of the results through patient organisations and newsletters to participants. TRIAL REGISTRATION NUMBER ISRCTN13467772; Pre-results.
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Affiliation(s)
- Rachael Heys
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Serban Stoica
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Gianni Angelini
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Heart Institue, University of Bristol, Bristol, UK
| | - Richard Beringer
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Rebecca Evans
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | | | - William Lansdowne
- 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
| | - Guido Pieles
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Barnaby Reeves
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Chris Rogers
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
| | - Rohit Saxena
- Cardiac Intensive Care, Great Ormond Street Hospital For Children NHS Foundation Trust, London, UK
| | - Karen Sheehan
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Stella Smith
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | - Terrie Walker-Smith
- Bristol Trials Centre, Clincal Trials and Evaulation Unit, Bristol Medical School, University of Bristol, Bristol, UK
| | - Robert Mr Tulloh
- National Institute for Health Research Bristol Biomedical Research Centre, University Hospitals Bristol NHS Foundation Trust and University of Bristol, Bristol, UK
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
- Bristol Heart Institue, University of Bristol, Bristol, UK
| | - Massimo Caputo
- Bristol Royal Hospital for Children, University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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8
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White matter injury and neurodevelopmental disabilities: A cross-disease (dis)connection. Prog Neurobiol 2020; 193:101845. [PMID: 32505757 DOI: 10.1016/j.pneurobio.2020.101845] [Citation(s) in RCA: 37] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2019] [Revised: 05/19/2020] [Accepted: 06/01/2020] [Indexed: 12/13/2022]
Abstract
White matter (WM) injury, once known primarily in preterm newborns, is emerging in its non-focal (diffused), non-necrotic form as a critical component of subtle brain injuries in many early-life diseases like prematurity, intrauterine growth restriction, congenital heart defects, and hypoxic-ischemic encephalopathy. While advances in medical techniques have reduced the number of severe outcomes, the incidence of tardive impairments in complex cognitive functions or psychopathology remains high, with lifelong detrimental effects. The importance of WM in coordinating neuronal assemblies firing and neural groups synchronizing within multiple frequency bands through myelination, even mild alterations in WM structure, may interfere with the cognitive performance that increasing social and learning demands would exploit tardively during children growth. This phenomenon may contribute to explaining longitudinally the high incidence of late-appearing impairments that affect children with a history of perinatal insults. Furthermore, WM abnormalities have been highlighted in several neuropsychiatric disorders, such as autism and schizophrenia. In this review, we gather and organize evidence on how diffused WM injuries contribute to neurodevelopmental disorders through different perinatal diseases and insults. An insight into a possible common, cross-disease, mechanism, neuroimaging and monitoring, biomarkers, and neuroprotective strategies will also be presented.
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Luo Q, Su Z, Jia Y, Liu Y, Wang H, Zhang L, Li Y, Wu X, Liu Q, Yan F. Risk Factors for Prolonged Mechanical Ventilation After Total Cavopulmonary Connection Surgery: 8 Years of Experience at Fuwai Hospital. J Cardiothorac Vasc Anesth 2020; 34:940-948. [DOI: 10.1053/j.jvca.2019.10.043] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Revised: 10/21/2019] [Accepted: 10/26/2019] [Indexed: 02/07/2023]
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10
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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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11
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Xu H, Xu G, Ren C, Liu L, Wei L. Effect of forced-air warming system in prevention of postoperative hypothermia in elderly patients: A Prospective controlled trial. Medicine (Baltimore) 2019; 98:e15895. [PMID: 31145350 PMCID: PMC6708676 DOI: 10.1097/md.0000000000015895] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
Abstract
BACKGROUND Postoperative hypothermia in elderly patients is a well-known serious complication as it impairs wound healing, induces coagulopathy, increases the risk of blood loss, enhances oxygen consumption, and precipitates cardiac arrhythmias. We conducted this randomized controlled trial to evaluate the effect of a forced-air warming system on rewarming elderly patients undergoing total knee or hip arthroplasty. METHODS We recruited 243 elderly patients undergoing total knee or hip arthroplasty between May and December 2016. They were divided into three groups according to a computer-generated randomization table: group C (n = 78, rewarmed with only a regular blanket), group F1 (n = 82, rewarmed with a forced-air warming system set at 38°C), and group F2 (n = 83, rewarmed with a forced-air warming system set at 42°C). The nasopharyngeal temperature was recorded every 5 min for the first half hour, then every 10 min up to the end of the PACU (postanesthesia care unit) stay. The primary outcome was the rewarming time. The rewarming rate, increase in nasopharyngeal temperature (compared to the start of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded. RESULTS No significant differences were found among the three groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the elderly patients in groups C and F1, both the heart rate and mean arterial pressure of those in group F2 were significantly increased 20 min after arrival at the PACU (P < .05). Patients in group F2 had the shortest rewarming time (35.89 ± 6.45 min, P < .001), highest rewarming efficiency (0.028 ± 0.001°C/min, P < .001), and fastest increased nasopharyngeal temperature among the three groups. Moreover, the elderly patients in group F2 had lower incidences of arrhythmia and shivering (P < .05). CONCLUSIONS The use of a forced-air warming system set at 42°C was shown to be the most effective way of rewarming elderly patients with postoperative hypothermia.
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12
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Liu Y, Xing J, Li Y, Luo Q, Su Z, Zhang X, Zhang H. Chronic hypoxia–induced Cirbp hypermethylation attenuates hypothermic cardioprotection via down-regulation of ubiquinone biosynthesis. Sci Transl Med 2019; 11:11/489/eaat8406. [PMID: 31019028 DOI: 10.1126/scitranslmed.aat8406] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2018] [Revised: 10/25/2018] [Accepted: 03/25/2019] [Indexed: 12/24/2022]
Abstract
Therapeutic hypothermia is commonly used during cardiopulmonary bypass (CPB) to protect the heart against myocardial injury in cardiac surgery. Patients who suffer from chronic hypoxia (CH), such as those with certain heart or lung conditions, are at high risk of severe myocardial injury after cardiac surgery, but the underlying mechanisms are unknown. This study tested whether CH attenuates hypothermic cardioprotection during CPB. Using a rat model of CPB, we found that hypothermic cardioprotection was impaired in CH rats but was preserved in normoxic rats. Cardiac proteomes showed that cold-inducible RNA binding protein (CIRBP) was significantly (P = 0.03) decreased in CH rats during CPB. Methylation analysis of neonatal rat cardiomyocytes under CH and myocardium specimens from patients with CH showed that CH induced hypermethylation of the Cirbp promoter region, resulting in its depression and failure to respond to cold stress. Cirbp-knockout rats showed attenuated hypothermic cardioprotection, whereas Cirbp-transgenic rats showed an enhanced response. Proteomics analysis revealed that the cardiac ubiquinone biosynthesis pathway was down-regulated during CPB in Cirbp-knockout rats, resulting in a significantly (P = 0.01) decreased concentration of ubiquinone (CoQ10). Consequently, cardiac oxidative stress was aggravated and adenosine 5′-triphosphate production was impaired, leading to increased myocardial injury during CPB. CoQ10-supplemented cardioplegic solution improved cardioprotection in rats exposed to CH, but its effect was limited in normoxic rats. Our study suggests that an individualized cardioprotection strategy should be used to fully compensate for the consequences of epigenetic modification of Cirbp in patients with CH who require therapeutic hypothermia.
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Affiliation(s)
- Yiwei Liu
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Junyue Xing
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Heart Center of Henan Provincial People Hospital and Key Laboratory of Cardiac Regenerative Medicine, National Health Commission, Zhengzhou 451464, China
| | - Yongnan Li
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Department of Cardiac Surgery, Lanzhou University Second Hospital, Lanzhou University, Lanzhou 730030, China
| | - Qipeng Luo
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Zhanhao Su
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
| | - Xiaoling Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Heart Center of Henan Provincial People Hospital and Key Laboratory of Cardiac Regenerative Medicine, National Health Commission, Zhengzhou 451464, China
| | - Hao Zhang
- State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China.
- Heart Center of Henan Provincial People Hospital and Key Laboratory of Cardiac Regenerative Medicine, National Health Commission, Zhengzhou 451464, China
- Center for Pediatric Cardiac Surgery, Fuwai Hospital, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing 100037, China
- Heart Center and Shanghai Institute of Pediatric Congenital Heart Diseases, Shanghai Children's Medical Center, Shanghai Jiaotong University School of Medicine, Shanghai 200127, China
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13
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Hannon CE, Osman Z, Grant C, Chung EML, Corno AF. Part II. Comparison of Neurodevelopmental Outcomes Between Normothermic and Hypothermic Pediatric Cardiopulmonary Bypass. Front Pediatr 2019; 7:447. [PMID: 31750278 PMCID: PMC6848377 DOI: 10.3389/fped.2019.00447] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Accepted: 10/15/2019] [Indexed: 12/02/2022] Open
Abstract
Objectives: In the previous study we demonstrated that normothermic cardiopulmonary bypass (N-CPB, ≥35°C) provided better early clinical outcomes compared to mild/moderate hypothermic cardiopulmonary bypass (H-CPB, 28-34°C) for congenital heart surgery. In this follow-up study we compare early neurodevelopmental outcomes 2-3 years post-surgery. Methods: In this retrospective, non-randomized observational study, the medical notes of children from our previous cohort were reviewed after 2-3 years. Demographic and neurodevelopmental outcomes were tabulated to enable blinded statistical analysis comparing outcomes between N-CPB and H-CPB surgery for congenital heart defects. Multivariate logistic regression models were developed to identify any differences in outcomes after adjustment for confounders. Results: Ninety-five children who underwent H-CPB (n = 50) or N-CPB (n = 45) were included. The proportions of patients with one or more adverse neurodevelopmental outcomes 2-3 years later were 14/50 (28.0%) in the H-CPB group and 11/45 (24.4%) in N-CPB, which was not significantly different between groups (p = 0.47). The two CPB groups were balanced for demographic and surgical risk factors, with the exception of genetic conditions. A higher incidence of H-CPB patients acquired learning difficulties [23.1% compared to 2.56% for N-CPB (p = 0.014)] and neurological deficits [30.8% compared to 7.69% for N-CPB (p = 0.019)], but these differences were not robust to adjustment for genetic syndromes. Conclusions: Our study did not reveal any significant differences in early neurodevelopmental outcomes between H-CPB or N-CPB surgery for congenital heart defects. The most important factor in predicting outcomes was, as expected, the presence of a genetic syndrome. We found no evidence that CPB temperature affects early neurodevelopmental outcomes.
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Affiliation(s)
- Claire E Hannon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Zachary Osman
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Cathy Grant
- Department of Paediatric Neuropsychology, Nottingham University Hospital NHS Trust, Nottingham, United Kingdom
| | - Emma M L Chung
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,NIHR Leicester Cardiovascular Research Centre, Leicester, United Kingdom.,Department of Medical Physics, University of Leicester, Leicester, United Kingdom
| | - Antonio F Corno
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom.,East Midlands Congenital Heart Centre, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
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14
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Romolo H, Hernisa L, Fakhri D, Rachmat J, Dwi Mulia D, Rahmat B. Comparison between blood and non-blood cardioplegia in tetralogy of Fallot. Asian Cardiovasc Thorac Ann 2018; 27:75-79. [PMID: 30580530 DOI: 10.1177/0218492318820992] [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: 11/16/2022]
Abstract
BACKGROUND Cardioplegia is an integral part of myocardial protection. The superiority of blood cardioplegia in adult patients has been reported. However, this is yet to be studied in cyanotic pediatric patients. METHODS A randomized open-label trial was conducted in 70 patients with tetralogy of Fallot. They were divided into two groups: 35 patients had crystalloid cardioplegia (controls), and 35 had blood cardioplegia. Lactate and coronary oxygen extraction in arterial blood and the coronary sinus were measured immediately after cessation of cardiopulmonary bypass, 15 and 30 min later. Postoperative mortality, major adverse cardiac events, mechanical ventilation time, inotrope administration, arrhythmias, right ventricular function, intensive care unit and hospital length of stay were observed. RESULTS There were no significant differences in clinical outcomes or lactate levels. There was a significant difference in coronary oxygen extraction immediately and 15 min after cessation of cardiopulmonary bypass ( p = 0.038, p = 0.015). CONCLUSION Blood cardioplegia gave a better postoperative oxygen extraction value but there were no differences in myocardial damage or clinical outcome between the two groups.
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Affiliation(s)
- Harvey Romolo
- 1 Department of Pediatric Cardiac Surgery, Rumah Sakit Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia
| | - Latifa Hernisa
- 1 Department of Pediatric Cardiac Surgery, Rumah Sakit Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia
| | - Dicky Fakhri
- 1 Department of Pediatric Cardiac Surgery, Rumah Sakit Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia
| | - Jusuf Rachmat
- 1 Department of Pediatric Cardiac Surgery, Rumah Sakit Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia
| | - Dina Dwi Mulia
- 2 Department of Surgery, Rumah Sakit Cipto Mangunkusumo, Faculty of Medicine Universitas Indonesia, Jakarta, Indonesia
| | - Budi Rahmat
- 1 Department of Pediatric Cardiac Surgery, Rumah Sakit Jantung dan Pembuluh Darah Nasional Harapan Kita, Jakarta, Indonesia
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15
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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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16
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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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17
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Mylonas KS, Tzani A, Metaxas P, Schizas D, Boikou V, Economopoulos KP. Blood Versus Crystalloid Cardioplegia in Pediatric Cardiac Surgery: A Systematic Review and Meta-analysis. Pediatr Cardiol 2017; 38:1527-1539. [PMID: 28948337 DOI: 10.1007/s00246-017-1732-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 09/13/2017] [Indexed: 01/01/2023]
Abstract
The benefit of blood cardioplegia (BCP) compared to crystalloid cardioplegia (CCP) is still debatable. Our aim was to systematically review and synthesize all available evidence on the use of BCP and CCP to assess if any modality provides superior outcomes in pediatric cardiac surgery. A systematic literature search of the PubMed and Cochrane databases was performed with respect to the PRISMA statement (end-of-search date: January 30th, 2017). We extracted data on study design, demographics, cardioplegia regimens, and perioperative outcomes as well as relevant biochemical markers, namely cardiac troponin I (cTnI), lactate, and ATP levels at baseline, after reperfusion and postoperatively at 1, 4, 12, and 24 h as applicable. Data were appropriately pooled using random and mixed effects models. Our systematic review includes 56 studies reporting on a total of 7711 pediatric patients. A meta-analysis of the 10 eligible studies directly comparing BCP (n = 416) to CCP (n = 281) was also performed. There was no significant difference between the two groups with regard to cTnI and Lac at any measured time point, ATP levels after reperfusion, length of intensive care unit stay (WMD: -0.08, 95% CI -1.52 to 1.36), length of hospital stay (WMD: 0.13, 95% CI -0.85 to 1.12), and 30-day mortality (OR 1.11, 95% CI 0.43-2.88). Only cTnI levels at 4 h postoperatively were significantly lower with BCP (WMD: -1.62, 95% CI -2.07 to -1.18). Based on the available data, neither cardioplegia modality seems to be superior in terms of clinical outcomes, ischemia severity, and overall functional recovery.
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Affiliation(s)
- Konstantinos S Mylonas
- Division of Pediatric Surgery, Massachusetts General Hospital, Harvard Medical School, Warren 11, 55 Fruit Street, Boston, MA, 02114, USA. .,Surgery Working Group, Society of Junior Doctors, Athens, Greece.
| | - Aspasia Tzani
- Surgery Working Group, Society of Junior Doctors, Athens, Greece
| | | | - Dimitrios Schizas
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,First Department of Surgery, Laiko General Hospital, National and Kapodistrian University of Athens, Athens, Greece
| | | | - Konstantinos P Economopoulos
- Surgery Working Group, Society of Junior Doctors, Athens, Greece.,Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
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18
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Liu X, Shi Y, Ren C, Li X, Zhang Z. Effect of an electric blanket plus a forced-air warming system for children with postoperative hypothermia: A randomized controlled trial. Medicine (Baltimore) 2017; 96:e7389. [PMID: 28658172 PMCID: PMC5500094 DOI: 10.1097/md.0000000000007389] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
BACKGROUND Postoperative hypothermia in children in postanesthesia care unit (PACU) is a well-known serious complication as it increases the risk of blood loss, wound infections, and cardiac arrhythmias. We conducted this prospective randomized controlled trial to evaluate the effect of an electric blanket plus a forced-air warming system on rewarming in children with postoperative hypothermia. METHODS We recruited 346 children (aged < 3 years) who were admitted to a PACU after surgery and diagnosed with hypothermia between March and August 2016. They were randomly divided into 3 groups: group C (n = 108, rewarmed with only a regular blanket), group E (n = 123, rewarmed with a regular blanket plus an electric blanket), and group EF (n = 115, rewarmed with an electric blanket plus a forced-air warming system). From the beginning of rewarming, the rectal temperature was recorded every 5 minutes for the first half hour, then every 10 minutes up to when the patient left the PACU. The primary outcome was the rewarming time of children (from the beginning of rewarming to recovery of normothermia). The rewarming rate, increase in temperature (compared with the beginning of rewarming), hemodynamics, recovery time, and incidences of adverse effects were recorded. RESULTS There were no significant differences among the 3 groups in terms of the baseline clinical characteristics, use of narcotic drugs, intraoperative temperature, and hemodynamics (P > .05). Compared with the children in groups C and E, both the heart rate and mean arterial pressure of those in group EF were significantly increased after 10 minutes of arriving at the PACU (P < .05). Children in the EF group had the shortest rewarming time (35.61 ± 16.45 minutes, P < .001) and highest rewarming efficiency (0.028 ± 0.001 °C/min, P < .001), while there was no evidence of a difference in increased rectal temperature among the 3 groups. Children in the EF group had lower incidences of arrhythmia, shivering, nausea, and vomiting (P < .05). CONCLUSION The combination of an electric blanket and a forced-air warming system was shown to be an effective rewarming method for children with postoperative hypothermia.
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Affiliation(s)
- Xiaohui Liu
- Department of Anesthesiology Department of Operation Room Department of Pediatrics, Liaocheng People's Hospital, Liaocheng, Shandong, China
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Wang ZH, An Y, Du MC, Qin TJ, Liu YB, Xu HZ, Yang LQ. Clinical Assessment of Histidine-Tryptophan-Ketoglutarate Solution and Modified St. Thomas' Solution in Pediatric Cardiac Surgery of Tetralogy of Fallot. Artif Organs 2016; 41:470-475. [PMID: 27878830 DOI: 10.1111/aor.12771] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/12/2015] [Revised: 03/10/2016] [Accepted: 03/21/2016] [Indexed: 11/29/2022]
Abstract
The objective of this study is to compare the myocardium protective effect of Bretschneider's histidine-tryptophan-ketoglutarate (HTK) solution versus Modified St. Thomas' (STH) solution in pediatric cardiac surgery of Tetralogy of Fallot (TOF). Seventy-seven pediatric patients of TOF who received the total surgical repair were reviewed, from January 2014 to October 2015. A horizontal comparison between HTK solution and modified STH solution has been made since the HTK solutions were started to be used in our hospital. The patients were divided into the HTK group (n = 35) and the STH group (n = 33). The perioperative values of the groups were assessed in this study. The primary endpoints including spontaneous cardiac re-beating time, intensive care unit (ICU) stay, overall stay, mechanical ventilation postoperation, postoperation stay, overall stay, and perioperative echocardiographic results were analyzed in this study. We found that spontaneous cardiac re-beating time of the HTK group was significantly shorter than that of the STH group (0.26 min ± 0.56 vs. 1.33 ± 1.02, P < 0.001). There were no significant differences between the two groups in ICU stay (P = 0.29), postoperative mechanical ventilation time (P = 0.84), overall stay (0.73); and the mortalities of the two groups were similar (2.9 vs. 3.0%). Aimed at pediatric cardiac surgery of TOF, this study suggests that with similar aorta cross-clamping time, modified STH solution is as safe as HTK solution.
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Affiliation(s)
- Zhao-Hui Wang
- Department of Cardiac Surgery, People's Hospital of Dongyang, Dongyang
| | - Yong An
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University
| | - Ming-Cheng Du
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University
| | - Ting-Jiang Qin
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University
| | - Yin-Bei Liu
- Department of Cardiothoracic Surgery, Children's Hospital of Chongqing Medical University
| | - Hong-Zhen Xu
- Department of Anesthesiology and Cardiovascular Perfusion, Children's Hospital of Chongqing Medical University, Chongqing, R.P. China
| | - Li-Qun Yang
- Department of Anesthesiology and Cardiovascular Perfusion, Children's Hospital of Chongqing Medical University, Chongqing, R.P. China
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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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Durandy YD. Is there a rationale for short cardioplegia re-dosing intervals? World J Cardiol 2015; 7:658-664. [PMID: 26516420 PMCID: PMC4620077 DOI: 10.4330/wjc.v7.i10.658] [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: 05/26/2015] [Revised: 08/16/2015] [Accepted: 09/16/2015] [Indexed: 02/06/2023] Open
Abstract
While cardioplegia has been used on millions of patients during the last decades, the debate over the best technique is still going on. Cardioplegia is not only meant to provide a non-contracting heart and a field without blood, thus avoiding the risk of gas emboli, but also used for myocardial protection. Its electromechanical effect is easily confirmed through direct vision of the heart and continuous electrocardiogram monitoring, but there is no consensus on the best way to assess the quality of myocardial protection. The optimal approach is thus far from clear and the considerable amount of literature on the subject fails to provide a definite answer. Cardioplegia composition (crystalloid vs blood, with or without various substrate enhancement), temperature and site(s) of injection have been extensively researched. While less frequently studied, re-dosing interval is also an important factor. A common and intuitive idea is that shorter re-dosing intervals lead to improved myocardial protection. A vast majority of surgeons use re-dosing intervals of 20-30 min, or even less, during coronary artery bypass graft and multidose cardioplegia has been the “gold standard” for decades. However, one-shot cardioplegia is becoming more commonly used and is likely to be a valuable alternative. Some surgeons prefer the comfort of single-shot cardioplegia while others feel more confident with shorter re-dosing intervals. There is no guarantee that a single strategy can be safely applied to all patients, irrespective of their age, comorbidities or cardiopathy. The goal of this review is to discuss the rationale for short re-dosing intervals.
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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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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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Fang Y, Long C, Lou S, Guan Y, Fu Z. Blood versus crystalloid cardioplegia for pediatric cardiac surgery: a meta-analysis. Perfusion 2014; 30:529-36. [PMID: 25336140 DOI: 10.1177/0267659114556402] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVE Blood and crystalloid cardioplegia are the main myocardial protective solutions used in pediatric cardiac surgery. However, the effectiveness of these two solutions on myocardial metabolism, reperfusion injury and clinical outcomes in pediatric patients is still under debate. The purpose of this meta-analysis was to compare the efficacy of these two cardioplegia solutions in pediatric cardiac surgery. METHODS Keyword searches were performed on PUBMED, EMBASE and The Cochrane Library for randomized, controlled, clinical studies which were primarily comparing blood and crystalloid cardioplegia in pediatric cardiac surgery and provided data of postoperative cardiac troponin I (cTnI), lactate, mechanical ventilation time, length of intensive care unit (ICU) stay and inotropic support. Databases were searched from 1966 to June 2013 and were restricted to peer-reviewed English language publications of human subjects. We summarized the combined results of the data as mean difference (MD, when outcome measurements were made on the same scale) or standard mean difference (SMD, when the studies assess the same outcome with different scales), with 95% confidence intervals. RESULTS Five studies were identified, with a total of 323 patients. Lactate level after cardiopulmonary bypass (CPB) was significantly lower after blood cardioplegia compared with crystalloid cardioplegia (SMD 1.09, 95%CI 0.12 to 2.06, p=0.03); cTnI release postoperatively at 4-6 h (MD 0.92 ng/ml, 95%CI -0.13 to 1.97, p=0.09), 12 h (MD 0.2 ng/ml, 95% CI -0.43 to 0.84, p=0.53) and 24 h (MD 0.98 ng/ml, 95%CI -0.26 to 2.22, p=0.12) was not significantly different between the groups; ventilation duration (MD 5.15 hours, 95%CI -7.51 to 17.81, p=0.42) and length of ICU stay (SMD -0.3, 95%CI -0.80 to 0.21, p=0.25) were not significantly different between the groups either. CONCLUSION Myocardial metabolism was better in the blood cardioplegia group compared with the crystalloid cardioplegia group. However, there was no evidence of improvement in myocardial damage or clinical outcome for either cardioplegia solution.
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Affiliation(s)
- Y Fang
- Department of Extracorporeal Circulation, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - C Long
- Department of Extracorporeal Circulation, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - S Lou
- Department of Extracorporeal Circulation, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Y Guan
- Department of Extracorporeal Circulation, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
| | - Z Fu
- Department of Extracorporeal Circulation, State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College, Beijing, P.R. China
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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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Rungatscher A, Linardi D, Giacomazzi A, Tessari M, Menon T, Mazzucco A, Faggian G. Cardioprotective effect of δ-opioid receptor agonist vs mild therapeutic hypothermia in a rat model of cardiac arrest with extracorporeal life support. Resuscitation 2013; 84:244-8. [DOI: 10.1016/j.resuscitation.2012.06.016] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2012] [Revised: 06/11/2012] [Accepted: 06/20/2012] [Indexed: 12/22/2022]
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Sá MPBO, Rueda FG, Ferraz PE, Chalegre ST, Vasconcelos FP, Lima RC. Is there any difference between blood and crystalloid cardioplegia for myocardial protection during cardiac surgery? A meta-analysis of 5576 patients from 36 randomized trials. Perfusion 2012; 27:535-46. [DOI: 10.1177/0267659112453754] [Citation(s) in RCA: 37] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Objective: To compare the efficacy of blood versus crystalloid cardioplegia for myocardial protection in patients undergoing cardiac surgery. Methods: MEDLINE, EMBASE, CENTRAL/CCTR, SciELO, LILACS, Google Scholar and reference lists of relevant articles were searched for clinical studies that reported in-hospital outcomes after blood or crystalloid cardioplegia for myocardial protection during cardiac surgery procedures from 1966 to 2011. The principal summary measures were risk ratio (RR) for blood compared to crystalloid cardioplegia with 95% Confidence Interval (CI) and P values (considered statistically significant when <0.05). The RRs were combined across studies using the DerSimonian-Laird random effects model and fixed effects model using the Mantel-Haenszel model - both models were weighted. The meta-analysis was completed using the software Comprehensive Meta-Analysis version 2 (Biostat Inc., Englewood, New Jersey). Results: Thirty-six studies (randomized trials) were identified and included a total of 5576 patients (2834 for blood and 2742 for crystalloid). There was no significant difference between the blood and crystalloid groups in the risk for death (risk ratio [RR] 0.951, 95% CI 0.598 to 1.514, P=0.828, for both effect models) or myocardial infarction (RR 0.795, 95% CI 0.547 to 1.118, P=0.164, for both effect models) or low cardiac output syndrome (RR 0.765, 95% CI 0.580 to 1.142, P=0.094, for the fixed effect model; RR 0.690, 95% CI 0.480 to 1.042, P=0.072, for the random effect model). It was observed that there was no publication bias or heterogeneity of effects about any outcome. Conclusion: We found evidence that argues against any superiority in terms of hard outcomes between blood or crystalloid cardioplegia for myocardial protection during cardiac surgery.
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Affiliation(s)
- MPBO Sá
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - FG Rueda
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - PE Ferraz
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - ST Chalegre
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
| | - FP Vasconcelos
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
| | - RC Lima
- Division of Cardiovascular Surgery of Pronto Socorro Cardiològico de Pernambuco – PROCAPE, Recife – Brazil
- University of Pernambuco – UPE, Recife – Brazil
- Nucleus of Postgraduate and Research in Health Sciences, Faculty of Medical Sciences and Biological Sciences Instituite – FCM/ICB, Recife – Brazil
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Patel PA, Desai ND. Con: Cardiac surgery should be performed under warm conditions. J Cardiothorac Vasc Anesth 2012; 26:949-51. [PMID: 22790159 DOI: 10.1053/j.jvca.2012.05.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/02/2012] [Indexed: 11/11/2022]
Affiliation(s)
- Prakash A Patel
- Department of Anesthesiology and Critical Care, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA 19104, USA.
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Pouard P, Bojan M. Editorial comment: A tiny light in the darkness of pediatric myocardial protection and cardiopulmonary bypass! Eur J Cardiothorac Surg 2011; 40:1390-1. [PMID: 21903409 DOI: 10.1016/j.ejcts.2011.06.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2011] [Revised: 06/05/2011] [Accepted: 06/07/2011] [Indexed: 11/26/2022] Open
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