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Echieh CP, Ryan A, Cherian A, Rohilla Y, Wang K, Kazui T. Preemptive Impella 5.5 insertion to reduce operative risk in high-risk cardiac surgery: A case report. Int J Surg Case Rep 2024; 121:109947. [PMID: 38964234 PMCID: PMC11268359 DOI: 10.1016/j.ijscr.2024.109947] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2024] [Revised: 06/18/2024] [Accepted: 06/24/2024] [Indexed: 07/06/2024] Open
Abstract
INTRODUCTION AND IMPORTANCE Society of thoracic surgery (STS) risk score has been used as a tool to gauge operative risk of cardiac surgery patients. High-risk patients, with STS risk score > 8 %, are considered as having prohibitive risk and are not offered surgery. There is no established strategy to minimize postoperative hemodynamic instability using mechanical circulatory support (MCS), despite growing interest in utilizing MCS prior to hemodynamic instability. The Impella 5.5 can provide enough perfusion and unload the left ventricle. CASE PRESENTATION We managed a 75-year-old male with multiple comorbidities and a presumed Society of Thoracic Surgeons (STS) score higher than 9.8 %, who had redo coronary artery bypass grafting and aortic and mitral valve replacement with concomitant implantation of the Impella 5.5. Patient had a good recovery despite developing post-operative atrial fibrillation. DISCUSSION Impella is used as a mechanical circulatory support device in patients with cardiogenic shock. It provides forward flow and effectively unloads the left ventricle. The concomitant placement of the Impella 5.5 in high-risk cardiac candidates may be associated with reduced operative risk. CONCLUSION Placement of the device as part of surgical plan can potentially mitigate the perioperative risk by providing adequate endogean perfusion, decrease pressor support, unloading LV.
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Affiliation(s)
- Chidiebere Peter Echieh
- Division of Cardiothoracic Surgery, Department of Surgery, University of Arizona, United States of America
| | - Alex Ryan
- University of Arizona College of Medicine, United States of America
| | - Abel Cherian
- University of Arizona College of Medicine, United States of America
| | - Yash Rohilla
- University of Arizona College of Science, United States of America
| | - Kevin Wang
- Department of Surgery, Banner University Medical Center Tucson, United States of America
| | - Toshinobu Kazui
- Division of Cardiothoracic Surgery, Department of Surgery, Banner University Medical Center, Tucson, United States of America.
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Weiss R, Meersch M, Pavenstädt HJ, Zarbock A. Acute Kidney Injury: A Frequently Underestimated Problem in Perioperative Medicine. DEUTSCHES ARZTEBLATT INTERNATIONAL 2020; 116:833-842. [PMID: 31888797 DOI: 10.3238/arztebl.2019.0833] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 03/20/2019] [Revised: 03/20/2019] [Accepted: 10/10/2019] [Indexed: 01/04/2023]
Abstract
BACKGROUND Surgical patients are getting older with increasing comorbidity. Acute kidney injury (AKI) is a commonly underesti- mated perioperative complication. 2-18% of hospitalized patients and 22-57% of patients in the intensive care unit develop AKI. Even though it has a major impact on patients' outcomes, it goes unrecognized in 57-75.6% of cases. METHODS This review is based on pertinent papers retrieved by a selective search in PubMed and the Cochrane Library employ- ing the searching terms "acute kidney injury," "biomarker," "perioperative," "renal function," and "KDIGO." RESULTS The pathophysiology of AKI is complex. Conventional biomarkers are either not specific enough (urine output) or not sensitive enough (serum creatinine) for timely diagnosis. In view of the pathophysiology of the condition and the limited treat- ment options for it, the early detection of subclinical AKI (kidney damage without functional impairment) would seem to be a reasonable first step toward the prevention of worsening or permanent renal injury. New biomarkers of damage enable the early initiation of nephroprotective interventions. According to the "Kidney Disease: Improving Global Outcomes" (KDIGO) statement, a multimodal treatment approach is needed, including, among other things, optimization of hemodynamics and the discontinu- ation of nephrotoxic drugs. CONCLUSION It is essential to identify patients at risk and sensitize the treating personnel to the implementation of the guidelines. The incorporation of new biomarkers into routine clinical practice is also reasonable and necessary. Future clinical trials must show in what form these biomarkers should be used (singly or collectively).
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Affiliation(s)
- Raphael Weiss
- Department of Anesthesiology, Intensive Care, and Pain Medicine, University Hospital Münster; Department of Internal Medicine D, General Internal Medicine, Renal and Hypertensive Dieases, and Rheumatology, University Hospital Münster
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Fux T, Holm M, Corbascio M, Lund LH, van der Linden J. Venoarterial extracorporeal membrane oxygenation for postcardiotomy shock: Risk factors for mortality. J Thorac Cardiovasc Surg 2018; 156:1894-1902.e3. [DOI: 10.1016/j.jtcvs.2018.05.061] [Citation(s) in RCA: 39] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/04/2017] [Revised: 05/10/2018] [Accepted: 05/14/2018] [Indexed: 10/14/2022]
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Wang Y, Bellomo R. Cardiac surgery-associated acute kidney injury: risk factors, pathophysiology and treatment. Nat Rev Nephrol 2017; 13:697-711. [DOI: 10.1038/nrneph.2017.119] [Citation(s) in RCA: 430] [Impact Index Per Article: 61.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
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Kurapeev DI, Kabanov VO, Grebennik VK, Sheshurina TA, Dorofeykov VV, Galagudza MM, Shlyakhto EV. New technique of local ischemic preconditioning induction without repetitive aortic cross-clamping in cardiac surgery. J Cardiothorac Surg 2015; 10:9. [PMID: 25608502 PMCID: PMC4307141 DOI: 10.1186/s13019-015-0206-0] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2014] [Accepted: 01/07/2015] [Indexed: 11/13/2022] Open
Abstract
Background Several studies have demonstrated that local ischemic preconditioning can reduce myocardial ischemia–reperfusion injury in cardiac surgery patients; however, preconditioning has not become a standard cardioprotective intervention, primarily because of the increased risk of atheroembolism during repetitive aortic cross-clamping. In the present study, we aimed to describe and validate a novel technique of preconditioning induction. Methods Patients undergoing coronary artery bypass grafting (12 women and 78 men; mean age, 56 ± 11 years) were randomized into 3 groups: (1) Controls (n = 30), (2) Perfusion (n = 30), and (3) Preconditioning (n = 30). All patients were operated under cardiopulmonary bypass using normothermic blood cardioplegia. Preconditioning was induced by subjecting the hemodynamically unloaded heart to 2 cycles of 3 min of ischemia and 3 min of reperfusion with normokalemic blood prior to cardioplegia. In the Perfusion group, the heart perfusion remained unaffected for 12 min. Troponin I (TnI) levels were analyzed before surgery, and 12, 24, 48 h, and 7 days after surgery. The secondary endpoints included the cardiac index, plasma natriuretic peptide level, and postoperative use of inotropes. Results Preconditioning resulted in a significant reduction in the TnI level on the 7th postoperative day only (0.10 ± 0.05 and 0.33 ± 0.88 ng/ml in Preconditioning and Perfusion groups, respectively, P < 0.05). In addition, cardiac index was significantly higher in the Preconditioning group than in the Control and Perfusion groups just after weaning from cardiopulmonary bypass. The number of patients requiring inotropic support with ≥ 2 agents after surgery was significantly lower in the Preconditioning and Perfusion group than in the Control group (P < 0.05). No complications of the procedure were recorded in the Preconditioning group. Conclusions The preconditioning procedure described can be performed safely in cardiac surgery patients. The application of this technique of preconditioning was associated with certain benefits, including improved left ventricular function after weaning from cardiopulmonary bypass and a reduced need for inotropic support. However, the infarct-limiting effect of preconditioning in the early postoperative period was not evident. The procedure does not involve repetitive aortic cross-clamping, thus avoiding possible embolic complications.
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Affiliation(s)
- Dmitry I Kurapeev
- Institute of Experimental Medicine, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Viktor O Kabanov
- Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Vadim K Grebennik
- Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Tatyana A Sheshurina
- Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Vladimir V Dorofeykov
- Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
| | - Michael M Galagudza
- Institute of Experimental Medicine, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation. .,Department of Pathophysiology, First I.P. Pavlov Federal Medical University of St. Petersburg, Saint Petersburg, Russian Federation.
| | - Eugene V Shlyakhto
- Institute of Heart and Vessels, Federal Almazov Medical Research Centre, Saint Petersburg, Russian Federation.
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Erb J, Beutlhauser T, Feldheiser A, Schuster B, Treskatsch S, Grubitzsch H, Spies C. Influence of levosimendan on organ dysfunction in patients with severely reduced left ventricular function undergoing cardiac surgery. J Int Med Res 2014; 42:750-64. [PMID: 24781725 DOI: 10.1177/0300060513516293] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2013] [Accepted: 11/19/2013] [Indexed: 11/16/2022] Open
Abstract
OBJECTIVES Levosimendan is an inotropic drug with organ-protective properties due to its activation of mitochondrial K(ATP) channels. This prospective, randomized, double-blind, placebo-controlled study investigated whether administration of levosimendan prior to cardiopulmonary bypass could reduce organ dysfunction and influence subsequent secondary endpoints. PATIENTS AND METHODS Patients with left ventricular ejection fraction <30% scheduled for elective coronary artery bypass surgery (with or without valve surgery) received either levosimendan (12.5 mg, 0.1 µg kg(-1) per min; n = 17) or placebo (n = 16) central venous infusion, immediately after anaesthesia induction, as add-on medication to a goal-orientated treatment algorithm. RESULTS A total of 33 patients completed the study. There were no statistically significant differences in Sequential Organ Failure Assessment scores, survival, haemodynamic parameters, time to extubation, time in intensive care unit, need for haemodialysis or health-related quality-of-life at 6 months post operation. The levosimendan group compared with the placebo group had significantly lower use of epinephrine (35% versus 81%) and nitroglycerine (6% versus 44%) 24 h postoperation, and significantly less frequent serious adverse events (13% versus 47%). CONCLUSIONS These preliminary results show that timely perioperative levosimendan treatment is feasible, has a favourable safety profile safe and may help to prevent low cardiac output syndrome. However, organ function was not preserved. Further studies, using larger sample sizes, are required.
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Affiliation(s)
- Joachim Erb
- Department of Anaesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital of Basel, Basel, Switzerland
| | - Torsten Beutlhauser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Aarne Feldheiser
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Birgit Schuster
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Sascha Treskatsch
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Herko Grubitzsch
- Department of Cardiovascular Surgery, Campus Charité Mitte, Charité - Universitätsmedizin Berlin, Berlin, Germany
| | - Claudia Spies
- Department of Anaesthesiology and Intensive Care Medicine, Campus Charité Mitte and Campus Virchow-Klinikum, Charité - Universitätsmedizin Berlin, Berlin, Germany
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Shaw A. Update on acute kidney injury after cardiac surgery. J Thorac Cardiovasc Surg 2012; 143:676-81. [PMID: 22340031 DOI: 10.1016/j.jtcvs.2011.08.054] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/20/2010] [Revised: 06/22/2011] [Accepted: 08/24/2011] [Indexed: 11/24/2022]
Abstract
OBJECTIVES To review the current state of clinical practice and discuss recent advances in the diagnosis and management of acute kidney injury (AKI) in the context of cardiac surgery. METHODS A review of the published data pertaining to AKI in the setting of cardiac surgery and cardiothoracic surgical critical care medicine was conducted, and the relevant data were synthesized from appropriate interventional and observational study reports. RESULTS Significant advances have occurred in the diagnosis of AKI, and consensus has been reported on a system of diagnosis using the serum creatinine and urine output. New biomarkers of injury and function are available that are likely to improve the interval to diagnosis of AKI after cardiac surgery. The adverse effect on outcome of small changes in serum creatinine is appreciated. Novel prevention and rescue therapies are now entering phase I and II studies. Urinary alkalinization was effective in a phase II blinded clinical trial and is now the subject of a multicenter, double-blind, randomized clinical trial of cardiac surgery patients. CONCLUSIONS In 2011, the field of AKI could be emerging from a period of stagnation that has lasted more than 2 decades. The failure to translate successful animal model interventions to the clinic might have resulted from delays in diagnosis that might now be avoidable with the advent of novel diagnostic biomarkers.
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Affiliation(s)
- Andrew Shaw
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Abstract
Acute cardiac failure caused by myocardial infarction or inadequate cardioprotection during heart surgery is associated with increased mortality and morbidity. Levosimendan is a new drug used in heart failure though it is limited by the systemic hypotension, which develops with intravenous administration. Intracoronary (IC) administration however should affect systemic circulation less while maintaining the beneficial cardiac effects of the drug. We herewith report the results from the first such clinical series. Levosimendan was administered IC in 33 consecutive patients who developed cardiogenic shock during heart surgery and were unable to wean off cardiopulmonary bypass despite maximal support. Preadministration/postadministration coronary graft flows, hemodynamic parameters, left ventricular function, and metabolic requirements were measured and compared. Levosimendan significantly increased graft flows and improved hemodynamic parameters. Systolic blood pressure (93 ± 26.4 vs. 106 ± 18.2 mm Hg, P < 0.05) and cardiac index (2.0 ± 0.5 vs. 3.1 ± 0.2, P < 0.001) were increased, whereas systemic vascular resistance (1470.7 ± 114 vs. 1195.8 ± 112, P < 0.01) was reduced. Better myocardial perfusion improved metabolic requirements, with myocardial oxygen extraction and glucose uptake increasing by 72% and 74%, respectively, whereas lactate production was reduced by 64%. Echocardiography demonstrated additional ventricular segment recruitment. Therefore, IC Levosimendan administration in acute heart failure is safe and efficacious producing improved cardiac function without significant detrimental hypotension.
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Westaby S, Anastasiadis K, Wieselthaler GM. Cardiogenic shock in ACS. Part 2: role of mechanical circulatory support. Nat Rev Cardiol 2012; 9:195-208. [DOI: 10.1038/nrcardio.2011.205] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
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Elahi MM, Lam J, Asopa S, Matata BM. Levosimendan Versus an Intra-aortic Balloon Pump in Adult Cardiac Surgery Patients With Low Cardiac Output. J Cardiothorac Vasc Anesth 2011; 25:1154-62. [DOI: 10.1053/j.jvca.2011.01.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2010] [Indexed: 11/11/2022]
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Sylvin EA, Stern DR, Goldstein DJ. Mechanical Support for Postcardiotomy Cardiogenic Shock: Has Progress Been Made? J Card Surg 2010; 25:442-54. [DOI: 10.1111/j.1540-8191.2010.01045.x] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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Westaby S, Mehta V, Flynn F, Wilson N. Mechanical left ventricular unloading to prevent recurrent myocardial rupture. J Thorac Cardiovasc Surg 2009; 140:e16-7. [PMID: 19717170 DOI: 10.1016/j.jtcvs.2009.07.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/17/2009] [Accepted: 07/05/2009] [Indexed: 11/30/2022]
Affiliation(s)
- Stephen Westaby
- Department of Cardiac Surgery, John Radcliffe Hospital, Oxford, Untied Kingdom.
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Yamashita M, Ando M, Higuchi Y, Akita K, Tochii M, Ishida M, Kaneko K, Sato M, Takagi Y. Circulatory assistance and surgery for residual pulmonary hypertension following thromboendarterectomy. Ann Vasc Dis 2009; 2:144-7. [PMID: 23555374 DOI: 10.3400/avd.avdctpe003009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/13/2010] [Indexed: 11/13/2022] Open
Affiliation(s)
- Mitsuru Yamashita
- Department of Cardiovascular Surgery, Fujita-Health University, Aichi, Japan
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Yamashita M, Ando M, Higuchi Y, Akita K, Tochii M, Ishida M, Kaneko K, Sato M, Takagi Y. Circulatory Assistance and Surgery for Residual Pulmonary Hypertension Following Thromboendarterectomy. Ann Vasc Dis 2009. [DOI: 10.3400/avd.ctpe003009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
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