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Choi AY, Anand J, Bishawi M, Halpern SE, Contreras FJ, Mendiola MA, Daneshmand MA, Schroder JN, Vatsaas C, Agarwal SM, Milano CA. Incidence and Diagnostic Challenges of Bowel Ischemia after Continuous-flow Left Ventricular Assist Device Therapy. ASAIO J 2022; 68:676-682. [PMID: 34437327 PMCID: PMC8866539 DOI: 10.1097/mat.0000000000001553] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Long-term continuous-flow left ventricular assist device (CFLVAD) therapy is limited by complications. Compared with stroke and renal dysfunction, post-CFLVAD bowel ischemia is poorly characterized. Adult patients who underwent first-time durable CFLVAD implantation at our institution between 2008 and 2018 were identified and screened for bowel ischemia using Current Procedural Terminology codes for abdominal surgical exploration and International Classification of Disease codes for intestinal vascular insufficiency. Patients who developed biopsy-proven bowel ischemia (cases) were matched to controls (1:1, nearest neighbor, caliper = 0.29) based on preoperative characteristics. Incidences of postoperative right heart failure and renal replacement therapy were compared using McNemar's test. One year survival was estimated using the Kaplan-Meier method. Overall, 711 patients underwent CFLVAD implantation. Nineteen (2.7%) developed bowel ischemia (cases) median 17 days postimplantation (IQR 8-71). The majority of cases were male (78.9%), Black (63.2%), received HeartMate II (57.9%), treated as destination therapy (78.9%), and had a history of hypertension (89.5%), chronic kidney disease (84.2%), hyperlipidemia (84.2%), smoking (78.9%), and atrial fibrillation (57.9%). Post-LVAD, case patients were more likely to develop moderate-severe right heart failure (89.5% vs. 68.4%, p = 0.005), require renal replacement therapy (21.1% vs. 0%, p < 0.001), and less likely to survive to discharge (52.6% vs. 89.5%, p = 0.02) compared with controls. Case subjects demonstrated worse 1 year survival. While less common than stroke and renal dysfunction, post-CFLVAD bowel ischemia is associated with high 1 year mortality. Multi-institutional registries should consider reporting abdominal complications such as bowel ischemia as an adverse event to further investigate these trends and identify predictors of this complication to reduce patient mortality.
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Affiliation(s)
| | - Jatin Anand
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Muath Bishawi
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | | | | | | | - Mani A. Daneshmand
- Division of Cardiothoracic Surgery, Department of Surgery, Emory University, Atlanta, GA
| | - Jacob N. Schroder
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
| | - Cory Vatsaas
- Division of Trauma and Critical Care Surgery, Department of Surgery, Duke University, Durham, NC
| | - Suresh M. Agarwal
- Division of Trauma and Critical Care Surgery, Department of Surgery, Duke University, Durham, NC
| | - Carmelo A. Milano
- Division of Cardiothoracic Surgery, Duke University Medical Center, Durham, NC
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Kayali F, Sarodaya V, Shah HI, Hayat MY, Leung MST, Harky A. Predicting outcomes of mesenteric ischemia postcardiac surgery: A systematic review. J Card Surg 2022; 37:2025-2039. [PMID: 35488799 DOI: 10.1111/jocs.16516] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 12/28/2022]
Abstract
OBJECTIVE This systematic review aims to identify predictors of outcomes of mesenteric ischemia in patients following cardiac surgery. METHODS A comprehensive literature search was done on EMBASE, PubMed, Ovid MEDLINE, and SCOPUS using keywords relating to bowel ischemia and cardiac surgery. Database search results were screened by at least two authors and 32 articles were selected for inclusion in this review. RESULTS Data on 1907 patients were analyzed. The mean age was 70.0 ± 2.99 years and the prevalence of bowel ischemia was 1.74%. Advanced age was a significant risk factor. 63.16% of patients reported were men, and 58.4% of patients died in hospital. There was heterogeneity in the reported significance of the following preoperative risk factors: hypertension, smoking status, type 2 diabetes mellitus, end-stage renal disease, preoperative left ventricular ejection fraction <35%. Cardiopulmonary bypass (CPB) time, preoperative/operative intra-aortic balloon pump (IABP) support, and inotrope usage were significantly associated with the development of mesenteric ischemia; however, other intraoperative factors including the type of cardiac surgery and duration of aortic cross-clamping had varying levels of reported significance. There were discrepancies in the reported significance of leukocytosis and metabolic acidosis (pH <7.3) as postoperative markers. Postoperative vasopressor use, prolonged ventilation time, and elevation in lactate, transaminases, creatinine, and intestinal fatty acid-binding protein (IFABP) levels were found to be strongly associated with bowel ischemia. CONCLUSION This systematic review found the strongest associations of mesenteric ischemia postcardiac surgery to be advanced age, CPB time, rise in lactate, transaminases, creatinine, and IFABP. IABP support, vasopressor, and inotrope use as well as prolonged ventilation were strongly linked too.
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Affiliation(s)
- Fatima Kayali
- UCLan Medical School, University of Central Lancashire, Preston, UK
| | - Varun Sarodaya
- Department of Critical Care Medicine, Barts Health NHS Trust, London, UK
| | - Hussain I Shah
- UCL Medical School, University College London, London, UK
| | - Muhammad Y Hayat
- Faculty of Medicine, St George's Hospital Medical School, London, UK
| | - Marco S T Leung
- Department of Surgery, Imperial Healthcare Trust, London, UK
| | - Amer Harky
- Department of Cardiothoracic Surgery, Liverpool Heart and Chest Hospital, Liverpool, UK
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Idhrees M, Williams I, Bashir M, Velayudhan BV. Mesenteric ischemia postcardiac surgery-Elusive and less stratified complexity. J Card Surg 2022; 37:2040-2041. [PMID: 35441726 DOI: 10.1111/jocs.16523] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 04/02/2022] [Accepted: 04/04/2022] [Indexed: 11/27/2022]
Affiliation(s)
- Mohammed Idhrees
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
| | - Ian Williams
- Department of Vascular Surgery, University Hospital of Wales, Cardiff, UK
| | - Mohamad Bashir
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India.,Vascular & Endovascular Surgery, Velindre University NHS Trust, Health Education & Improvement Wales (HEIW), Cardiff, UK
| | - Bashi V Velayudhan
- Institute of Cardiac and Aortic Disorders (ICAD), SRM Institutes for Medical Science (SIMS Hospital), Chennai, Tamil Nadu, India
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Mothes H, Mueller-Mau V, Lehmkuhl L, Lehmann T, Settmacher U, Teichgräber U, Ludewig S. The role of computed tomography in the diagnostic pathway of acute mesenteric ischemia: a nested case-control study. Acta Radiol 2020; 61:1444-1451. [PMID: 32077303 DOI: 10.1177/0284185120905086] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
BACKGROUND Computed tomography (CT) can be used as the primary screening modality for the evaluation of patients suspected of having acute mesenteric ischemia known to show high sensitivity and specificity rates. PURPOSE To prove the value of CT in patients with pathological abdominal findings following cardiac surgery. MATERIAL AND METHODS In a retrospective case-control study, 12 different CT scan parameters of patients with or without mesenteric ischemia following cardiac surgery were compared using univariate and logistic regression analyses. RESULTS Of 14,176 patients, 133 (0.9%) received an abdominal CT scan during postoperative care due to pathological abdominal findings. Sixty-eight patients were diagnosed with acute mesenteric ischemia. In-hospital mortality was 73.5% for this group. CT parameters with the highest specificity for indicating colonic ischemia were intestinal (99%) or porto-venous (96%) pneumatosis, abnormal contrast medium enhancement (89%), and occlusion of the proximal inferior mesenteric artery (81%). All of those parameters showed low sensitivity levels in the range of 15%-23%. A statistically significant association between acute mesenteric ischemia and CT appearance was obtained for contrast medium enhancement (odds ratio [OR] 12.2, 95% confidence interval [CI] 1.5-99.2) and intestinal pneumatosis (OR 21.0, 95% CI 2.7-165.2) only. CONCLUSION The typical CT criteria indicating mesenteric ischemia lose their accuracy in patients under critical clinical conditions. As CT remains the first-line diagnostic imaging modality for abnormal abdominal findings following cardiac surgery, negative signs should not prevent early laparotomy if clinical suspicion remains high.
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Affiliation(s)
- Henning Mothes
- Department of General, Visceral and Vascular Surgery, Sophien- und Hufeland-Klinikum, Weimar, Germany
| | - Vetlana Mueller-Mau
- Department of General, Visceral and Vascular Surgery, Robert-Koch-Krankenhaus, Apolda, Germany
| | - Lukas Lehmkuhl
- Rhön-Klinikum Campus Bad-Neustadt, Department of Diagnostic Radiology, Bad Neustadt, Germany
| | - Thomas Lehmann
- Institute of Medical Statistics, Informatics and Documentation, University Hospital, Jena, Germany
| | - Utz Settmacher
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Ulf Teichgräber
- Department of Diagnostic and Interventional Radiology, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
| | - Stefan Ludewig
- Department of General, Visceral and Vascular Surgery, University Hospital, Friedrich-Schiller-University Jena, Jena, Germany
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Sato H, Nakamura M, Uzuka T, Kondo M. Detection of patients at high risk for nonocclusive mesenteric ischemia after cardiovascular surgery. J Cardiothorac Surg 2018; 13:115. [PMID: 30445964 PMCID: PMC6240249 DOI: 10.1186/s13019-018-0807-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/18/2018] [Accepted: 11/05/2018] [Indexed: 01/26/2023] Open
Abstract
Objectives Nonocclusive mesenteric ischemia (NOMI) is a rare but life-threatening complication after cardiovascular surgery. Early diagnosis and treatment is essential for a chance to cure. The aim of this study is to identify the independent risk factors for NOMI based on the evaluation of 12 cases of NOMI after cardiovascular surgery. Methods We retrospectively analyzed 12 patients with NOMI and 674 other patients without NOMI who underwent cardiovascular surgery in our hospital. We reviewed the clinical data on NOMI patients, including their characteristics and the clinical course. In addition, we performed a statistical comparison of each factor from both NOMI and non-NOMI groups to identify the independent risk factors for NOMI. Results The median duration between the cardiac surgery and the diagnosis of NOMI was 14.0 (10.3–20.3) days. The in-hospital mortality of NOMI patients was 75.0%. Age (p < 0.05), peripheral arterial disease (p < 0.001), postoperative hemodialysis (p < 0.001), intraaortic balloon pump (p < 0.05), norepinephrine (NOE) > 0.10γ (p < 0.0001), percutaneous cardiopulmonary support (p < 0.001), sepsis (p < 0.05), loss of sinus rhythm (p < 0.05), prolonged ventilation (p < 0.0001), and resternotomy for bleeding (p < 0.05) showed significant differences between NOMI and non-NOMI groups. In the multivariate logistic regression model, prolonged ventilation [odds ratio (OR) = 18.1, p < 0.001] and NOE > 0.10 μg/kg/min (OR = 130.0, p < 0.0001) were detected as independent risk factors for NOMI. Conclusions We have identified the risk factors for NOMI based on the evaluation of the 12 cases of NOMI after cardiovascular surgery. This result may be useful in predicting NOMI, which is considered difficult in clinical practice. For the patient with suspected of NOMI who has these risk factors, early CT scan and surgical exploration should be performed without delay.
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Affiliation(s)
- Hiroshi Sato
- Department of Cardiovascular Surgery, Sapporo Medical University School of Medicine, S1W16, Chuo-ku, Sapporo, 060-8543, Japan.
| | - Masanori Nakamura
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Takeshi Uzuka
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
| | - Mayo Kondo
- Department of Cardiovascular Surgery, Sapporo City General Hospital, N11W13, Chuo-ku, Sapporo, 060-8604, Japan
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Misiakos EP, Tsapralis D, Karatzas T, Lidoriki I, Schizas D, Sfyroeras GS, Moulakakis KG, Konstantos C, Machairas A. Advents in the Diagnosis and Management of Ischemic Colitis. Front Surg 2017; 4:47. [PMID: 28929100 PMCID: PMC5591371 DOI: 10.3389/fsurg.2017.00047] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/26/2017] [Accepted: 08/14/2017] [Indexed: 12/18/2022] Open
Abstract
BACKGROUND Ischemic colitis (IC) is a common type of ischemic insult, resulting from decreased arterial blood flow to the colon. This disease can be caused from either atherosclerotic occlusive vascular disease or non-occlusive disease. The aim of this study is to present the diagnostic methodology and management of this severe disease based on current literature. METHODS A literature search has been done including articles referring to modern diagnosis and management of IC. RESULTS IC is usually a transient disease, but it can also cause gangrene of the colon, requiring emergency surgical exploration. Diagnosis is troublesome and is based on imaging examinations, mainly computerized tomography, which in association with colonoscopy can delineate the distribution pattern and severity of disease. CONCLUSION The majority of patients with mild disease have usually complete clinical recovery within a short period. The severe forms of the disease carry high morbidity and mortality rates and prompt surgical intervention is the only way to improve the associated severe prognosis.
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Affiliation(s)
- Evangelos P. Misiakos
- 3rd Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Dimitrios Tsapralis
- Department of General Surgery, General Hospital/Health Center of Ierapetra, Ierapetra, Greece
| | - Theodore Karatzas
- 2nd Department of Propedeutic Surgery, School of Medicine, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Irene Lidoriki
- 1st Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - Dimitrios Schizas
- 1st Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, Laiko Hospital, Athens, Greece
| | - George S. Sfyroeras
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Konstantinos G. Moulakakis
- Department of Vascular Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Chrysostomos Konstantos
- 2nd Department of Radiology, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
| | - Anastasios Machairas
- 3rd Department of Surgery, School of Medicine, National and Kapodistrian University of Athens, Attikon University Hospital, Athens, Greece
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7
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Singh NG, Nagaraja PS, Gopal D, Manjunath V, Nagesh KS, Manjunatha N, Patel GP, Mishra SK. Feasibility of measuring superior mesenteric artery blood flow during cardiac surgery under hypothermic cardiopulmonary bypass using transesophageal echocardiography: An observational study. Ann Card Anaesth 2017; 19:399-404. [PMID: 27397442 PMCID: PMC4971966 DOI: 10.4103/0971-9784.185518] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
Background: Abdominal complications being rare but results in high mortality, commonly due to splanchnic organ hypoperfusion during the perioperative period of cardiac surgery. There are no feasible methods to monitor intraoperative superior mesenteric artery blood flow (SMABF). Hence, the aim of this study was to evaluate the feasibility and to measure SMABF using transesophageal echocardiography (TEE) during cardiac surgery under hypothermic cardiopulmonary bypass (CPB). Methodology: Thirty-five patients undergoing elective cardiac surgery under CPB were enrolled. Heart rate, mean arterial pressure (MAP), cardiac output (CO), SMABF, superior mesenteric artery (SMA) diameter, superior mesentric artery blood flow over cardiac output (SMA/CO) ratio and arterial blood lactates were recorded at three time intervals. T0: before sternotomy, T1: 30 min after initiation of CPB and T2: after sternal closure. Results: SMA was demonstrated in 32 patients. SMABF, SMA diameter, SMA/CO, MAP and CO decreased significantly (P < 0.0001) between T0 and T1, increased significantly (P ≤ 0.001) between T0 and T2. Lactates increased progressively from T0 to T2. Conclusion: Study shows that there is decrease in SMABF during CPB and returns to baseline after CPB. Hence, it is feasible to measure SMABF using TEE in patients undergoing cardiac surgery under hypothermic CPB. TEE can be a promising tool in detecting and preventing splanchnic hypoperfusion during perioperative period.
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Affiliation(s)
- Naveen G Singh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - P S Nagaraja
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Divya Gopal
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - V Manjunath
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - K S Nagesh
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - N Manjunatha
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Guru Police Patel
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
| | - Satish Kumar Mishra
- Department of Cardiac Anaesthesiology, Sri Jayadeva Institute of Cardiovascular Sciences and Research, Bengaluru, Karnataka, India
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Hummitzsch L, Zitta K, Berndt R, Kott M, Schildhauer C, Parczany K, Steinfath M, Albrecht M. Doxycycline protects human intestinal cells from hypoxia/reoxygenation injury: Implications from an in-vitro hypoxia model. Exp Cell Res 2017; 353:109-114. [PMID: 28300560 DOI: 10.1016/j.yexcr.2017.03.017] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2017] [Revised: 03/07/2017] [Accepted: 03/09/2017] [Indexed: 12/29/2022]
Abstract
Intestinal ischemia/reperfusion (I/R) injury is a grave clinical emergency and associated with high morbidity and mortality rates. Based on the complex underlying mechanisms, a multimodal pharmacological approach seems necessary to prevent intestinal I/R injury. The antibiotic drug doxycycline, which exhibits a wide range of pleiotropic therapeutic properties, might be a promising candidate for also reducing I/R injury in the intestine. To investigate possible protective effects of doxycycline on intestinal I/R injury, human intestinal CaCo-2 cells were exposed to doxycycline at clinically relevant concentrations. In order to mimic I/R injury, CaCo-2 were thereafter subjected to hypoxia/reoxygenation by using our recently described two-enzyme in-vitro hypoxia model. Investigations of cell morphology, cell damage, apoptosis and hydrogen peroxide formation were performed 24h after the hypoxic insult. Hypoxia/reoxygenation injury resulted in morphological signs of cell damage, elevated LDH concentrations in the respective culture media (P<0.001) and increased protein expression of proapoptotic caspase-3 (P<0.05) in the intestinal cultures. These events were associated with increased levels hydrogen peroxide (P<0.001). Preincubation of CaCo-2 cells with different concentrations of doxycycline (5µM, 10µM, 50µM) reduced the hypoxia induced signs of cell damage and LDH release (P<0.001 for all concentrations). The reduction of cellular damage was associated with a reduced expression of caspase-3 (5µM, P<0.01; 10µM, P<0.01; 50µM, P<0.05), while hydrogen peroxide levels remained unchanged. In summary, doxycycline protects human intestinal cells from hypoxia/reoxygenation injury in-vitro. Further animal and clinical studies are required to prove the protective potential of doxycycline on intestinal I/R injury under in-vivo conditions.
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Affiliation(s)
- Lars Hummitzsch
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Karina Zitta
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Rouven Berndt
- Department of Cardiovascular Surgery, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Matthias Kott
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Christin Schildhauer
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Kerstin Parczany
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Markus Steinfath
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany
| | - Martin Albrecht
- Department of Anaesthesiology and Intensive Care Medicine, University Hospital Schleswig-Holstein, Campus Kiel, Germany.
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Arif R, Farag M, Zaradzki M, Reissfelder C, Pianka F, Bruckner T, Kremer J, Franz M, Ruhparwar A, Szabo G, Beller CJ, Karck M, Kallenbach K, Weymann A. Ischemic Colitis after Cardiac Surgery: Can We Foresee the Threat? PLoS One 2016; 11:e0167601. [PMID: 27977704 PMCID: PMC5157983 DOI: 10.1371/journal.pone.0167601] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/27/2016] [Accepted: 11/16/2016] [Indexed: 01/29/2023] Open
Abstract
Introduction Ischemic colitis (IC) remains a great threat after cardiac surgery with use of extracorporeal circulation. We aimed to identify predictive risk factors and influence of early catecholamine therapy for this disease. Methods We prospectively collected and analyzed data of 224 patients, who underwent laparotomy due to IC after initial cardiac surgery with use of extracorporeal circulation during 2002 and 2014. For further comparability 58 patients were identified, who underwent bypass surgery, aortic valve replacement or combination of both. Age ±5 years, sex, BMI ± 5, left ventricular function, peripheral arterial disease, diabetes and urgency status were used for match-pair analysis (1:1) to compare outcome and detect predictive risk factors. Highest catecholamine doses during 1 POD were compared for possible predictive potential. Results Patients’ baseline characteristics showed no significant differences. In-hospital mortality of the IC group with a mean age of 71 years (14% female) was significantly higher than the control group with a mean age of 70 (14% female) (67% vs. 16%, p<0.001). Despite significantly longer bypass time in the IC group (133 ± 68 vs. 101 ± 42, p = 0.003), cross-clamp time remained comparable (64 ± 33 vs. 56 ± 25 p = 0.150). The majority of the IC group suffered low-output syndrome (71% vs. 14%, p<0.001) leading to significant higher lactate values within first 24h after operation (55 ± 46 mg/dl vs. 31 ± 30 mg/dl, p = 0.002). Logistic regression revealed elevated lactate values to be significant predictor for colectomy during the postoperative course (HR 1.008, CI 95% 1.003–1.014, p = 0.003). However, Receiver Operating Characteristic Curve calculates a cut-off value for lactate of 22.5 mg/dl (sensitivity 73% and specificity 57%). Furthermore, multivariate analysis showed low-output syndrome (HR 4.301, CI 95% 2.108–8.776, p<0.001) and vasopressin therapy (HR 1.108, CI 95% 1.012–1.213, p = 0.027) significantly influencing necessity of laparotomy. Conclusion Patients who undergo laparotomy for IC after initial cardiac surgery have a substantial in-hospital mortality risk. Early postoperative catecholamine levels do not influence the development of an IC except vasopressin. Elevated lactate remains merely a vague predictive risk factor.
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Affiliation(s)
- Rawa Arif
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
- * E-mail:
| | - Mina Farag
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Marcin Zaradzki
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Christoph Reissfelder
- Department of Visceral, Thoracic and Vascular Surgery, University Hospital Carl Gustav Carus, Technical University Dresden, Fetscherstr. Dresden, Germany
| | - Frank Pianka
- Department of General, Visceral and Transplantation Surgery, University Hospital Heidelberg, Heidelberg, Germany
| | - Thomas Bruckner
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Jamila Kremer
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Maximilian Franz
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Arjang Ruhparwar
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Gabor Szabo
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Carsten J. Beller
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Matthias Karck
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
| | - Klaus Kallenbach
- Department of Cardiac Surgery, HaerzZenter-INCCI, rue Ernest-Barblé, Luxembourg, Luxembourg
| | - Alexander Weymann
- Department of Cardiac Surgery, Heart and Marfan Center—University of Heidelberg, Heidelberg, Germany
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10
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Acute bowel ischemia after heart operations. Ann Thorac Surg 2014; 97:2219-27. [PMID: 24681032 DOI: 10.1016/j.athoracsur.2014.01.029] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2013] [Revised: 01/08/2014] [Accepted: 01/14/2014] [Indexed: 01/10/2023]
Abstract
Acute bowel ischemia is a perioperative complication that is frequently unrecognized as a cause of death after cardiac surgical procedures, with an in-hospital mortality of 50% to 100%. In recent years, controversy regarding the most appropriate approach to resolve clinical or laboratory suspicion and the limited therapeutic options have led to very little improvement in patient prognosis. This article reviews the related literature examining the actual prevalence, pathophysiologic mechanisms, predisposing factors, diagnostic tests, and therapeutic approaches providing a glance at new promising tools in diagnostic workup.
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11
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Acute mesenteric ischemia after cardiac surgery: an analysis of 52 patients. ScientificWorldJournal 2013; 2013:631534. [PMID: 24288499 PMCID: PMC3826337 DOI: 10.1155/2013/631534] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2013] [Accepted: 09/08/2013] [Indexed: 01/16/2023] Open
Abstract
OBJECTIVE Acute mesenteric ischemia (AMI) is a rare but serious complication after cardiac surgery. The aim of this retrospective study was to evaluate the incidence, outcome, and perioperative risk factors of AMI in the patients undergoing elective cardiac surgery. METHODS From January 2005 to May 2013, all patients who underwent cardiac surgery were screened for participation, and patients with registered gastrointestinal complications were retrospectively reviewed. Univariate analyses were performed. RESULTS The study included 6013 patients, of which 52 (0.86%) patients suffered from AMI, 35 (67%) of whom died. The control group (150 patients) was randomly chosen from among cases undergoing cardiopulmonary bypass (CPB). Preoperative parameters including age (P = 0.03), renal insufficiency (P = 0.004), peripheral vascular disease (P = 0.04), preoperative inotropic support (P < 0.001), poor left ventricular ejection fraction (P = 0.002), cardiogenic shock (P = 0.003), and preoperative intra-aortic balloon pump (IABP) support (P = 0.05) revealed significantly higher levels in the AMI group. Among intra- and postoperative parameters, CPB time (P < 0.001), dialysis (P = 0.04), inotropic support (P = 0.007), prolonged ventilator time (P < 0.001), and IABP support (P = 0.007) appeared significantly higher in the AMI group than the control group. CONCLUSIONS Prompt diagnosis and early treatment should be initiated as early as possible in any patient suspected of AMI, leading to dramatic reduction in the mortality rate.
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Nilsson J, Hansson E, Andersson B. Intestinal ischemia after cardiac surgery: analysis of a large registry. J Cardiothorac Surg 2013; 8:156. [PMID: 23777600 PMCID: PMC3688391 DOI: 10.1186/1749-8090-8-156] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2013] [Accepted: 06/06/2013] [Indexed: 12/17/2022] Open
Abstract
Background Intestinal ischemia after cardiac surgery is a rare but severe complication with a high mortality. Early surgery can be lifesaving. The aim was to analyze the incidence, outcome, and risk factors for these patients. Methods A prospectively collected database with patients who underwent 18,879 cardiac surgical procedures between 1996 and 2011 was investigated. All patients with registered gastrointestinal complications were retrospectively reviewed. Univariate and multivariate analyses were performed to compare patients with and without intestinal ischemia. Results Seventeen patients suffered from intestinal ischemia (0.09%), 10 of whom (59%) died. By investigating preoperative parameters independent risk factors were steroids, peripheral vascular disease, cardiogenic shock, and New York Heart Association class 4. When including pre-, per-, and postoperative parameters, only postoperative ones were significant, including elevated creatinine (> 200 μmol/L), prolonged ventilator time, need for intra-aortic balloon pump, and cerebrovascular insult (CVI). The gastrointestinal complications score (GICS) showed a ROC area of 0.87. This was superior compared with EuroSCORE (0.74), to predict intestinal ischemia. Conclusions Intestinal ischemia after cardiac surgery is more common in patients with a poor cardiac state, but the use of steroids, peripheral vascular disease, postoperative kidney failure, and CVI were also predictive. GICS score, developed for all GI complications after cardiac surgery, is also of value in predicting this particular complication. The risk factors presented can be used as an aid in the diagnosis of these patients.
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Affiliation(s)
- Johan Nilsson
- 1Department of Cardiothoracic Surgery, Clinical Sciences, Lund University and Skane University Hospital, Lund, Sweden
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Sever K, Ozbek C, Goktas B, Bas S, Ugurlucan M, Mansuroglu D. Gastrointestinal complications after open heart surgery: incidence and determinants of risk factors. Angiology 2013; 65:425-9. [PMID: 23574750 DOI: 10.1177/0003319713482357] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
Acute mesenteric ischemia is a rare but serious complication of open heart surgery. Between January 2009 and January 2012, 1360 adult patients underwent open heart surgery with cardiopulmonary bypass at our institution; 29 patients presented gastrointestinal complications. Eight patients developed acute mesenteric ischemia and all of them died. Significant predictors of the complication were New York Heart Association functional class III/IV, history of extensive atherosclerosis and chronic renal failure, acute renal failure following surgery, low cardiac output, use of 2 or more vasoconstrictor drugs, prolonged mechanical ventilation, and multiorgan failure. Atherosclerosis is a multisystemic disease that affects several organs. Radiologic evaluation of mesenteric arterial system should be performed in high-risk patient populations. Perioperative percutaneous and open vascular procedures will reduce the risk of acute mesenteric ischemia that may develop after cardiac surgery and consequent morbidity and mortality rates.
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Affiliation(s)
- Kenan Sever
- 1Cardiovascular Surgery Clinic, Gaziosmanpasa Hospital, Istanbul, Turkey
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Modulation of mesenteric vasoreactivity and inflammatory response by protein undernutrition in cardiopulmonary bypass. Nutrition 2013; 29:318-24. [DOI: 10.1016/j.nut.2012.08.010] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2012] [Revised: 08/22/2012] [Accepted: 08/22/2012] [Indexed: 11/21/2022]
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Pang PYK, Sin YK, Lim CH, Su JW, Chua YL. Outcome and survival analysis of intestinal ischaemia following cardiac surgery. Interact Cardiovasc Thorac Surg 2012; 15:215-8. [PMID: 22566510 DOI: 10.1093/icvts/ivs181] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Intestinal ischaemia is an uncommon (<1%) but serious complication of cardiac surgery with a mortality rate exceeding 50%. Diagnosis of this potentially lethal condition can be difficult and requires a high index of suspicion. The purpose of this study was to analyse the outcomes and prognostic factors in patients who develop intestinal ischaemia following cardiac surgery. METHODS In a retrospective review from August 1999 to December 2010, we identified 31 out of 9925 (0.31%) consecutive patients who developed acute intestinal ischaemia following cardiac surgery at our tertiary centre. RESULTS The overall mortality was 71.0%. The operative mortality was 65.4% in patients who underwent a laparotomy. Survivors of this complication had surgical intervention earlier (7.4 ± 4.9 h) compared with the non-survivors (13.9 ± 11.1 h). A total of 35 perioperative variables were analysed. A univariate analysis identified 12 variables associated with an increased risk of mortality. Logistic multivariate analysis identified the preoperative logistic EuroSCORE and the base excess at the point of diagnosis of intestinal ischaemia as significant predictors of mortality. These factors may aid prognostication in this group of patients. CONCLUSIONS Despite the high mortality rates associated with intestinal ischaemia following cardiac surgery, early diagnosis and surgical intervention remain the only effective means to reduce mortality.
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Affiliation(s)
- Philip Y K Pang
- Department of Cardiothoracic Surgery, National Heart Centre, Singapore, Singapore
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Guler M, Yamak B, Erdogan M, Aydin U, Kul S, Asil R, Kisacikoglu B. Risk factors for gastrointestinal complications in patients undergoing coronary artery bypass graft surgery. J Cardiothorac Vasc Anesth 2011; 25:637-41. [PMID: 21262572 DOI: 10.1053/j.jvca.2010.11.013] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2010] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To determine the risk factors for the development of gastrointestinal complications (GICs) after coronary artery bypass graft (CABG) surgery. DESIGN A single-center, retrospective study. SETTING A tertiary care hospital. PARTICIPANTS Six thousand seven hundred ninety-four patients undergoing isolated CABG surgery between 2002 and 2006. INTERVENTIONS Clinical characteristics of the patients with GICs and control group patients were analyzed by stepwise logistic regression analysis. The control group consisted of a total of 95 patients randomly selected among the ones who had no gastrointestinal finding or symptoms (cohort: control, 1:5 ratio). MEASUREMENTS AND MAIN RESULTS Nineteen patients (0.3%) developed major surgical GICs after CABG surgery. Overall, the 30-day mortality was 42.1% among patients with GICs and 2.6% without GICs. Multivariate analysis identified 4 independent predictors for GICs: age greater than 70 years (p = 0.001; odds ratio [OR] = 5.6; 95% confidence interval [CI], 2.1-25.9), reoperation for bleeding (p = 0.005; OR = 7.7; 95% CI, 2.8-56.2), a prolonged cardiopulmonary bypass time (p = 0.007; OR = 3.7; 95% CI, 1.3-15.6), and an increased postoperative creatinine level (p = 0.036; OR = 2.3; 95% CI, 1.1-13.4). CONCLUSION A delayed diagnosis of complications is an important problem in the management of major surgical GICs. The present results suggest that surgeons and intensivists must be alert to patients older than 70 years, a cardiopulmonary bypass time longer than 60 minutes, reoperation for bleeding after CABG surgery, and postoperative creatinine level higher than 1.7 mg/dL.
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Affiliation(s)
- Mehmet Guler
- Department of Surgery, Gaziantep University, Gaziantep, Turkey.
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Atherosclerosis aggravates ischemia/reperfusion injury in the gut and remote damage in the liver and the lung. Inflamm Res 2011; 60:555-67. [DOI: 10.1007/s00011-010-0304-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2010] [Revised: 12/13/2010] [Accepted: 12/16/2010] [Indexed: 10/18/2022] Open
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Abstract
Acute mesenteric ischemia (AMI) is a highly-lethal surgical emergency. Several pathophysiologic events (arterial obstruction, venous thrombosis and diffuse vasospasm) lead to a sudden decrease in mesenteric blood flow. Ischemia/reperfusion syndrome of the intestine is responsible for systemic abnormalities, leading to multi-organ failure and death. Early diagnosis is difficult because the clinical presentation is subtle, and the biological and radiological diagnostic tools lack sensitivity and specificity. Therapeutic options vary from conservative resuscitation, medical treatment, endovascular techniques and surgical resection and revascularization. A high index of suspicion is required for diagnosis, and prompt treatment is the only hope of reducing the mortality rate. Studies are in progress to provide more accurate diagnostic tools for early diagnosis. AMI can complicate the post-operative course of patients following cardio-pulmonary bypass (CPB). Several factors contribute to the systemic hypo-perfusion state, which is the most frequent pathophysiologic event. In this particular setting, the clinical presentation of AMI can be misleading, while the laboratory and radiological diagnostic tests often produce inconclusive results. The management strategies are controversial, but early treatment is critical for saving lives. Based on the experience of our team, we consider prompt exploratory laparotomy, irrespective of the results of the diagnostic tests, is the only way to provide objective assessment and adequate treatment, leading to dramatic reduction in the mortality rate.
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