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Park SJ, Kim HR, Kim HJ, Kim JB. Tailored surgical strategies for mini-access open total arch repair. JTCVS Tech 2024; 24:1-13. [PMID: 38835578 PMCID: PMC11145074 DOI: 10.1016/j.xjtc.2023.12.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/05/2023] [Accepted: 12/06/2023] [Indexed: 06/06/2024] Open
Abstract
Objective Open arch repair is perceived as a challenging, high-risk procedure, with a barrier against the use of a minimally invasive approach. We aimed to present a mini-access total arch replacement performed by stratified approaches and to evaluate perioperative outcomes to contribute to the body of evidence. Methods We evaluated 40 consecutive patients (aged 69.5 years; interquartile range, 65.6-76.3 years) undergoing elective total arch replacement using 5- to 8-cm upper mini-sternotomy between 2018 and 2022. Surgical strategies, including arterial inflow site and methods of branching vessel reconstruction, were systematically selected at the individual level. To evaluate comparative outcomes, contemporary cases undergoing total arch replacement via sternotomy with similar eligibility criteria served as a control group, and the inverse-treatment-weighting method was used to adjust for baseline characteristics. Results Arch-first anastomosis using trifurcate graft, distal-first anastomosis using 4-branch graft, and island anastomosis were used in 18 (45%), 12 (30.0%), and 10 (25%) patients, respectively. Lower body and cardiac ischemic times were 23.4 minutes (interquartile range, 18.0-29.0 minutes) and 66.7 minutes (interquartile range, 50.1-78.2 minutes). There was no early (30-day or in-hospital) mortality, and 2 patients experienced disabling stroke (5.0%). The contemporary control group comprised 55 patients. After an adjustment, a mini-access group showed lower risks of stroke (odds ratio, 0.88; 95% CI, 0.78-1.00; P = .049) and a composite of major complications (odds ratio, 0.79; 95% CI, 0.68-0.92; P = .003), compared with a sternotomy approach. Conclusions Based on present results, mini-access total arch replacement may be performed with reasonable safety and efficiency.
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Affiliation(s)
- Soo Jin Park
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Hong Rae Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Ho Jin Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
| | - Joon Bum Kim
- Department of Thoracic and Cardiovascular Surgery, Asan Medical Center, Seoul, Korea
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Räsänen J, Ellam S, Hartikainen J, Juutilainen A, Halonen J. Impact of perfusion method on perioperative red blood cell transfusions and new-onset postoperative atrial fibrillation in mitral valve surgery patients. Perfusion 2023; 38:1600-1608. [PMID: 35997658 PMCID: PMC10612370 DOI: 10.1177/02676591221122351] [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] [Indexed: 11/16/2022]
Abstract
INTRODUCTION Red blood cell (RBC) transfusions are common in cardiac surgery and reportedly associated with increased mortality and morbidity, including increased risk of postoperative new-onset atrial fibrillation (NOAF). The aim of this study was to compare minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC) in terms of RBC transfusions and the incidence of NOAF in mitral valve surgery. METHODS The study population consisted of 89 MiECC and 169 CECC patients undergoing mitral valve surgery as an isolated procedure (80.6% of the patients) or in combination with coronary artery bypass grafting (19.4% of patients). 79.4% of the patients were male and the mean age was 62.1 years. RESULTS 30.0% of patients aged < 65 years and 48.1% of patients aged ≥ 65 years needed RBC transfusion. The overall need for RBC transfusions did not differ between the treatment groups. Among patients < 65 years of age transfusions of ≥ 3 units were less frequent in MiECC than in CECC patients (OR 0.31, 95% CI 0.10-0.98, p = 0.045). The overall incidence of NOAF was 41.8% with no significant difference between MiECC and CECC groups. Red blood cell transfusions were associated with an increased risk of NOAF in an unadjusted analysis but not after adjustment for age and sex (OR 1.25, 95% CI 0.64-2.43, p = 0.515). CONCLUSIONS In mitral valve surgery MiECC compared to CECC was associated with less need of RBC units and platelets, particularly in patients aged < 65 years. Use of RBC transfusions was associated with increased risk of NOAF significantly only in unadjusted analysis.
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Affiliation(s)
- Jenni Räsänen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Juha Hartikainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Auni Juutilainen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
| | - Jari Halonen
- Institute of Clinical Medicine, School of Medicine, University of Eastern Finland, Kuopio, Finland
- Heart Center, Kuopio University Hospital, Kuopio, Finland
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Carrel T. Reduced Invasiveness of Cardiopulmonary Bypass: The Mini-Circuit and the Micro-Cardioplegia. J Cardiovasc Dev Dis 2023; 10:290. [PMID: 37504545 PMCID: PMC10380229 DOI: 10.3390/jcdd10070290] [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: 04/13/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
The aim of cardiopulmonary bypass is the maintenance of a sufficient whole body perfusion and gas exchange during open or closed heart surgery procedure (coronary artery bypass grafting, valve repair and replacement, surgical intervention on the ascending aorta and/or aortic arch, repair of congenital malformations, and finally implantation of ventricular assist devices or cardiac transplantation). The main components of cardiopulmonary bypass are the pump that supplies the circulation and the oxygenator that regulates gas exchange. However, even though this technology has been extensively developed and improved over the last decades, one of the major drawbacks-which is the fact that blood has to flow through tubing systems with foreign surfaces-persists so far. Nevertheless, interesting innovations have been made more recently in order to better control the side-effects that culminate into a major activation of the coagulation and inflammatory systems: among them, miniaturization of the circuits, together with reduction of the priming volume and a simplified cardioplegia concept. All of these lead to a significant decrease of hemodilution and thereby a significant reduction of volume overload during surgery. In this brief review we will present some of these most interesting topics around minimized circuits and the simplified low-volume cardioplegia and discuss their potential benefits on the clinical outcome.
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Affiliation(s)
- Thierry Carrel
- Departement of Cardiac Surgery, University of Zürich, CH-8006 Zürich, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, CH-4052 Basel, Switzerland
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Abstract
Minimally invasive extracorporeal circulation (MiECC) technology is characterized by improved biocompatibility due to closed-loop design, minimized priming, and markedly reduced artificial surface. Despite well-evidenced clinical advantages in coronary surgery, MiECC penetration in complex open-heart surgery is low. Concerns have been raised by surgeons and perfusionist regarding safety of perfusion in situations when the heart is opened and air is entering the closed system. Moreover, issues of blood and volume management are deemed impractical without having a reservoir. In the evolution of MiECC safety aspects as well as means of air and volume management have been addressed. The integration of active air removal devices, and the possibility of venting and volume buffering made MiECC suitable for valvular or even more complex surgery. However, typical clinical benefits found with MiECC in coronary artery bypass grafting (CABG) surgery, in particular blood sparing effects, were not reproducible. Air handling and blood management remain the main issues of MiECC in non-coronary surgery. With the introduction of modular (type IV) MiECC systems containing a second, accessory circuit for immediate conversion to open cardiopulmonary bypass (CPB), the last obstacles seem to be cleared away. The first reports using this latest development in MiECC technology sound promising. It is now up to the cardiac surgical community to adopt this technology and produce data helping to answer the question whether MiECC is the best perfusion strategy for all comer's cardiac surgery.
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Affiliation(s)
- Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
| | - Günter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University Hospital, Ulm, Germany
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Schmidt AK, Assmann A, Lichtenberg A, Boeken U. Systemische Inflammation und Herzchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2018. [DOI: 10.1007/s00398-017-0173-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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Basciani R, Kröninger F, Gygax E, Jenni H, Reineke D, Stucki M, Hagenbuch N, Carrel T, Eberle B, Erdoes G. Cerebral Microembolization During Aortic Valve Replacement Using Minimally Invasive or Conventional Extracorporeal Circulation: A Randomized Trial. Artif Organs 2016; 40:E280-E291. [DOI: 10.1111/aor.12744] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2016] [Revised: 02/22/2016] [Accepted: 02/23/2016] [Indexed: 11/30/2022]
Affiliation(s)
- Reto Basciani
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Felix Kröninger
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Erich Gygax
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Hansjörg Jenni
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - David Reineke
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Monika Stucki
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | | | - Thierry Carrel
- Department of Cardiovascular Surgery; Swiss Cardiovascular Center, Inselspital, Bern University Hospital, University of Bern; Bern
| | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
| | - Gabor Erdoes
- Department of Anesthesiology and Pain Therapy; Inselspital, Bern University Hospital, University of Bern; Bern Switzerland
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Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E, Schaarschmidt J, Fromes Y, Philipp A, Eberle B, Punjabi P, Argiriadou H, Kadner A, Jenni H, Albrecht G, van Boven W, Liebold A, de Somer F, Hausmann H, Deliopoulos A, El-Essawi A, Mazzei V, Biancari F, Fernandez A, Weerwind P, Puehler T, Serrick C, Waanders F, Gunaydin S, Ohri S, Gummert J, Angelini G, Falk V, Carrel T. Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS). Interact Cardiovasc Thorac Surg 2016; 22:647-62. [PMID: 26819269 DOI: 10.1093/icvts/ivv380] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022] Open
Abstract
Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.
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Affiliation(s)
| | - John Murkin
- Department of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, Canada
| | | | - Adrian Bauer
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Marco Ranucci
- Department of Anaesthesia and Intensive Care, Policlinico S. Donato, Milan, Italy
| | - Erich Gygax
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Jan Schaarschmidt
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Yves Fromes
- University Pierre and Marie Curie (Paris 06), Paris, France
| | | | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University of Bern, Bern, Switzerland
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Alexander Kadner
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Guenter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | - Wim van Boven
- Department of Cardiothoracic Surgery, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | | | - Harald Hausmann
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | | | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Braunschweig, Germany
| | - Valerio Mazzei
- Department of Adult Cardiac Surgery, Mater Dei Hospital, Bari, Italy
| | - Fausto Biancari
- Department of Cardiac Surgery, Oulu University Hospital, Oulu, Finland
| | - Adam Fernandez
- Department of Surgery, Sidra Medical & Research Centre, Doha, Qatar
| | - Patrick Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thomas Puehler
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | | | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Medline Hospitals, Adana, Turkey
| | - Sunil Ohri
- Department of Cardiothoracic Surgery, Wessex Cardiac Centre, University Hospital Southampton, Hampshire, UK
| | - Jan Gummert
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | - Gianni Angelini
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, German Heart Centre, Berlin, Germany
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
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What We have Learned about Minimized Extracorporeal Circulation versus Conventional Extracorporeal Circulation: An Updated Meta-Analysis. Int J Artif Organs 2015; 38:444-53. [PMID: 26349528 DOI: 10.5301/ijao.5000427] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/27/2015] [Indexed: 12/29/2022]
Abstract
Introduction The benefits of minimized extracorporeal circulation (MECC) compared with conventional extracorporeal circulation (CECC) are still in debate. Methods PubMed, EMBASE and the Cochrane Library were searched until November 10, 2014. After quality assessment, we chose a fixed-effects model when the trials showed low heterogeneity, otherwise a random-effects model was used. We performed univariate meta-regression and sensitivity analysis to search for the potential sources of heterogeneity. Cumulative meta-analysis was performed to access the evolution of outcome over time. Results 41 RCTs enrolling 3744 patients were included after independent article review by 2 authors. MECC significantly reduced atrial fibrillation (RR, 0.76; 95% CI, 0.66 to 0.89; P<0.001; I2 = 0%), and myocardial infarction (RR, 0.43; 95% CI, 0.26 to 0.71; P = 0.001; I2 = 0%). In addition, the results regarding chest tube drainage, transfusion rate, blood loss, red blood cell transfusion volume, and platelet count favored MECC as well. Conclusions MECC diminished morbidity of cardiovascular complications postoperatively, conserved blood cells, and reduced allogeneic blood transfusion.
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Bennett MJ, Weatherall M, Webb G, Dudnikov SF, Lloyd CT. The impact of haemodilution and bypass pump flow on cerebral oxygen desaturation during cardiopulmonary bypass--A comparison of two systems of cardiopulmonary bypass. Perfusion 2014; 30:389-94. [PMID: 25143413 DOI: 10.1177/0267659114548256] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE To determine the influence of haemodilution, bypass flow rates and calculated oxygen delivery during cardiopulmonary bypass (CPB) with either a conventional CPB (C-CPB) circuit or a miniaturised (Mini-CPB) circuit on cerebral oxygen desaturation. The effect of minimal haemodilution with a Mini-CPB was investigated. PARTICIPANTS Eighty patients scheduled for elective cardiac surgery. INTERVENTION Oxygenated haemoglobin (O2Hb) and tissue oxygenation index (TOI) were measured with near-infrared spectroscopy (NIRS). RESULTS The average indexed bypass pump flow was significantly lower with Mini-CPB. When combined with haemoglobin concentration, the average oxygen delivery was the same between groups. Patients in the C-CPB group had a greater duration and severity of cerebral desaturation to a level <20% below baseline values, but none reached the depth and duration of the cerebral desaturation associated with poor outcome. Cerebral oxygen desaturation with C-CPB was significantly associated with low flows during bypass, whereas desaturation with Mini-CPB was associated with low perioperative haemoglobin concentration.
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Affiliation(s)
- M J Bennett
- Department of Cardiothoracic Anaesthesia, South West Cardiothoracic Centre, Plymouth, UK
| | - M Weatherall
- Department of Clinical Perfusion, South West Cardiothoracic Centre, Plymouth, UK
| | - G Webb
- Department of Clinical Perfusion, South West Cardiothoracic Centre, Plymouth, UK
| | - S F Dudnikov
- Department of Cardiothoracic Anaesthesia, South West Cardiothoracic Centre, Plymouth, UK
| | - C T Lloyd
- Department of Cardiac Surgery, South West Cardiothoracic Centre, Plymouth, UK
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Impact of different surgical strategies on perioperative protein S100β release in elderly patients undergoing coronary artery bypass grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2014; 8:230-6. [PMID: 23989819 DOI: 10.1097/imi.0b013e3182a3496a] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
OBJECTIVE This study was designed to compare neurological injury-associated protein S100β release during three different treatment modalities, minimized closed circuit coronary artery bypass grafting (CABG) (MCABG), off-pump CABG (OPCAB), and conventional CABG (CCABG), comprising high-volume prime and cold crystalloid cardioplegia. Our working hypothesis was that fluid restriction as provided by MCABG may decrease neurological injury-associated protein S100β release. METHODS In this prospective trial, in a tertiary center, 30 surgical patients (aged >70 years, 25 men and 5 women) undergoing first-time elective CABG were enrolled. The inclusion criteria were three-vessel disease and elective surgery. The exclusion criteria were left ventricular ejection fraction of less than 30%, use of clopidogrel, carotid disease, or needing fewer than three distal anastomoses. Protein S100β concentrations, hematocrit (Ht) levels, and PO2 levels were measured after induction of anesthesia, 10 minutes after reperfusion, upon arrival at the intensive care unit, 3 hours postoperatively at the intensive care unit, and the next morning. Statistics consisted of areas under the curve, peak levels, and correlation and variance tests. RESULTS A significant negative correlation was found indicating higher S100β release at lower Ht levels and at lower PO2 levels in all study groups. The lowest S100β variance was measured during MCABG (Wilks Λ P = 0.052). The perioperative Ht was significantly higher in the MCABG group and in the OPCAB group compared with the CCABG group (P = 0.04 vs P < 0.01). At all time points, the S100β protein concentration showed no significant differences between the different surgical techniques. The mean (95% confidence interval) values of S100 area under the curve were the following: CCABG, 2.3 (1.06-3.5); MCABG, 1.44 (0.6-2.21); and OPCAB, 1.87 (1.5-2.19) [independent nonparametric Kruskal-Wallis test (P = 0.13)]. The mean (95% confidence interval) peak S100 values (calculated as the maximum value seen in a patient during the research period) were the following: CCABG, 1.07 (0.4-1.68); MCABG, 0.59 (0.28-0.90); and OPCAB, 0.83 (0.59-1.06) [independent nonparametric Kruskal-Wallis test (P = 0.22)]. CONCLUSIONS Despite similar perioperative S100β protein release for all techniques studied, higher Ht and PO2 levels correlated with lower S100β release within all study groups. The low S100β variance during the fluid restrictive MCABG technique may be due to more efficient oxygen transport to the brain provided by significantly higher perioperative Ht levels. Further prospective data are required to better understand this complex issue.
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Minimised closed circuit coronary artery bypass grafting in the elderly is associated with lower levels of organ-specific biomarkers. Eur J Anaesthesiol 2013; 30:685-94. [DOI: 10.1097/eja.0b013e328364febf] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Anastasiadis K, Asteriou C, Antonitsis P, Argiriadou H, Grosomanidis V, Kyparissa M, Deliopoulos A, Konstantinou D, Tossios P. Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study. J Cardiothorac Vasc Anesth 2013; 27:859-64. [DOI: 10.1053/j.jvca.2013.01.010] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2012] [Indexed: 11/11/2022]
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Hogan AM, Shipolini A, Brown MM, Hurley R, Cormack F. Fixing hearts and protecting minds: a review of the multiple, interacting factors influencing cognitive function after coronary artery bypass graft surgery. Circulation 2013; 128:162-71. [PMID: 23836829 DOI: 10.1161/circulationaha.112.000701] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Affiliation(s)
- Alexandra M Hogan
- MBBS, Developmental Cognitive Neuroscience Unit, UCL Institute of Child Health, 30 Guildford St, London, WC1E 6BT, United Kingdom.
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Zanatta P, Forti A, Minniti G, Comin A, Mazzarolo AP, Chilufya M, Baldanzi F, Bosco E, Sorbara C, Polesel E. Brain emboli distribution and differentiation during cardiopulmonary bypass. J Cardiothorac Vasc Anesth 2013; 27:865-75. [PMID: 23706643 DOI: 10.1053/j.jvca.2012.12.022] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Cardiopulmonary bypass (CPB) is a lifesaving practice in cardiac surgery, but its use frequently is associated with cerebral injury and neurocognitive dysfunctions. Despite the involvement of numerous factors, microembolism occurring during CPB seems to be one of the main mechanisms leading to such alterations. The aim of the present study was to characterize the occurrence of cerebral microembolism with reference to microembolic amount, nature, and distribution in different combinations of cardiac procedures and CPB on the microembolic load. DESIGN A retrospective observational clinical study. SETTING A single-center regional hospital. PARTICIPANTS Fifty-five patients undergoing elective cardiac surgery with CPB. INTERVENTIONS Bilateral detection of the patients' middle cerebral arteries using a multifrequency transcranial Doppler. MEASUREMENTS AND MAIN RESULTS Patients were divided into 3 groups depending on the CPB circuit used (open, open with vacuum, or closed). There was a significant difference between the number of solid and gaseous microemboli (p<0.001), with the solid lower than the gaseous ones. The number of solid microemboli was affected by group (p< 0.05), CPB phase (p<0.001), and laterality (p<0.01). The number of gaseous microemboli was affected only by group (p<0.05) and CPB phase (p<0.001). Generally, the length of CPB phase did not affect the number of microemboli. CONCLUSIONS Surgical procedures combined with CPB circuits, but not the CPB phase length, affected the occurrence, nature, and laterality of microemboli.
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Affiliation(s)
- Paolo Zanatta
- Department of Anesthesia and Intensive Care, Treviso Regional Hospital, Italy
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Aboud A, Liebing K, Börgermann J, Ensminger S, Zittermann A, Renner A, Hakim-Meibodi K, Gummert J. Excessive negative venous line pressures and increased arterial air bubble counts during miniaturized cardiopulmonary bypass: an experimental study comparing miniaturized with conventional perfusion systems. Eur J Cardiothorac Surg 2013; 45:69-74. [PMID: 23666376 DOI: 10.1093/ejcts/ezt257] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Miniaturized cardiopulmonary bypass (MCPB) is increasingly used in cardiac surgery, because it can lower clinically significant complications such as systemic inflammatory response, haemolysis and high transfusion requirements. A limitation of MCPB is the risk of excessive negative pressure in the venous line during volume depletion, probably leading to gaseous microembolism. METHODS In an experimental study with 24 pigs, we compared conventional open cardiopulmonary bypass (CCPB group, n = 11) with MCPB (n = 13). The same pump and identical tubing materials were used in both groups. Primary endpoints were pressure values in the venous line and the right atrium as well as the amount of air bubbles >500 µm. Secondary endpoints were biochemical parameters of systemic inflammatory response, ischaemia, haemodilution and haemolysis. RESULTS Nearly 20% of venous pressure values were below -150 mmHg and approximately 10% of the right atrial pressure values were below -100 mmHg in the MCPB group, during the experiment. No such low values were observed in the CCPB group. In addition, the number of large arterial air bubbles was higher in the MCPB group compared with the CCPB group (mean ± standard deviation [SD]: 13 444 ± 5709 vs 0.9 ± 0.6, respectively; P < 0.001). Bubble volume was also significantly larger during MCPB compared with CCPB (mean ± SD: 1522 ± 654 vs 4.1 ± 2.5 µl, respectively; P < 0.001). Blood levels of interleukin-6, free haemoglobin and creatine kinase were significantly higher in the CCPB group compared with the MCPB group. CONCLUSIONS Despite the benefits of MCPB regarding systemic inflammatory response and haemolysis, this technique is associated with excessive negative venous line pressures and a significant increase in the number and volume of arterial air bubbles compared with CCPB. Mini-perfusion systems and the management of MCPB require further refinements to avoid such adverse effects.
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Affiliation(s)
- Anas Aboud
- Clinic for Thoracic and Cardiovascular Surgery, Heart and Diabetes Center NRW, Ruhr University Bochum, Bad Oeynhausen, Germany
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van Boven WJP, Morariu A, Salzberg SP, Gerritsen WB, Waanders FG, Korse TC, Aarts LP. Impact of Different Surgical Strategies on Perioperative Protein S100β Release in Elderly Patients Undergoing Coronary Artery Bypass Grafting. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2013. [DOI: 10.1177/155698451300800311] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
Affiliation(s)
- Wim Jan P. van Boven
- Department of Cardio Thoracic Surgery, and Leiden University Medical Centre, Leiden, the Netherlands
| | - Aurora Morariu
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
| | - Sacha P. Salzberg
- Department of Cardiothoracic Surgery, Academic Medical Center, Amsterdam, the Netherlands
| | - Wim B. Gerritsen
- Department of Clinical Chemistry and Haematological Laboratory, Gelre Hospital, Apeldoorn, the Netherlands
| | | | - Tiny C. Korse
- Department of Clinical Chemistry, Netherlands Cancer Institute, Amsterdam, the Netherlands
| | - Leon P. Aarts
- Department of Anaesthesiology, Leiden University Medical Centre, Leiden, the Netherlands
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Wittwer T, Sabashnikov A, Rahmanian PB, Choi YH, Zeriouh M, Mehler TO, Wahlers T. Less invasive coronary artery revascularization with a minimized extracorporeal circulation system: preliminary results of a comparative study with off-pump-procedures. J Cardiothorac Surg 2013; 8:75. [PMID: 23577663 PMCID: PMC3639032 DOI: 10.1186/1749-8090-8-75] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2012] [Accepted: 01/11/2013] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Coronary-artery-bypass-grafting (CABG) with conventional extracorporeal circulation (CECC) is associated with adverse effects such as systemic inflammatory response leading to a decrease in systemic vascular resistance and hemodynamic instability. Modern "less invasive" procedures have been established recently which potentially avoid negative side effects of CECC. The aim of this study was to compare perioperative outcome following coronary revascularization using either a minimized extracorporeal circuit (Mini-HLM) or off-pump technique (OPCAB). METHODS In this prospective ethics-approved trial, 120 patients referred for CABG were randomly assigned either to off-pump coronary artery bypass (OPCAB) or to a Mini-HLM procedure. Patient demographics, preoperative characteristics and extensive postoperative outcome were analyzed for both groups. Hemodynamic data were measured at seven time points perioperatively. RESULTS Operation-time was longer in the Mini-HLM group (178,3 ± 32,9 min) compared to OPCAB (133,2 ± 32,7 min, p < 0,001) with higher graft numbers in Mini-HLM group (3,11 ± 0,7 vs. 1,78 ± 0,7, p < 0.001). There were no significant differences in perioperative hemodynamic criteria, catecholaminergic support, hospital (p = 0,534) and intensive care unit stay (p = 0,880), ventilation time (p = 0,113), blood loss (p = 0,570), transfusion requirements, postoperative atrial fibrillation rate (p = 0,706) and neurocognitive disturbance (p = 0,297). No deaths and no myocardial infarctions were observed. CONCLUSIONS Coronary revascularisation with Mini-HLM represents a suitable and "less invasive" procedure which achieves all benefits of OPCAB but may allow for less demanding revascularisation than OPCAB in special patients with complex coronary anatomy and can therefore be used both on a routine basis and in all "conversion" cases of OPCAB.
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Affiliation(s)
- Thorsten Wittwer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Parwis B Rahmanian
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Mohamed Zeriouh
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Thorsten O Mehler
- Department of Anesthesiology, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Kerpener Str. 62, Cologne, 50924, Germany
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Anastasiadis K, Antonitsis P, Haidich AB, Argiriadou H, Deliopoulos A, Papakonstantinou C. Use of minimal extracorporeal circulation improves outcome after heart surgery; a systematic review and meta-analysis of randomized controlled trials. Int J Cardiol 2013; 164:158-69. [DOI: 10.1016/j.ijcard.2012.01.020] [Citation(s) in RCA: 94] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/27/2011] [Revised: 12/30/2011] [Accepted: 01/10/2012] [Indexed: 11/15/2022]
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Asteriou C, Antonitsis P, Argiriadou H, Deliopoulos A, Konstantinou D, Foroulis C, Papakonstantinou C, Anastasiadis K. Minimal extracorporeal circulation reduces the incidence of postoperative major adverse events after elective coronary artery bypass grafting in high-risk patients. A single-institutional prospective randomized study. Perfusion 2013; 28:350-6. [DOI: 10.1177/0267659113479135] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Coronary artery bypass grafting (CABG) using minimal extracorporeal circulation (MECC) has been associated with an improved short-term clinical outcome compared to conventional extracorporeal circulation (CECC). The aim of this study was to evaluate the impact of MECC compared to CECC on postoperative major adverse events in high-risk patients undergoing elective coronary revascularization procedures. Two hundred patients undergoing elective CABG were randomized into two groups. In Group A (n=100), MECC was used while Group B (n=100) included patients who were operated on CECC. The incidence of postoperative major adverse events (myocardial infarction, renal failure, stroke, death) was the primary end-point of the study. MECC was associated with a 77% relative risk reduction in the incidence of major adverse events compared to CECC (p=0.004). The rate of major adverse events occurring in the high-risk patient subgroup (preoperative left ventricular ejection fraction ≤40%, age >65 years, EuroSCORE II >5) operated on with MECC was significantly lower in comparison to their CECC counterparts. Based on our results, cardiac centres should be encouraged to use MECC as the standard circuit when performing elective coronary procedures, even in a high-risk population.
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Affiliation(s)
- C Asteriou
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - P Antonitsis
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - H Argiriadou
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - A Deliopoulos
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - D Konstantinou
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - C Foroulis
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - C Papakonstantinou
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
| | - K Anastasiadis
- Department of Cardiothoracic Surgery, AHEPA University Hospital, Thessaloniki, Greece
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Zeitani J, Buccisano F, Nardella S, Flaminio M, Prati P, Chiariello G, Venditti A, Chiariello L. Mini-extracorporeal circulation minimizes coagulation abnormalities and ameliorates pulmonary outcome in coronary artery bypass grafting surgery. Perfusion 2013; 28:298-305. [PMID: 23411504 DOI: 10.1177/0267659113478322] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Hemostasis is impaired during CABG and coagulation abnormalities often result in clinically relevant organ dysfunctions, eventually increasing morbidity and mortality rates. Fifteen consecutive patients with coronary artery disease submitted to conventional extracorporeal circulation (cECC) have been compared with 15 matched patients, using mini-ECC (MECC). Postoperative lung function was evaluated according to gas exchange, intubation time and lung injury score. In the MECC group, thrombin-antithrombin complex levels (TaTc), prothrombin fragments (PF1+2) formation and thromboelastography (TEG) clotting times were lower compared to the cECC group (p=0.002 and p<0.001, respectively) whereas postoperative blood loss was higher in the cECC group (p=0.030) and more patients required blood transfusion (p=0.020). In the MECC group, postoperative gas exchange values were better, intubation time shorter and lung injury score lower (p<0.001 for all comparisons). Our study suggests that MECC induces less coagulation disorders, leading to lower postoperative blood loss and better postoperative lung function. This approach may be advantageous in high-risk patients.
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Affiliation(s)
- J Zeitani
- Department of Cardiac Surgery, Tor Vergata University of Rome, Rome, Italy
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Donndorf P, Kühn F, Vollmar B, Rösner J, Liebold A, Gierer P, Steinhoff G, Kaminski A. Comparing microvascular alterations during minimal extracorporeal circulation and conventional cardiopulmonary bypass in coronary artery bypass graft surgery: A prospective, randomized study. J Thorac Cardiovasc Surg 2012; 144:677-83. [DOI: 10.1016/j.jtcvs.2012.05.037] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/16/2011] [Revised: 04/04/2012] [Accepted: 05/15/2012] [Indexed: 10/28/2022]
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Sjatskig J, Yilmaz A, van Boven JW, Sonker U, Waanders FG, Kloppenburg GTL. Feasibility of mitral valve surgery using minimal extracorporeal circulation. Perfusion 2012; 27:264-8. [PMID: 22450336 DOI: 10.1177/0267659112442099] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
AIM Using minimal extracorporeal circulation (MECC) in isolated coronary artery bypass grafting or aortic valve replacement has been proven to be safe, feasible and superior compared to standard cardiopulmonary bypass (CPB) in terms of postoperative complications, total hospital stay and blood product transfusions. This feasibility study evaluates the clinical outcomes of mitral valve surgery performed with MECC. METHODS From March 2006 to January 2011, seventy-five patients who underwent mitral valve surgery performed with MECC (n=75) in our institution were retrospectively evaluated. Demographic characteristics, operative data and clinical outcomes were collected in a prospectively designed database. RESULTS The mean age was 68.8 ± 10.2 years with a EuroSCORE of 7.0 ± 2.3. Thirty-seven patients had a moderate left ventricular function (with a range of 30-40%). All patients except two had severe mitral valve incompetence (MI). Surgery was successful in all procedures. The mean duration of surgery was 210 ± 44 min (range 118-356 min). The mean CPB time was 128 ± 30 (range 67-249) min. The cross-clamp time was 99 ± 26 (range 48-205) min. There were no intraoperative perfusion problems or airlocks reported. The mean intensive care unit (ICU) length of stay was two days. Subsequent analysis showed a first postoperative haemoglobin value of 9.4 g/dL ± 1.7. There were no peroperative neurological complications. One patient developed an ischaemic cerebrovascular accident (CVA) on the forth postoperative day due to inadequate anticoagulation. Other postoperative complications included eight patients with pneumonia, one superficial wound infection, temporary renal insufficiency in two patients and four patients needed re-exploration for excessive postoperative leakage. Overall in-hospital mortality was four percent. CONCLUSION Our results show, for the first time, that isolated or combined mitral valve surgery using MECC is feasible and safe.
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Affiliation(s)
- J Sjatskig
- Department of Cardiothoracic Surgery, St. Antonius Hospital, Nieuwegein, the Netherlands
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Ried M, Kobuch R, Rupprecht L, Keyser A, Hilker M, Schmid C, Diez C. Reduced 30-day mortality in men after elective coronary artery bypass surgery with minimized extracorporeal circulation-a propensity score analysis. BMC Cardiovasc Disord 2012; 12:17. [PMID: 22424497 PMCID: PMC3323468 DOI: 10.1186/1471-2261-12-17] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2011] [Accepted: 03/16/2012] [Indexed: 11/30/2022] Open
Abstract
Background Impact of minimized extracorporeal circulation (MECC) for coronary surgery on mortality remains controversial and gender significantly influence outcome. Methods We analyzed 3,139 male patients undergoing elective coronary surgery between 01/2004 and 05/2009. Using propensity score matching after binary logistic regression, 1,005 patients (from 1,119 patients) undergoing surgery with MECC could be matched with 1,005 patients (from 2,020 patients) undergoing surgery with conventional extracorporeal circulation (CECC). Primary outcome was 30-day mortality. Results Unadjusted 30-day mortality was 2.7% in patients with CECC and 0.8% in those with MECC (mean difference -1.9%; p < 0.001). The adjusted mean difference (average treatment effect of the treated) after matching was -1.5% (95% confidence interval (CI) -2.6 to -0.4; p = 0.006). Postoperative hospital stay was shorter in patients operated with minimized systems (adjusted mean difference -0.8 days; 95% CI -1.46 to -0.09; p = 0.03) and incidence of postoperative neurocognitive dysfunction was also lower (adjusted mean difference -1.3%; 95% CI -2.2 to -0.4; p = 0.001). Chest tube drainage (adjusted mean difference +22 mL; 95% CI -47 to 91; p = 0.5) and risk for acute kidney injury, kidney injury and failure according to RIFLE criteria (adjusted mean difference -1.0%; 95% CI -2.5 to 0.6; p = 0.24) proved to be insignificant between both groups. Apart from reduced 30-day mortality, however, average treatment effects for intensive care unit stay, postoperative hospital stay, chest tube drainage and kidney injury did not significantly differ. Conclusion Using propensity score analysis, we observed an association between MECC and reduced 30-day mortality in men, but our results call for further analysis.
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Affiliation(s)
- Michael Ried
- Department of Cardiothoracic Surgery, University Medical Center Regensburg, Franz-Josef-Strauß-Allee 11, Regensburg 93053, Germany.
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Wittwer T, Choi YH, Neef K, Schink M, Sabashnikov A, Wahlers T. Off-pump or minimized on-pump coronary surgery--initial experience with Circulating Endothelial Cells (CEC) as a supersensitive marker of tissue damage. J Cardiothorac Surg 2011; 6:142. [PMID: 22011515 PMCID: PMC3228796 DOI: 10.1186/1749-8090-6-142] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2011] [Accepted: 10/19/2011] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND Off-pump-coronary-artery-bypass-grafting (OPCAB) and minimized-extracorporeal-circulation (Mini-HLM) have been proposed to avoid harmful effects of cardiopulmonary-bypass (CPB). Controversies exist whether OPCAB is still superior in perioperative outcome. Circulating endothelial cells (CEC) are sensitive markers of endothelial damage and are significantly elevated in conventional-CPB-procedures as compared to Mini-HLM-revascularisation. Therefore, CEC might be of specific value in evaluating effectiveness of Mini-HLM and OPCAB as currently applied less-invasive coronary procedures. METHODS 76 coronary patients were randomly assigned either to OPCAB (n = 34) or to Mini-HLM (ROCsafe™, Terumo Inc., n = 42) procedures. Perioperative data, clinical and serological outcome and measurements of CEC-release and parameters of endothelial function (v.Willebrand-Factor, soluble-thrombomodulin) perioperatively (pre-operative-baseline, post-Mini-HLM/release of OPCAB-stabilizer, 6 h, 12 h, 24 h and 5 days postoperatively) were obtained and compared by ANOVA models including repeated-measures-analysis. RESULTS Mean graft-number was 3.06 ± 0.72 in Mini-HLM-patients and 1.89 ± 0.74 in OPCAB-patients (p < 0.001). However, ventilation-, ICU- and total-hospital duration were comparable between groups as well as chest-tube-drainage, transfusion requirements, hemodynamics and catecholaminergic support (p > 0.05). CEC-release did not differ between groups (p = 0.274) and was generally within normal limits, Troponin-T levels where not significanty different (p = 0.108). No myocardial infarctions, strokes or deaths occurred, neuron specific enolase (NSE) did not show any differences between groups (p = 0.194). CONCLUSION Conceptional advantages of minimized CPB systems (ROCsafe™) result in morbidity and mortality comparable with OPCAB procedures. Mini-HLM therefore minimizes CPB-related systemic and organ injury as demonstrated by low CEC-values which indicates intact endothelial integrity. Furthermore, Mini-HLM combines OPCAB-benefits with low morbidity in high-risk patients while facilitating more complete revascularization in complex patients.
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Affiliation(s)
- Thorsten Wittwer
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
- Center of Molecular Medicine Cologne, University Hospital of Cologne, Germany
| | - Yeong-Hoon Choi
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
- Center of Molecular Medicine Cologne, University Hospital of Cologne, Germany
| | - Klaus Neef
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
- Center of Molecular Medicine Cologne, University Hospital of Cologne, Germany
| | - Mareike Schink
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
- Center of Molecular Medicine Cologne, University Hospital of Cologne, Germany
| | - Anton Sabashnikov
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
| | - Thorsten Wahlers
- Department of Cardiothoracic Surgery, Heart Center, University Hospital of Cologne, Germany
- Center of Molecular Medicine Cologne, University Hospital of Cologne, Germany
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Rimpiläinen R, Hautala N, Koskenkari J, Rimpiläinen J, Ohtonen P, Mustonen P, Surcel HM, Savolainen ER, Mosorin M, Ala-Kokko T, Juvonen T. Comparison of the use of minimized cardiopulmonary bypass with conventional techniques on the incidence of retinal microemboli during aortic valve replacement surgery. Perfusion 2011; 26:479-86. [PMID: 21727175 DOI: 10.1177/0267659111415564] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
OBJECTIVES Minimized cardiopulmonary bypass (MCPB) circuits have been shown to reduce cerebral and retinal microembolisation during coronary artery bypass graft (CABG) surgery compared to conventional CPB (CCPB) circuits. Our aim was to evaluate whether the reduction of microembolisation is sustained in aortic valve surgery, as well as to evaluate the effects of MCPB on inflammatory, endothelial, and platelet activation markers. MATERIAL AND METHODS Patients were randomized to undergo aortic valve replacement (AVR), with or without CABG, with MPCB (n=20) or CCPB (n=20). After anaesthesia induction and termination of CPB, standardized digital retinal fluorescein angiography images were obtained on both eyes and analyzed in a blinded fashion. Blood samples were collected at eight time points until the third postoperative day. RESULTS Fewer patients in the MCPB group showed evidence of microembolic perfusion defects on postperfusion retinal fluorescein angiographs compared to the CCPB group (37% vs. 63%, absolute difference 26%, 95% CI -5% -51%, P = 0.194). Polymorphonuclear leukocyte (PMN) elastase and von Willebrand factor release were statistically significantly reduced in the MCPB group, but there were no significant differences in other markers of inflammation, coagulation or endothelial activation. A significantly higher three-fold increase in the amount of shed blood was collected to the cell saver with a higher rate of intraoperative platelet transfusion in the MCPB group compared to CCPB. CONCLUSIONS The use of MCPB was associated statistically insignificantly with less retinal microemboli compared to CCPB. MCPB was complicated by excess bleeding and need for transfusion. The feasibility of MCPB techniques in valve surgery requires further studies.
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Affiliation(s)
- R Rimpiläinen
- Department of Anesthesiology and Surgery, Division of Anesthesiology and Intensive Care, Oulu University Hospital, Oulu, Finland.
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Ferraris VA, Brown JR, Despotis GJ, Hammon JW, Reece TB, Saha SP, Song HK, Clough ER, Shore-Lesserson LJ, Goodnough LT, Mazer CD, Shander A, Stafford-Smith M, Waters J, Baker RA, Dickinson TA, FitzGerald DJ, Likosky DS, Shann KG. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg 2011; 91:944-82. [PMID: 21353044 DOI: 10.1016/j.athoracsur.2010.11.078] [Citation(s) in RCA: 859] [Impact Index Per Article: 66.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/17/2010] [Revised: 11/20/2010] [Accepted: 11/29/2010] [Indexed: 12/16/2022]
Abstract
BACKGROUND Practice guidelines reflect published literature. Because of the ever changing literature base, it is necessary to update and revise guideline recommendations from time to time. The Society of Thoracic Surgeons recommends review and possible update of previously published guidelines at least every three years. This summary is an update of the blood conservation guideline published in 2007. METHODS The search methods used in the current version differ compared to the previously published guideline. Literature searches were conducted using standardized MeSH terms from the National Library of Medicine PUBMED database list of search terms. The following terms comprised the standard baseline search terms for all topics and were connected with the logical 'OR' connector--Extracorporeal circulation (MeSH number E04.292), cardiovascular surgical procedures (MeSH number E04.100), and vascular diseases (MeSH number C14.907). Use of these broad search terms allowed specific topics to be added to the search with the logical 'AND' connector. RESULTS In this 2011 guideline update, areas of major revision include: 1) management of dual anti-platelet therapy before operation, 2) use of drugs that augment red blood cell volume or limit blood loss, 3) use of blood derivatives including fresh frozen plasma, Factor XIII, leukoreduced red blood cells, platelet plasmapheresis, recombinant Factor VII, antithrombin III, and Factor IX concentrates, 4) changes in management of blood salvage, 5) use of minimally invasive procedures to limit perioperative bleeding and blood transfusion, 6) recommendations for blood conservation related to extracorporeal membrane oxygenation and cardiopulmonary perfusion, 7) use of topical hemostatic agents, and 8) new insights into the value of team interventions in blood management. CONCLUSIONS Much has changed since the previously published 2007 STS blood management guidelines and this document contains new and revised recommendations.
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Nakahira A, Sasaki Y, Hirai H, Matsuo M, Morisaki A, Suehiro S, Shibata T. Cardiotomy suction, but not open venous reservoirs, activates coagulofibrinolysis in coronary artery surgery. J Thorac Cardiovasc Surg 2011; 141:1289-97. [DOI: 10.1016/j.jtcvs.2010.07.024] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2010] [Revised: 07/01/2010] [Accepted: 07/13/2010] [Indexed: 11/15/2022]
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Do Miniaturized Extracorporeal Circuits Confer Significant Clinical Benefit Without Compromising Safety? A Meta-Analysis of Randomized Controlled Trials. ASAIO J 2011; 57:141-51. [DOI: 10.1097/mat.0b013e318209d63b] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022] Open
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Clinical Evaluation of the Air Removal Characteristics of an Oxygenator with Integrated Arterial Filter in a Minimized Extracorporeal Circuit. Int J Artif Organs 2011; 34:374-82. [DOI: 10.5301/ijao.2011.7749] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/05/2011] [Indexed: 11/20/2022]
Abstract
The use of minimized extracorporeal circuits (MECC) in cardiac surgery is an important measure to increase the biocompatibility of cardiopulmonary bypass during coronary artery bypass grafting (CABG). These circuits eliminate volume storage reservoirs and bubble traps to minimize the circuit. However, the reduction in volume may increase the risk of gaseous microemboli (GME). The MECC system as used by our group consists of a venous bubble trap, centrifugal pump, and an oxygenator. To further reduce the risk of introducing GME, an oxygenator with an integrated arterial filter was developed based on the concept of minimal volume and foreign surface. We studied the air removal characteristics of this oxygenator with and without integrated arterial filter. The quantity and volume of GME were measured with precision at both the inlet and outlet of the devices. Our results showed that integration of an arterial filter into this oxygenator increased GME reducing capacity from 69.2% to 92%. Moreover, we were able to obtain data on the impact of an arterial filter on the exact size-distribution of GME entering the arterial line. The present study demonstrates that an MECC system and oxygenator with integrated arterial filter significantly reduces the volume and size of GME. The use of an integrated arterial filter in an MECC system may protect the patient from the deleterious effects of CPB and may further improve patient safety.
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Stellenwert der minimierten extrakorporalen Zirkulation in der modernen Koronarchirurgie. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2011. [DOI: 10.1007/s00398-010-0823-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
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Minimized Cardiopulmonary Bypass Reduces Retinal Microembolization: A Randomized Clinical Study Using Fluorescein Angiography. Ann Thorac Surg 2011; 91:16-22. [DOI: 10.1016/j.athoracsur.2010.08.049] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/21/2010] [Revised: 08/23/2010] [Accepted: 08/24/2010] [Indexed: 11/21/2022]
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Roosenhoff TP, Stehouwer MC, De Vroege R, Butter RP, Van Boven WJ, Bruins P. Air Removal Efficiency of a Venous Bubble Trap in a Minimal Extracorporeal Circuit During Coronary Artery Bypass Grafting. Artif Organs 2010; 34:1092-8. [DOI: 10.1111/j.1525-1594.2009.00986.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Curtis N, Vohra HA, Ohri SK. Mini extracorporeal circuit cardiopulmonary bypass system: a review. Perfusion 2010; 25:115-24. [DOI: 10.1177/0267659110371705] [Citation(s) in RCA: 31] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Improved knowledge of the pathophysiological processes experienced in response to cardiopulmonary bypass has led to new developments in extracorporeal technology and understanding. The use of mini extracorporeal circuits (MECC) is rapidly expanding in clinical practice. The mini extracorporeal circuit differs by a greatly reduced tubing length and the number of components when compared with current circuit designs. The MECC is believed to offer potential benefits to the surgical patient by reducing the systemic inflammatory response that remains strongly implicated in post-operative organ dysfunction. We present a review of the available literature and find the MECC to show an acceptable safety profile with a reduction in post-operative complications and transfusion requirements and no evidence of any negative impairment to the surgeon, anaesthetist or perfusionist. The observed post-bypass inflammatory response is seen to be lower after MECC bypass and this is of clear clinical benefit.
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Affiliation(s)
- Nathan Curtis
- Wessex Cardiothoracic Department, Southampton General Hospital, Southampton, UK
| | - Hunaid A Vohra
- Wessex Cardiothoracic Department, Southampton General Hospital, Southampton, UK
| | - Sunil K Ohri
- Wessex Cardiothoracic Department, Southampton General Hospital, Southampton, UK,
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Zangrillo A, Garozzo FA, Biondi-Zoccai G, Pappalardo F, Monaco F, Crivellari M, Bignami E, Nuzzi M, Landoni G. Miniaturized cardiopulmonary bypass improves short-term outcome in cardiac surgery: A meta-analysis of randomized controlled studies. J Thorac Cardiovasc Surg 2010; 139:1162-9. [PMID: 19775708 DOI: 10.1016/j.jtcvs.2009.07.048] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/04/2009] [Revised: 06/19/2009] [Accepted: 07/16/2009] [Indexed: 02/08/2023]
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Koivisto SP, Wistbacka JO, Rimpiläinen R, Nissinen J, Loponen P, Teittinen K, Biancari F. Miniaturized versus conventional cardiopulmonary bypass in high-risk patients undergoing coronary artery bypass surgery. Perfusion 2010; 25:65-70. [DOI: 10.1177/0267659110364443] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Objective: To review our results with the use of miniaturized cardiopulmonary bypass (Mini-CPB) versus conventional cardiopulmonary bypass (C-CPB) in high-risk patients (additive EuroSCORE≥6) who have undergone coronary artery bypass graft surgery (CABG). Patients and methods: This study includes a consecutive series of 236 patients with an additive EuroSCORE≥6 who underwent CABG, employing either C-CPB or Mini-CPB. Propensity score analysis was performed. Results: The study groups had similar EuroSCOREs. Stroke rate was significantly higher among C-CPB patients (5.4% vs. 0%, p=0.026). In-hospital mortality (4.8% vs. 3.4%, p=0.75) and combined adverse end-point rate were higher in C-CPB patients (20.4% vs. 13.5%, p=0.18). Postoperative bleeding and need for transfusion were similar in the study groups, but re-sternotomy for bleeding was more frequent among C-CPB patients (4.8% vs. 1.1%, p=0.26). Seventy-four propensity matched pairs had similar immediate postoperative results: C-CPB patients had higher mortality (6.8% vs. 4.1%, p=0.72), stroke (5.4% vs. 0%, p=0.12) and combined adverse end-point rates (27.0% vs. 16.2%, p=0.11), but such differences failed to reach statistical significance. Conclusions: Mini-CPB achieved somewhat better results than C-CPB in these high-risk patients undergoing isolated CABG. This study confirmed that cerebral protection could be the main benefit associated with the use of Mini-CPB.
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Affiliation(s)
| | - Jan-Ola Wistbacka
- Department of Anesthesiology, Vaasa Central Hospital, Vaasa, Finland
| | | | - Juha Nissinen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - Pertti Loponen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - Kari Teittinen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - Fausto Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland,
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37
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Puehler T, Philipp A, Schmid C. Minimal extracorporeal circulation is a promising alternative for off-pump revascularization in adults. J Thorac Cardiovasc Surg 2010; 139:233; author reply 233-4. [PMID: 20106368 DOI: 10.1016/j.jtcvs.2009.08.048] [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: 08/03/2009] [Accepted: 08/17/2009] [Indexed: 10/20/2022]
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38
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Benedetto U, Angeloni E, Refice S, Capuano F, Goracci M, Roscitano A, Sinatra R. Is minimized extracorporeal circulation effective to reduce the need for red blood cell transfusion in coronary artery bypass grafting? Meta-analysis of randomized controlled trials. J Thorac Cardiovasc Surg 2009; 138:1450-3. [DOI: 10.1016/j.jtcvs.2009.03.042] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2008] [Revised: 03/10/2009] [Accepted: 03/23/2009] [Indexed: 11/28/2022]
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39
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Assmann A, Feindt P. Minimierte extrakorporale Zirkulation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2009. [DOI: 10.1007/s00398-009-0731-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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40
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Castiglioni A, Verzini A, Colangelo N, Nascimbene S, Laino G, Alfieri O. Comparison of minimally invasive closed circuit versus standard extracorporeal circulation for aortic valve replacement: a randomized study☆. Interact Cardiovasc Thorac Surg 2009; 9:37-41; discussion 41. [DOI: 10.1510/icvts.2008.192559] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
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41
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Rimpiläinen R, Biancari F, Wistbacka JO, Loponen P, Koivisto SP, Rimpiläinen J, Teittinen K, Nissinen J. Outcome after coronary artery bypass surgery with miniaturized versus conventional cardiopulmonary bypass. Perfusion 2009; 23:361-7. [DOI: 10.1177/0267659109105254] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We have reviewed the results of our experience with the use of miniaturized (Mini-CPB) versus conventional (C-CPB) cardiopulmonary bypass in coronary artery bypass surgery (CABG). This study included 365 patients who underwent CABG with C-CPB and 101 patients with Mini-CPB. In-hospital mortality was lower in the C-CPB group (1.4% vs. 3.0%, P = 0.38). A better, but not statistically significant, immediate outcome was observed in the C-CPB group as indicated by a shorter length of stay in the intensive care unit as well as a lower incidence of combined adverse end-point. However, this was probably due to significantly higher operative risk in the Mini-CPB group (logistic EuroSCORE: 8.5 ± 10.0 vs. 4.6 ± 7.1, P < 0.0001). Seventy-seven propensity score-matched pairs had similar immediate postoperative results after Mini-CPB and C-CPB (30-day mortality: 1.3% vs. 1.3%; stroke: 0% vs. 0%; intensive care unit stay ≥5 days: 6.5% vs. 9.1%; combined adverse events: 14.3% vs. 11.7%). Mini-CPB achieves similar results to C-CPB in patients undergoing isolated CABG. The potential efficacy of Mini-CPB is expected to be more evident in high-risk patients or in complex cardiac surgery requiring much longer cardiopulmonary perfusion.
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Affiliation(s)
- R Rimpiläinen
- Department of Anesthesiology, Oulu University Hospital, Oulu, Finland
| | - F Biancari
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - JO Wistbacka
- Department of Anesthesiology, Vaasa Central Hospital, Vaasa, Finland
| | - P Loponen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - SP Koivisto
- Department of Anesthesiology, Vaasa Central Hospital, Vaasa, Finland
| | - J Rimpiläinen
- Department of Surgery, Oulu University Hospital, Oulu, Finland
| | - K Teittinen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
| | - J Nissinen
- Department of Surgery, Vaasa Central Hospital, Vaasa, Finland
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Ranucci M, Castelvecchio S, Romitti F, Isgrò G, Ballotta A, Conti D. Living without aprotinin: the results of a 5-year blood saving program in cardiac surgery. Acta Anaesthesiol Scand 2009; 53:573-80. [PMID: 19173686 DOI: 10.1111/j.1399-6576.2008.01899.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND After 20 years of regular use in cardiac surgery patients, aprotinin has recently been withdrawn from the market due to many concerns about its safety. For a number of reasons aprotinin has not been available in Italy since 1998. The present study presents an aprotinin-free treatment protocol applied at our institution during the last 5 years, and aims to verify the results of this protocol in terms of allogeneic blood product transfusions, postoperative blood loss and surgical re-exploration rate. METHODS Retrospective study on 7988 consecutive patients who underwent cardiac surgery during the years 2003-2007. All the patients received specific hemostasis/coagulation management based on (a) routine use of tranexamic acid, (b) heparin dose-response monitoring, thromboelastography, platelet (PLT) function analysis in a select population of patients, and (c) use of fresh frozen plasma (FFP), PLTs, and desmopressin according to the hemostasis/coagulation profile. Data retrieved from the institutional database were quantity of packed red cells (PRCs), FFP, PLT transfusion rate, blood loss in the first 12 postoperative hours, and surgical re-exploration rate. RESULTS PRCs were transfused in 40.4% of patients (with higher rates for selected high-risk subpopulations), FFP in 12.9% and PLTs in 2.6%. Surgical re-exploration rate was 3.7%. With respect to historical controls, a significant reduction of PRCs and FFP transfusions was obtained using closed circuits, point of care coagulation tests, and combination of the two. CONCLUSION This aprotinin-free blood saving program is an effective strategy for allogeneic blood products transfusion containment.
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Affiliation(s)
- M Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico S. Donato, Milan, Italy.
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Alevizou A, Dunning J, Park JD. Can a mini-bypass circuit improve perfusion in cardiac surgery compared to conventional cardiopulmonary bypass? Interact Cardiovasc Thorac Surg 2009; 8:457-66. [PMID: 19153170 DOI: 10.1510/icvts.2008.200857] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the 'mini-bypass technique' can give a reduction in complications after cardiac surgery compared to the conventional cardiopulmonary bypass circuit. Altogether 144 papers were found using the reported search, of which 14 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that 10 out of these 14 studies show reduced hemodilution, 7 show reduced red blood cell transfusion, 2 show reduced fresh frozen plasma use (one showing increased use), and 2 show reduced platelet use. Three studies show reduced postoperative blood loss, but one shows increased blood loss. Three studies show better renal function. Four studies show a better cardiac index and 2 show shorter intensive care unit stay. One study found an increased minute volume and reduced oxygenation for one hour post-mini-bypass. Six studies find significantly reduced inflammatory markers, and 5 measure superior myocardial protection. There are several anecdotal references to a 'learning curve' with this technique but no significant morbidity with complications arising from this were found. Mini-bypass seems to be a promising technique with many documented benefits in studies reporting as many as 1000 patients undergoing this technique.
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Affiliation(s)
- Anastasia Alevizou
- Department of Cardiothoracic Anaesthesia, James Cook University Hospital, Middlesbrough, UK
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45
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Albes JM. Minimierte Herz-Lungen-Maschinen im klinischen Alltag. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2008. [DOI: 10.1007/s00398-008-0655-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Hare GMT, Tsui AKY, McLaren AT, Ragoonanan TE, Yu J, Mazer CD. Anemia and cerebral outcomes: many questions, fewer answers. Anesth Analg 2008; 107:1356-70. [PMID: 18806052 DOI: 10.1213/ane.0b013e318184cfe9] [Citation(s) in RCA: 77] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023]
Abstract
A number of clinical studies have associated acute anemia with cerebral injury in perioperative patients. Evidence of such injury has been observed near the currently accepted transfusion threshold (hemoglobin [Hb] concentration, 7-8 g/dL), and well above the threshold for cerebral tissue hypoxia (Hb 3-4 g/dL). However, hypoxic and nonhypoxic mechanisms of anemia-induced cerebral injury have not been clearly elucidated. In addition, protective mechanisms which may minimize cerebral injury during acute anemia have not been well defined. Vasodilatory mechanisms, including nitric oxide (NO), may help to maintain cerebral oxygen delivery during anemia as all three NO synthase (NOS) isoforms (neuronal, endothelial, and inducible NOS) have been shown to be up-regulated in different experimental models of acute hemodilutional anemia. Recent experimental evidence has also demonstrated an increase in an important transcription factor, hypoxia inducible factor (HIF)-1alpha, in the cerebral cortex of anemic rodents at clinically relevant Hb concentrations (Hb 6-7 g/dL). This suggests that cerebral oxygen homeostasis may be in jeopardy during acute anemia. Under hypoxic conditions, cytoplasmic HIF-1alpha degradation is inhibited, thereby allowing it to accumulate, dimerize, and translocate into the nucleus to promote transcription of a number of hypoxic molecules. Many of these molecules, including erythropoietin, vascular endothelial growth factor, and inducible NOS have also been shown to be up-regulated in the anemic brain. In addition, HIF-1alpha transcription can be increased by nonhypoxic mediators including cytokines and vascular hormones. Furthermore, NOS-derived NO may also stabilize HIF-1alpha in the absence of tissue hypoxia. Thus, during anemia, HIF-1alpha has the potential to regulate cerebral cellular responses under both hypoxic and normoxic conditions. Experimental studies have demonstrated that HIF-1alpha may have either neuroprotective or neurotoxic capacity depending on the cell type in which it is up-regulated. In the current review, we characterize these cellular processes to promote a clearer understanding of anemia-induced cerebral injury and protection. Potential mechanisms of anemia-induced injury include cerebral emboli, tissue hypoxia, inflammation, reactive oxygen species generation, and excitotoxicity. Potential mechanisms of cerebral protection include NOS/NO-dependent optimization of cerebral oxygen delivery and cytoprotective mechanisms including HIF-1alpha, erythropoietin, and vascular endothelial growth factor. The overall balance of these activated cellular mechanisms may dictate whether or not their up-regulation leads to cytoprotection or cellular injury during anemia. A clearer understanding of these mechanisms may help us target therapies that will minimize anemia-induced cerebral injury in perioperative patients.
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Affiliation(s)
- Gregory M T Hare
- Department of Anesthesia, University of Toronto, St. Michael's Hospital, 30 Bond Street, Toronto, ON M5B 1W8, Canada.
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Sauren LD, Mooren EJ, Severdija EE, Weerwind PW, Maessen JG. Emboli occurrence during coronary artery bypass surgery: the influence of a new method of perfusionist blood sampling. Perfusion 2008; 23:261-5. [DOI: 10.1177/0267659109103390] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Peri-operative cerebral microemboli in cardiac surgery are associated with post-operative neurological complications. Cardiopulmonary bypass (CPB) and perfusionist interventions are important contributors of microemboli. In this study, we examined the influence of blood sampling by the perfusionist on the appearance of microembolic signals (MES) in an open and a closed CPB system. Fourteen patients underwent isolated coronary artery bypass grafting (CABG), using either an open or closed CPB system. Patients were monitored with transcranial Doppler (TCD) for the occurrence MES in both middle cerebral arteries (MCA) as well as in the arterial and venous lines of the CPB. In the closed system, two sampling methods were used, namely the “traditional” and the “E-line”. In the latter, a shunt line was applied from the manifold to the cardiotomy reservoir). In the open system, one method of blood sampling was used. Blood sampling in an open system or in a closed system using the E-line resulted in 0.2 (±0.56) MES, which was significantly lower than the traditional method (72 (±69) MES). The use of a shunt line reduces MES during blood sampling in a closed CPB system.
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Affiliation(s)
- LD Sauren
- Academic Hospital Maastricht, Department Cardiothoracic Surgery, Maastricht, the Netherlands
| | - EJ Mooren
- Academic Hospital Maastricht, Department Cardiothoracic Surgery, Maastricht, the Netherlands
| | - EE Severdija
- Academic Hospital Maastricht, Department Cardiothoracic Surgery, Maastricht, the Netherlands
| | - PW Weerwind
- Academic Hospital Maastricht, Department Cardiothoracic Surgery, Maastricht, the Netherlands
| | - JG Maessen
- Academic Hospital Maastricht, Department Cardiothoracic Surgery, Maastricht, the Netherlands
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Zamora E, Delgado L, Castro MA, Fernández M, Orrit J, Romero B, Cámara ML, Ruyra X. Cirugía coronaria con mini-circulación extracorpórea: experiencia de un grupo en España. Rev Esp Cardiol 2008. [DOI: 10.1157/13117729] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
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49
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Lau K, Shah H, Kelleher A, Moat N. Coronary artery surgery: cardiotomy suction or cell salvage? J Cardiothorac Surg 2007; 2:46. [PMID: 17961227 PMCID: PMC2173896 DOI: 10.1186/1749-8090-2-46] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2007] [Accepted: 10/25/2007] [Indexed: 11/29/2022] Open
Abstract
Coronary artery bypass grafting (CABG) today results in what may be regarded as acceptable levels of blood loss with many institutions avoiding allogeneic red cell transfusion in over 60% of their patients. The majority of cardiac surgeons employ cardiotomy suction to preserve autologous blood during on-pump coronary artery bypass surgery; however the use of cardiotomy suction is associated with a more pronounced systemic inflammatory response and a resulting coagulopathy as well as exacerbating the microembolic load. This leads to a tendency to increased blood loss, transfusion requirement and organ dysfunction. Conversely, the avoidance of cardiotomy suction in coronary artery bypass surgery is not associated with an increased transfusion requirement. There is therefore no indication for the routine use of cardiotomy suction in on-pump coronary artery surgery.
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Affiliation(s)
- Kelvin Lau
- Department of Cardiac Surgery, Royal Brompton Hospital, and NHLI at Imperial College, London SW3 6NP, UK.
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50
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Cohn SM. Near-infrared spectroscopy: potential clinical benefits in surgery. J Am Coll Surg 2007; 205:322-32. [PMID: 17660081 DOI: 10.1016/j.jamcollsurg.2007.02.024] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2006] [Revised: 01/31/2007] [Accepted: 02/06/2007] [Indexed: 10/23/2022]
Affiliation(s)
- Stephen M Cohn
- Department of Surgery, University of Texas Health Science Center, San Antonio, TX 78229-3900, USA
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