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Dang HQ, Nguyen HC, Le TN. Totally Endoscopic Atrial Septal Defect Repair on Beating Heart: Clinical Outcome and Single-Surgeon Learning Curve Experience. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2023; 18:574-582. [PMID: 37997659 DOI: 10.1177/15569845231208457] [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: 11/25/2023]
Abstract
OBJECTIVE To evaluate the safety and efficacy of the Hanoi ASD procedure, which is totally endoscopic surgery for atrial septal defect (ASD) repair on beating heart. In addition, the present study also aimed to analyze the learning curve for this procedure. METHODS From May 2016 to February 2023, 198 consecutive ASD patients weighing ≥20 kg were enrolled in the retrospective study. The Hanoi ASD procedure includes (1) unilateral or bilateral femoral arterial cannulation; (2) two or three 5 mm trocars and a 15 mm port; (3) ASD repair on beating heart, preventing air embolism with CO2 insufflation and keeping the left atrium full of blood; and (4) not snaring the inferior vena cava. Cumulative sum (CUSUM) analysis was used to evaluate the cardiopulmonary bypass (CPB) and operation time learning curves. Variables among the learning curve phases were compared. RESULTS The CPB and operation times were 90 (72 to 115) min and 180 (150 to 220) min, respectively. Total drainage volume was 190 (120 to 290) mL. No endoscopic failure or major complications were complications were excluding factors causing bias, the CUSUMCPBtime analysis for the remaining 131 patients included 3 phases. Phase 1 was the initial learning period (cases 1 to 34), phase 2 represented the technical competence period (cases 35 to 54), and phase 3 was the challenging period (cases 55 to 131). CONCLUSIONS The Hanoi ASD procedure is safe and feasible for repairing ASD in patients weighing ≥20 kg. According to the learning curve analysis, 34 cases were required to achieve technical efficiency, and 54 cases were required to address highly challenging cases.
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Affiliation(s)
- Huy Q Dang
- Division of Minimally Invasive Cardiac Surgery, Cardiovascular Center, Hanoi Heart Hospital, Vietnam
| | - Huu C Nguyen
- Departments of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Thanh N Le
- Departments of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
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2
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Crockett S, Hanna L, Singh A, Gunning S, Nicholas R, Bicknell C, Hamady M, Gable D, Sallam M, Modarai B, Abisi S, Lyons O, Gibbs R. Carbon dioxide flushing versus saline flushing of thoracic aortic stents (INTERCEPTevar): protocol for a multicentre pilot randomised controlled trial. BMJ Open 2023; 13:e067605. [PMID: 37105705 PMCID: PMC10151986 DOI: 10.1136/bmjopen-2022-067605] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Accepted: 02/21/2023] [Indexed: 04/29/2023] Open
Abstract
INTRODUCTION Thoracic endovascular aortic repair (TEVAR) carries a 3%-6.1% stroke risk, including risk of 'silent' cerebral infarction (SCI). Stent-grafts are manufactured in room air and retain air. Instructions for use recommend saline flushing to 'de-air' the system prior to insertion, but substantial amounts of air are released when deploying them, potentially leading to downstream neuronal injury and SCI. Carbon dioxide (CO2) is more dense and more soluble in blood than air, without risk of bubble formation, so could be used in addition to saline to de-air stents. This pilot trial aims to assess the feasibility of a full-scale randomised controlled trial (RCT) investigating the neuroprotective benefit against SCI with the use of CO2-flushed aortic stent-grafts. METHODS AND ANALYSIS This is a multicentre pilot RCT, which is taking place in vascular centres in the UK, USA and New Zealand. Patients identified for TEVAR will be enrolled after informed written consent. 120 participants will be randomised (1:1) to TEVAR-CO2 or TEVAR-saline, stratified according to TEVAR landing zone. Participants will undergo preoperative neurocognitive tests and quality of life assessments, which will be repeated at 6 weeks, or first outpatient appointment, and 6 months. Inpatient neurological testing will be performed within 48 hours of return to level 1 care for clinical stroke or delirium. Diffusion-weighted MRI will be undertaken within 72 hours postoperatively (1-7 days) and at 6 months to look for evidence and persistence of SCI. Feasibility will be assessed via measures of recruitment and retention, informing the design of a full-scale trial. ETHICS AND DISSEMINATION The study coordination centre has obtained approval from the London Fulham Research Ethics Committee (19/LO/0836) and Southern Health and Disability Ethics Committee (NZ) and UK's Health Regulator Authority (HRA). The study has received ethical approval for recruitment in the UK (Fulham REC, 19/LO/0836), New Zealand (21/STH/192) and the USA (IRB 019-264, Ref 378630). Consent for entering into the study will be taken using standardised consent forms by the local study team, led by a local PI. The results of the trial will be submitted for publication in an open access journal. TRIAL REGISTRATION NUMBER NCT03886675.
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Affiliation(s)
- Stephen Crockett
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Lydia Hanna
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Abhinav Singh
- Neuroradiology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Stephen Gunning
- Clinical Health and Psychology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Richard Nicholas
- Neurology Department, Imperial College Healthcare NHS Trust, London, UK
| | - Colin Bicknell
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Mohamad Hamady
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
| | - Dennis Gable
- Vascular Surgery Department, Baylor Scott & White Health, Dallas, Texas, USA
| | - Morad Sallam
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Bijan Modarai
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Said Abisi
- Vascular Surgery Department, Guy's and St Thomas' Hospitals NHS Trust, London, UK
| | - Oliver Lyons
- Vascular Surgery Department, Canterbury District Health Board, Christchurch, New Zealand
| | - Richard Gibbs
- Department of Surgery and Cancer, Imperial College London, London, UK
- Imperial Vascular Unit, Imperial College Healthcare NHS Trust, London, UK
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3
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Segal R, Mezzavia PM, Krieser RB, Sampurno S, Taylor M, Ramsay R, Kluger M, Lee K, Loh FL, Tatoulis J, O'Keefe M, Chen Y, Sindoni T, Ng I. Warm humidified CO2 insufflation improves pericardial integrity for cardiac surgery: a randomized control study. THE JOURNAL OF CARDIOVASCULAR SURGERY 2022; 63:369-375. [PMID: 35343658 DOI: 10.23736/s0021-9509.22.12004-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
BACKGROUND Flooding the surgical field with dry cold CO<inf>2</inf> during open-chamber cardiac surgery has been used to mitigate air entrainment into the systemic circulation. However, exposing epithelial surfaces to cold, dry gas causes tissue desiccation. This randomized controlled study was designed to investigate whether the use of humidified warm CO<inf>2</inf> insufflation into the cardiac cavity could reduce pericardial tissue damage and the incidence of micro-emboli when compared to dry cold CO<inf>2</inf> insufflation. METHODS Forty adult patients requiring elective open-chamber cardiac surgery were randomized to have either dry cold CO<inf>2</inf> insufflation via a standard catheter or humidified warm CO<inf>2</inf> insufflation via the HumiGard device (Fisher & Paykel Healthcare, Panmure, Auckland, New Zealand). The primary endpoint was biopsied pericardial tissue damage, assessed using electron microscopy. We assessed the percentage of microvilli and mesothelial damage, using a damage severity score (DSS) system. We compared the proportion of patients who had less damage, defined as DSS<2. Secondary endpoints included the severity of micro-emboli, by visual assessment of bubble load on transesophageal echocardiogram; lowest near infrared spectroscopy; total de-airing time; highest cardio-pulmonary bypass sweep speed; hospital length of stay and complications. RESULTS A higher proportion of patients in the humidified warm CO<inf>2</inf> group displayed conserved microvilli (47% vs. 11%, P=0.03) and preserved mesothelium (42% vs. 5%, P=0.02) compared to the control group. There were no differences in the secondary outcomes. CONCLUSIONS Humidified warm CO<inf>2</inf> insufflation significantly reduced pericardial epithelial damage when compared to dry cold CO<inf>2</inf> insufflation in open-chamber cardiac surgery. Further studies are warranted to investigate its potential clinical benefits.
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Affiliation(s)
- Reny Segal
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Paul M Mezzavia
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Roni B Krieser
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | | | | | - Robert Ramsay
- University of Melbourne, Melbourne, Australia
- Peter MacCallum Cancer Centre, Melbourne, Australia
| | - Michael Kluger
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Keat Lee
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Francis L Loh
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - James Tatoulis
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Michael O'Keefe
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
- University of Melbourne, Melbourne, Australia
| | - Yinwei Chen
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Teresa Sindoni
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia
| | - Irene Ng
- Department of Anesthesia and Pain Management, Royal Melbourne Hospital, Melbourne, Australia -
- University of Melbourne, Melbourne, Australia
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Andrási TB, Talipov I, Dinges G, Arndt C, Rastan AJ. Risk factors for postoperative delirium after cardiac surgical procedures with cardioplegic arrest. Eur J Cardiothorac Surg 2022; 62:6509257. [PMID: 35037042 DOI: 10.1093/ejcts/ezab570] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Revised: 04/30/2021] [Accepted: 12/05/2021] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES The pathophysiology of delirium after cardiac surgery is complex. The present study aims to determine perioperative risk factors and construct a scoring system for postoperative delirium based on the type of surgery. METHODS Three hundred patients undergoing coronary artery bypass grafting (CABG; n = 150) or valve and/or aortic surgery ± CABG (n = 150) were retrospectively evaluated. RESULTS The incidence of delirium (32%) was similar in subgroups (28.7% and 33.33%, P = 0.384). Delirium patients were older [71.3 (standard deviation: 8.5) vs 66.6 (standard deviation: 9.5), P < 0.001; 70.0 (standard deviation: 9.6) vs 62.5 (standard deviation: 12.6), P < 0.001] and required more packed red blood cell units [2.1 (standard deviation: 2.1) vs 4.2 (standard deviation: 4.0), P < 0.001; 2.4 (standard deviation: 3.3) vs 5.4 (standard deviation: 5.9), P < 0.001] and fresh frozen plasma units [6.1 (standard deviation: 2.9) vs. 8.0 (standard deviation: 4.2), P < 0.001; 6.3 (standard deviation: 3.4) vs 10.8 (standard deviation: 7.2), P < 0.001] in CABG and valve/aortic subgroups, respectively. Delirium was associated with longer operation time [298.3 (standard deviation: 98.4) vs 250.6 (standard deviation: 67.8) min, P < 0.001], cardiopulmonary bypass (CPB) time [171.5 (standard deviation: 54.9) vs 140.98 (standard deviation: 45.8) min, P < 0.001] and cardiac arrest time [112 (standard deviation: 35.9) vs 91.9 (standard deviation: 28.6), P < 0.001] only in the valve/aortic group (versus non-delirium). Multivariate regression analysis identified an association between delirium and age [odds ratio: 1.056 (95% confidence interval: 1.002-1.113), P = 0.041], CPB time [odds ratio: 1.1014 (95% confidence interval: 1.004-1.025), P = 0.007], fresh frozen plasma transfusion [odds ratio: 1.127 (95% confidence interval: 1.006-1.262), P = 0.039] and atrial fibrillation [odds ratio: 4.801 (95% confidence interval: 1.844-12.502), P < 0.001] after valve/aortic surgery (area under the curve 0.835, P < 0.001) and between delirium and age [odds ratio: 1.089 (95% confidence interval: 1.023-1.160), P = 0.007] and ventilation time [odds ratio: 1.068 (95% confidence interval: 1.026-1.113), P = 0.001] after isolated CABG (area under the curve 0.798, P < 0.001). The cross-validation of the results by k-fold logistic regression revealed for the entire patient cohort an overall average accuracy of the prediction model of 0.764, with a false-positive rate of 0.052 and a false-negative rate of 0.18. CONCLUSIONS Age, CPB time, ventilation, transfusion and atrial fibrillation are differently associated with delirium depending on the operative characteristics. Optimization of intraoperative parameters and use of risk calculators may enable early institution of pharmacotherapy and improve overall outcome after cardiac surgery.
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Affiliation(s)
- Terézia B Andrási
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
| | - Ildar Talipov
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
| | - Gerhard Dinges
- Department of Anesthesiology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
| | - Christian Arndt
- Department of Anesthesiology and Intensive Care Medicine, Phillips University of Marburg, Marburg, Germany
| | - Ardawan J Rastan
- Department of Cardiac Surgery, Philipps University of Marburg, Marburg, Germany
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5
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Augoustides JG. Protecting the Central Nervous System During Cardiac Surgery. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00022-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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6
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Newman MF, Berger M, Mathew JP. Postoperative Cognitive Dysfunction and Delirium. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00042-3] [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] Open
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7
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Wahba A, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Puis L. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Eur J Cardiothorac Surg 2021; 57:210-251. [PMID: 31576396 DOI: 10.1093/ejcts/ezz267] [Citation(s) in RCA: 26] [Impact Index Per Article: 8.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Affiliation(s)
- Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav's University Hospital, Trondheim, Norway.,Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia.,Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women's and Children's Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
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8
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Condello I, Santarpino G, Nasso G, Fiore F, Moscarelli M, Mastroroberto P, Speziale G. Air, inflammation and biocompatibility of the extracorporeal circuits. Perfusion 2020; 36:781-785. [PMID: 33112217 DOI: 10.1177/0267659120968364] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
The inflammatory response in cardiac surgery using extracorporeal circulation (ECC) has been widely discussed in the literature with analysis on cytokines released in humans; demonstrating manifold trigger causes. To mitigate this response-mainly linked to the contact and recognition by the blood of a "non-self" surface-many efforts have been made to make the circuits of the extra-corporeal circulation "biomimetics"; trying to emulate the cardio-vascular system. In other words, biomedical companies have developed many biocompatible products in order to reduce the invasiveness of the ECC. One of the techniques used to reduce the contact of blood with "nonself" surfaces is the "coating" of the internal surfaces of the ECC. This can be done with phospholipidic, electrically neutral, and heparin derivates with anticoagulant activity. The coating can be divided into two categories: the "passive coating" with Phosphorylcholine by biomedical companies and the administration of albumin added to the "priming" during the filling of the circuit by the perfusionist. Alternatively, we have the "active" coating: treatment of the internal surfaces in contact with the blood with neutral proteins and heparin. The latter are different according to the production company, but the aim is always to maintain high levels of systemic and local anticoagulation, inactivating the "contact" coagulation between the blood and the surfaces. A recent study demonstrates that the use of an "active coating" is associated with better preservation of the endothelial glycocalyx compared with "passive coating" circuits.
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Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Giuseppe Santarpino
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy.,Paracelsus Medical University, Nuremberg, Germany.,Department of Experimental and Clinical Medicine, Cardiac Surgery Unit, "Magna Graecia" University of Catanzaro, Italy
| | - Giuseppe Nasso
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Flavio Fiore
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Marco Moscarelli
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
| | - Pasquale Mastroroberto
- Department of Experimental and Clinical Medicine, Cardiac Surgery Unit, "Magna Graecia" University of Catanzaro, Italy
| | - Giuseppe Speziale
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
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9
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Vandenberghe S, Iseli D, Demertzis S. Direct visualization of carbon dioxide field flooding: Optical and concentration level comparison of diffusor effectiveness. J Thorac Cardiovasc Surg 2020; 159:958-968. [DOI: 10.1016/j.jtcvs.2019.04.040] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/29/2018] [Revised: 04/05/2019] [Accepted: 04/09/2019] [Indexed: 11/17/2022]
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10
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Puis L, Milojevic M, Boer C, De Somer FMJJ, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Kunst G, Wahba A. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Interact Cardiovasc Thorac Surg 2020; 30:161-202. [PMID: 31576402 PMCID: PMC10634377 DOI: 10.1093/icvts/ivz251] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Affiliation(s)
- Luc Puis
- Department of Perfusion, University Hospital Brussels, Jette, Belgium
| | - Milan Milojevic
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, Dedinje Cardiovascular Institute, Belgrade, Serbia
- Department of Cardiothoracic Surgery, Erasmus University Medical Center, Rotterdam, Netherlands
| | - Christa Boer
- Department of Anaesthesiology, Amsterdam UMC, VU University, Amsterdam Cardiovascular Sciences, Amsterdam, Netherlands
| | | | - Tomas Gudbjartsson
- Department of Cardiothoracic Surgery, Faculty of Medicine, Landspitali University Hospital, University of Iceland, Reykjavik, Iceland
| | - Jenny van den Goor
- Department of Cardiothoracic Surgery, Academic Medical Centre of the University of Amsterdam, Amsterdam, Netherlands
| | - Timothy J Jones
- Department of Paediatric Cardiac Surgery, Birmingham Women’s and Children’s Hospital, Birmingham, UK
| | - Vladimir Lomivorotov
- Department of Anesthesiology and Intensive Care, E. Meshalkin National Medical Research Center, Novosibirsk State University, Novosibirsk, Russia
| | - Frank Merkle
- Academy for Perfusion, Deutsches Herzzentrum, Berlin, Germany
| | - Marco Ranucci
- Department of Cardiovascular Anaesthesia and Intensive Care Unit, IRCCS Policlinico San Donato, Milan, Italy
| | - Gudrun Kunst
- Department of Anaesthetics and Pain Medicine, King's College Hospital NHS Foundation Trust and School of Cardiovascular Medicine & Sciences, King's College London British Heart Foundation Centre of Excellence, London, UK
| | - Alexander Wahba
- Department of Cardio-Thoracic Surgery, St Olav s University Hospital, Trondheim, Norway
- Department of Circulation and Medical Imaging, Norwegian University of Science and Technology, Trondheim, Norway
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11
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Kunst G, Milojevic M, Boer C, De Somer FM, Gudbjartsson T, van den Goor J, Jones TJ, Lomivorotov V, Merkle F, Ranucci M, Puis L, Wahba A, Alston P, Fitzgerald D, Nikolic A, Onorati F, Rasmussen BS, Svenmarker S. 2019 EACTS/EACTA/EBCP guidelines on cardiopulmonary bypass in adult cardiac surgery. Br J Anaesth 2019; 123:713-757. [DOI: 10.1016/j.bja.2019.09.012] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
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12
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Hinds ED, Marin MJ, George J, Delgado R. A coronary cameral fistula treated with coil embolization. JRSM Cardiovasc Dis 2019; 8:2048004019856801. [PMID: 31275575 PMCID: PMC6597856 DOI: 10.1177/2048004019856801] [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: 01/02/2019] [Revised: 05/21/2019] [Accepted: 05/22/2019] [Indexed: 11/25/2022] Open
Abstract
A 56-year-old man who had twice previously undergone orthotopic heart
transplantation was admitted with dyspnea and heart failure symptoms. A biopsy
excluded rejection. Left heart catheterization revealed a coronary cameral
fistula. After the patient was given mild diuretics, his condition improved. No
significant fistula flow was detected, and he was discharged. Several months
later, the patient was readmitted with worsening chest pain and dyspnea. Left
ventricular end-diastolic pressure and flow through the fistula were increased.
To correct the coronary cameral fistula, we performed a coil embolization
without complications. Several months later at follow-up, the patient’s symptoms
had resolved, and his left ventricular end-diastolic pressure had normalized. We
conclude that coronary fistulas may be caused by trauma to the heart during the
de-airing process, which may be prevented in the future with the development of
safer and more effective de-airing techniques.
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Affiliation(s)
- Ethan D Hinds
- School of Medicine, University of Texas Medical Branch, Galveston, USA
| | - Manuel J Marin
- Center for Clinical Research, Texas Heart Institute, Houston, USA
| | - Joggy George
- Center for Clinical Research, Texas Heart Institute, Houston, USA
| | - Reynolds Delgado
- Center for Clinical Research, Texas Heart Institute, Houston, USA
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13
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Dang HQ, Nguyen HC, Le HT, Le TN, Nguyen TQ. Right anterolateral mini-thoracotomy without inferior vena cava cannulation for atrial septal defect repair in small children: A feasible technique. Int J Surg Case Rep 2019; 60:314-318. [PMID: 31277042 PMCID: PMC6612002 DOI: 10.1016/j.ijscr.2019.05.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2019] [Revised: 05/02/2019] [Accepted: 05/28/2019] [Indexed: 11/04/2022] Open
Abstract
Minimally invasive cardiac surgery is limited in small children. Femoral cannulation has high risks in children with body weight <15 kg. 7–12 cm skin incision called “mini-thoracotomy” was used with less cosmetic results. Reducing the length of incision without femoral cannulation needs new approach. This technique is safe and feasible for atrial septal defect repair.
Objective To evaluate the effectiveness and safety of right anterolateral mini-thoracotomy without inferior vena cava (IVC) cannulation for closing atrial septal defect (ASD) in small children. Methods From February 2016 to August 2017, 10 patients (the mean age was 18.5 ± 10.1 months and the mean weight was 8.3 ± 2.1 kg) underwent ASD closure via right anterolateral mini-thoracotomy. The superior vena cava cannula was placed through the right internal jugular vein. A 3–4 cm incision was made on the right chest. The pleural and pericardial cavities were filled with CO2 and the heart was beating during the surgery. Blood returned from IVC was drained by a right heart sucker. All ASDs were closed using artificial patch, continuous suture. Mean follow-up was 18 months (range, 15–22 months). Results No post-operative complications or deaths occurred. Mean operation time and mean cardiopulmonary bypass time were 140.5 ± 27.8 min and 50.3 ± 16.5 min, respectively. These patients were extubated within the first 6 h. The intensive care unit stay time and the post-operative hospital stay time were 19.6 ± 2.6 h and 7.1 ± 1.2 days, respectively. Follow-up transthoracic echocardiography showed no residual shunts or lung atelectasis. Conclusions The right anterolateral mini-thoracotomy without IVC cannulation is feasible for repairing ASD in small children. This technique is effective and safe and can be used as a therapeutic option for ASD.
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Affiliation(s)
- Huy Q Dang
- Minimally Invasive Cardiac Surgery Unit, Cardiovascular Center, Hanoi Heart Hospital, Hanoi, Viet Nam.
| | - Huu C Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Viet Nam
| | - Huong T Le
- Institute of Preventive Medicine and Public Health, Hanoi Medical University (HMU), Hanoi, Viet Nam
| | - Thanh N Le
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Viet Nam
| | - Tuan Q Nguyen
- Minimally Invasive Cardiac Surgery Unit, Cardiovascular Center, Hanoi Heart Hospital, Hanoi, Viet Nam
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Mitchell RS. Commentary: Is surgical field insufflation with carbon dioxide an antidote for airhead(s)? J Thorac Cardiovasc Surg 2019; 159:970. [PMID: 31230810 DOI: 10.1016/j.jtcvs.2019.04.099] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/29/2019] [Accepted: 04/29/2019] [Indexed: 11/19/2022]
Affiliation(s)
- R Scott Mitchell
- Department of Surgery, V.A. Hospital Palo Alto, Palo Alto, Calif; Department of Cardiothoracic Surgery, Stanford University School of Medicine, Stanford, Calif.
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Nishida H, Ota T. Commentary: Thinking back about our routine use of carbon dioxide. J Thorac Cardiovasc Surg 2019; 159:969. [PMID: 31202451 DOI: 10.1016/j.jtcvs.2019.04.071] [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: 04/24/2019] [Accepted: 04/25/2019] [Indexed: 11/29/2022]
Affiliation(s)
- Hidefumi Nishida
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill
| | - Takeyoshi Ota
- Section of Cardiac Surgery, Department of Surgery, The University of Chicago, Chicago, Ill.
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Dang HQ, Le HT, Ngo LTH. Totally endoscopic atrial septal defect repair using transthoracic aortic cannulation in a 10.5-kg-boy. Int J Surg Case Rep 2018; 52:103-106. [PMID: 30336384 PMCID: PMC6197332 DOI: 10.1016/j.ijscr.2018.09.054] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2018] [Revised: 09/23/2018] [Accepted: 09/29/2018] [Indexed: 11/30/2022] Open
Abstract
INTRODUCTION Although totally endoscopic surgery (TES) has been widely applied for the treatment of atrial septal defect (ASD), small children receive few benefits from this technique due to risks of the femoral cannulation. CASE PRESENTATION A 23-month-old boy, weighing 10.5 kg, with the diagnosis of sinus venosus ASD underwent successful repair by TES. We performed this surgery through 4 small trocars (one 12 mm trocar and three 5 mm trocars), without robotic assistance. In this case, we inserted the arterial cannula directly into the ascending aorta instead of the femoral artery (FA). The defects were repaired on the beating heart with CO2 insufflation. DISCUSSION Femoral cannulation in small children pose some risks, such as increased arterial line pressure, critical lower limb ischaemia, and post-operative iliac or femoral arterial stenosis. Putting the arterial cannula directly into the ascending aorta is a good solution but is difficult to be performed through TES, especially in small children. The major concern of operating on the beating heart is the air embolism, which requires special preventative methods. CONCLUSION Transthoracic aortic cannulation may facilitate TES in small children. However, the safety and efficacy of this approach needs to be validated by larger studies preferably randomised controlled trials.
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Affiliation(s)
- Huy Q Dang
- Minimally Invasive Cardiac Surgery Unit, Cardiovascular Center, Hanoi Heart Hospital, Hanoi, Viet Nam.
| | - Huong T Le
- Minimally Invasive Cardiac Surgery Unit, Cardiovascular Center, Hanoi Heart Hospital, Hanoi, Viet Nam
| | - Linh T H Ngo
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Viet Nam
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Effects of carbon dioxide insufflation on anastomosis remodeling at a carotid artery site in rabbits. POLISH JOURNAL OF THORACIC AND CARDIOVASCULAR SURGERY 2018; 15:170-175. [PMID: 30310395 PMCID: PMC6180020 DOI: 10.5114/kitp.2018.78441] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/21/2018] [Accepted: 08/12/2018] [Indexed: 12/21/2022]
Abstract
Introduction Use of carbon dioxide (CO2) insufflation (CDI) on the surgical field during heart surgery has become widespread, and in some units routine. Aim To assess the effects of CDI on endothelial dysfunction in a carotid artery model in rabbits. Material and methods Twelve randomly selected rabbits were divided into two groups. Right carotid arteries of the animals were transected and sutured with running suture technique. Then, 1 l/min CO2 insufflation was initiated with a 45° angle. In the control group, the anastomotic field was irrigated with 0.1 ml/s flow of 0.9% saline. At day 28, the carotid artery segments were removed and prepared for histological specimens. Results In the cross-sections of the control group vessel samples, thickening of the tunica intima was observed. Scoring the quantity of endothelial nitric oxide synthase (e-NOS) and α-smooth muscle actin (α-SMA) positive staining revealed a nonsignificant difference between the experimental groups (p = 0.07). In the CO2 group, the intimal hyperplasia (p = 0.2) and the thickness of the tunica media (p = 0.2) were indistinguishable when compared to the control group. The mean luminal diameters and luminal areas of the experimental groups were all evaluated by histomorphometry and a significant differences was found between luminal areas (p = 0.016). On the other hand, no significant difference was found between mean luminal diameters (p = 0.055). Conclusions Our study indicated that CDI can affect endothelial cell damage and the mean luminal diameters.
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Oldham MA, Vachon J, Yuh D, Lee HB. Cognitive Outcomes After Heart Valve Surgery: A Systematic Review and Meta-Analysis. J Am Geriatr Soc 2018; 66:2327-2334. [PMID: 30307031 DOI: 10.1111/jgs.15601] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVES To summarize evidence on cognitive outcomes after heart valve surgery; secondary aim, to examine whether aortic and mitral valve surgery are associated with different cognitive outcomes. DESIGN Preferred Reporting Items for Systematic Reviews and Meta-Analyses systematic review and meta-analysis. SETTING Cardiac surgery. PARTICIPANTS Individuals undergoing heart valve surgery. MEASUREMENTS We searched MEDLINE, EMBASE, and PsycINFO for peer-reviewed reports of individuals undergoing heart valve surgery who underwent pre- and postoperative cognitive assessment. Our initial search returned 1,475 articles, of which 12 were included. Postoperative cognitive results were divided into those from 1 week to 1 month (early outcomes, npooled = 450) and from 2 to 6 months (intermediate outcomes; npooled = 722). No studies with longer-term outcomes were identified. RESULTS Subjects had moderate early cognitive decline from baseline (Becker mean gain effect size (ES)=-0.39 ± 0.27) that improved slightly by 2 to 6 months (ES=-0.25 ± 0.38). Individuals undergoing aortic valve surgery-who were older on average than those undergoing mitral valve surgery (68 vs 57)-had greater early cognitive decline than those undergoing mitral valve surgery (ES=-0.68 vs -0.12), but both cohorts had similar decline 2 to 6 months postoperatively (ES=-0.27 vs -0.20). CONCLUSIONS Heart valve surgery is associated with cognitive decline over the 6 months after surgery, but outcomes beyond 6 months are unclear. These findings highlight the cognitive vulnerability of this population, especially older adults with aortic stenosis. © 2018 American Geriatrics Society and Wiley Periodicals, Inc. J Am Geriatr Soc 66:2327-2334, 2018.
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Affiliation(s)
- Mark A Oldham
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
| | - Jacqueline Vachon
- Oncology Department, Ingram School of Nursing, McGill University, Montréal, Quebec, Canada
| | - David Yuh
- Department of Surgery, Stamford Hospital, Stamford, Connecticut
| | - Hochang B Lee
- Department of Psychiatry, University of Rochester Medical Center, Rochester, New York
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Listewnik M, Kotfis K, Ślozowski P, Mokrzycki K, Brykczyński M. The influence of carbon dioxide field flooding in mitral valve operations with cardiopulmonary bypass on S100ß level in blood plasma in the aging brain. Clin Interv Aging 2018; 13:1837-1845. [PMID: 30288036 PMCID: PMC6161743 DOI: 10.2147/cia.s177356] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Introduction The risk of air microembolism during cardiopulmonary bypass (CPB) is high and influences the postoperative outcome, especially in elderly patients. The use of carbon dioxide (CO2) atmosphere during cardiac surgery may reduce the risk of cerebral air microembolism. The aim of our study was to assess the influence of CO2 field flooding on microembolism-induced brain damage assessed by the level of S100ß protein, regarded as a marker of brain damage. Materials and methods A group of 100 patients undergoing planned mitral valve operation through median sternotomy using standard CPB was recruited for the study. Echocardiography was performed prior to and after the CPB. CO2 insufflation at 6 L/minute was conducted in the study group. Blood samples for S100ß protein analysis were collected after induction of anesthesia, 2 hours after aorta de-clamping, and 24 hours after operation. Results The S100ß level in blood plasma did not differ significantly between the study and the control group (0.13±0.08 µg/L, 1.12±0.59 µg/L, and 0.26±0.23 µg/L and 0.18±0.19 µg/L, 1.31±0.62 µg/L, and 0.23±0.12 µg/L, P=0.7, 0.14, and 0.78). The mean increase of the S100ß concentration was 13% lower in the group with CO2 protection than in the control group (0.988 µg/L vs 1.125 µg/L), although statistically insignificant. Tricuspid valve annuloplasties (TVAs) had significant impact on the increase in S100ß concentration in the treatment group after 24 hours (TVA [−] 0.21±0.09 vs TVA [+] 0.42±0.42, P=0.05). In patients <60 years, there were significant differences in the S100ß level 2 and 24 hours after the procedure (1.59±0.682 µg/L vs 1.223±0.571 µg/L, P=0.048, and 0.363±0.318 µg/L vs 0.229±0.105 µg/L, P=0.036) as compared with younger patients. Conclusion The increase in S100ß concentration was lower in the group with CO2 protection than in the control group. Age and an addition of TVA significantly influenced the level of S100ß concentration in the tests performed 2 hours after aortic clamp release.
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Affiliation(s)
- Mariusz Listewnik
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Katarzyna Kotfis
- Department of Anesthesiology, Intensive Therapy and Acute Intoxications, Pomeranian Medical University, Szczecin, Poland,
| | - Paweł Ślozowski
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
| | - Krzysztof Mokrzycki
- Department of Cardiac Surgery, Pomeranian Medical University, Szczecin, Poland
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Berger M, Terrando N, Smith SK, Browndyke JN, Newman MF, Mathew JP. Neurocognitive Function after Cardiac Surgery: From Phenotypes to Mechanisms. Anesthesiology 2018; 129:829-851. [PMID: 29621031 PMCID: PMC6148379 DOI: 10.1097/aln.0000000000002194] [Citation(s) in RCA: 140] [Impact Index Per Article: 23.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
For half a century, it has been known that some patients experience neurocognitive dysfunction after cardiac surgery; however, defining its incidence, course, and causes remains challenging and controversial. Various terms have been used to describe neurocognitive dysfunction at different times after cardiac surgery, ranging from "postoperative delirium" to "postoperative cognitive dysfunction or decline." Delirium is a clinical diagnosis included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Postoperative cognitive dysfunction is not included in the DSM-5 and has been heterogeneously defined, though a recent international nomenclature effort has proposed standardized definitions for it. Here, the authors discuss pathophysiologic mechanisms that may underlie these complications, review the literature on methods to prevent them, and discuss novel approaches to understand their etiology that may lead to novel treatment strategies. Future studies should measure both delirium and postoperative cognitive dysfunction to help clarify the relationship between these important postoperative complications.
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Affiliation(s)
- Miles Berger
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Niccolò Terrando
- Assistant Professor, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - S. Kendall Smith
- Critical Care Fellow, Department of Anesthesiology, Duke University Medical Center, Durham, NC
| | - Jeffrey N. Browndyke
- Assistant Professor, Division of Geriatric Behavioral Health, Department of Psychiatry & Behavioral Sciences, Duke University Medical Center, Durham, NC
| | - Mark F. Newman
- Merel H. Harmel Professor of Anesthesiology, and President of the Private Diagnostic Clinic, Duke University Medical Center, Durham, NC
| | - Joseph P. Mathew
- Jerry Reves, MD Professor and Chair, Department of Anesthesiology, Duke University Medical Center, Durham, NC
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Totally Endoscopic Cardiac Surgery for Atrial Septal Defect Repair on Beating Heart Without Robotic Assistance in 25 Patients. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017; 12:446-452. [PMID: 29232303 PMCID: PMC5737448 DOI: 10.1097/imi.0000000000000436] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Supplemental digital content is available in the text. Objective The aim of the study was to investigate the effectivity and safety of totally endoscopic cardiac surgery without robotic assistance for atrial septal defect (ASD) closure on beating hearts. Methods Twenty-five patients (adults/children: 15/10) underwent ASD closure using nonrobotically assisted totally endoscopic approach on beating heart. Three 5-mm trocars and one 12-mm trocar were used, only the superior vena cava is snared, filling the pleural and pericardial cavities with CO2, and the heart was beating during the surgery. Twenty-three patients had isolated secundum ASD (2 of which had severe tricuspid regurgitation) and two patients had ASD combined with partial anomalous pulmonary venous connection. All ASDs were closed using artificial patch, continuous suture; tricuspid regurgitations were repaired and the anomalous pulmonary veins were drained to the left atrium. Results No postoperative complications or deaths occurred. Mean ± SD operation time and mean cardiopulmonary bypass time were 267.2 ± 44.6 and 156.1 ± 33.6 min, respectively. These patients were extubated within the first 5 hours, and the volume of blood drainage on the first day was less than 80 mL. Four days after surgery, patients did not need analgesics and were able to return to normal activities 1 week postoperatively. Conclusions Totally endoscopic operation for ASD closure on beating heart is safe, with short recovery period, and surgical scars are of high cosmetic value, especially in a woman and girl.
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Dang QH, Le NT, Nguyen CH, Tran DD, Nguyen DH, Nguyen TH, Ngo THL. Totally Endoscopic Cardiac Surgery for Atrial Septal Defect Repair on Beating Heart without Robotic Assistance in 25 Patients. INNOVATIONS-TECHNOLOGY AND TECHNIQUES IN CARDIOTHORACIC AND VASCULAR SURGERY 2017. [DOI: 10.1177/155698451701200613] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- Quang-Huy Dang
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Ngoc-Thanh Le
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Cong-Huu Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Dac-Dai Tran
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Do-Hung Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Trung-Hieu Nguyen
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
| | - Thi-Hai-Linh Ngo
- Department of Cardiovascular and Thoracic Surgery, Cardiovascular Center, E Hospital, Hanoi, Vietnam
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Benedetto U, Caputo M, Guida G, Bucciarelli-Ducci C, Thai J, Bryan A, Angelini GD. Carbon Dioxide Insufflation During Cardiac Surgery: A Meta-analysis of Randomized Controlled Trials. Semin Thorac Cardiovasc Surg 2017; 29:301-310. [DOI: 10.1053/j.semtcvs.2017.05.002] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/19/2017] [Indexed: 11/11/2022]
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Landenhed M, Cunha-Goncalves D, Al-Rashidi F, Pierre L, Höglund P, Koul B. Pulmonary collapse alone provides effective de-airing in cardiac surgery: a prospective randomized study. Perfusion 2015; 31:320-6. [PMID: 26354741 DOI: 10.1177/0267659115604712] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
OBJECTIVES We previously described and showed that the method for cardiac de-airing involving: (1) bilateral, induced pulmonary collapse by opening both pleurae and disconnecting the ventilator before cardioplegic arrest and (2) gradual pulmonary perfusion and ventilation after cardioplegic arrest is superior to conventional de-airing methods, including carbon dioxide insufflation of the open mediastinum. This study investigated whether one or both components of this method are responsible for the effective de-airing of the heart. METHODS Twenty patients scheduled for open, left heart surgery were randomized to two de-airing techniques: (1) open pleurae, collapsed lungs and conventional pulmonary perfusion and ventilation; and (2) intact pleurae, expanded lungs and gradual pulmonary perfusion and ventilation. RESULTS The number of cerebral microemboli measured by transcranial Doppler sonography was lower in patients with open pleurae 9 (6-36) vs 65 (36-210), p = 0.004. Residual intra-cardiac air grade I or higher as monitored by transesophageal echocardiography 4-6 minutes after weaning from cardiopulmonary bypass was seen in few patients with open pleurae 0 (0%) vs 7 (70%), p = 0.002. CONCLUSIONS Bilateral, induced pulmonary collapse alone is the key factor for quick and effective de-airing of the heart. Gradual pulmonary perfusion and ventilation, on the other hand, appears to be less important.
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Affiliation(s)
- Maya Landenhed
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Doris Cunha-Goncalves
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Faleh Al-Rashidi
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Leif Pierre
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
| | - Peter Höglund
- Clinical Research and Competence Center, Skane University Hospital, Lund University, Lund, Sweden
| | - Bansi Koul
- Department of Cardiothoracic Surgery, Anesthesia and Intensive Care, Skane University Hospital, Lund University, Lund, Sweden
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Size distribution of air bubbles entering the brain during cardiac surgery. PLoS One 2015; 10:e0122166. [PMID: 25837519 PMCID: PMC4383554 DOI: 10.1371/journal.pone.0122166] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2014] [Accepted: 02/08/2015] [Indexed: 12/22/2022] Open
Abstract
Background Thousands of air bubbles enter the cerebral circulation during cardiac surgery, but whether high numbers of bubbles explain post-operative cognitive decline is currently controversial. This study estimates the size distribution of air bubbles and volume of air entering the cerebral arteries intra-operatively based on analysis of transcranial Doppler ultrasound data. Methods Transcranial Doppler ultrasound recordings from ten patients undergoing heart surgery were analysed for the presence of embolic signals. The backscattered intensity of each embolic signal was modelled based on ultrasound scattering theory to provide an estimate of bubble diameter. The impact of showers of bubbles on cerebral blood-flow was then investigated using patient-specific Monte-Carlo simulations to model the accumulation and clearance of bubbles within a model vasculature. Results Analysis of Doppler ultrasound recordings revealed a minimum of 371 and maximum of 6476 bubbles entering the middle cerebral artery territories during surgery. This was estimated to correspond to a total volume of air ranging between 0.003 and 0.12 mL. Based on analysis of a total of 18667 embolic signals, the median diameter of bubbles entering the cerebral arteries was 33 μm (IQR: 18 to 69 μm). Although bubble diameters ranged from ~5 μm to 3.5 mm, the majority (85%) were less than 100 μm. Numerous small bubbles detected during cardiopulmonary bypass were estimated by Monte-Carlo simulation to be benign. However, during weaning from bypass, showers containing large macro-bubbles were observed, which were estimated to transiently affect up to 2.2% of arterioles. Conclusions Detailed analysis of Doppler ultrasound data can be used to provide an estimate of bubble diameter, total volume of air, and the likely impact of embolic showers on cerebral blood flow. Although bubbles are alarmingly numerous during surgery, our simulations suggest that the majority of bubbles are too small to be harmful.
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Sun Y, Ji B, Zhu X, Zheng Z. Efficacy of Carbon Dioxide Insufflation for Cerebral and Cardiac Protection During Open Heart Surgery: A Systematic Review and Meta-Analysis. Artif Organs 2013; 37:439-46. [DOI: 10.1111/aor.12042] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Affiliation(s)
- Yanhua Sun
- Department of Cardiopulmonary Bypass; State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing; China
| | - Bingyang Ji
- Department of Cardiopulmonary Bypass; State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing; China
| | - Xian Zhu
- Department of Cardiopulmonary Bypass; State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing; China
| | - Zhe Zheng
- Department of Cardiovascular Surgery; State Key Laboratory of Cardiovascular Disease, Fuwai Hospital, National Center for Cardiovascular Diseases, Chinese Academy of Medical Sciences and Peking Union Medical College; Beijing; China
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Borojevic M, Vrljic D, Biocina B. Impact of perioperative risk factors for the development of neurocognitive decline after cardiac surgery. Perfusion 2013; 28:463-4. [PMID: 23474748 DOI: 10.1177/0267659113478994] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
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28
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Borojevic M, Colak Z, Biocina B. Importance of standardization of surgical techniques in analyzing neurologic outcomes. J Thorac Cardiovasc Surg 2013; 145:611-2. [PMID: 23321137 DOI: 10.1016/j.jtcvs.2012.09.089] [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: 09/15/2012] [Accepted: 09/21/2012] [Indexed: 11/25/2022]
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