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Kokki H, Maaroos M, Ellam S, Halonen J, Ojanperä I, Ranta M, Ranta VP, Tolonen A, Lindberg O, Viitala M, Hartikainen J. How do different extracorporeal circulation systems affect metoprolol bioavailability in coronary artery bypass surgery patients. Eur J Clin Pharmacol 2018. [PMID: 29523917 DOI: 10.1007/s00228-018-2437-1] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE Cardiac surgery and conventional extracorporeal circulation (CECC) impair the bioavailability of drugs administered by mouth. It is not known whether miniaturized ECC (MECC) or off-pump surgery (OPCAB) affect the bioavailability in similar manner. We evaluated the metoprolol bioavailability in patients undergoing CABG surgery with CECC, MECC, or having OPCAB. METHODS Thirty patients, ten in each group, aged 44-79 years, scheduled for CABG surgery were administered 50 mg metoprolol by mouth on the preoperative day at 8-10 a.m. and 8 p.m., 2 h before surgery, and thereafter daily at 8 a.m. and 8 p.m. Blood samples were collected up to 12 h after the morning dose on the preoperative day and on first and third postoperative days. Metoprolol concentration in plasma was analyzed using liquid chromatography-mass spectrometry. RESULTS The absorption of metoprolol was markedly reduced on the first postoperative day in all three groups, but recovered to the preoperative level on the third postoperative day. The geometric means (90% confidence interval) of AUC0-12 on the first and third postoperative days versus the preoperative day were 44 (26-74)% and 109 (86-139)% in the CECC-group, 28 (16-50)% and 79 (59-105)% in the MECC-group, and 26 (12-56)% and 96 (77-119)% in the OPCAB-group, respectively. Two patients in the CECC-group and two in the MECC-group developed atrial fibrillation (AF). The bioavailability and the drug concentrations of metoprolol in patients developing AF did not differ from those who remained in sinus rhythm. CONCLUSION The bioavailability of metoprolol by mouth was markedly reduced in the early phase after CABG with no difference between the CECC-, MECC-, and OPCAB-groups.
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Affiliation(s)
- Hannu Kokki
- School of Medicine, University of Eastern Finland, Kuopio, Finland. .,Department of Anaesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, KYS, Finland.
| | - Martin Maaroos
- Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Sten Ellam
- Department of Anaesthesia and Operative Services, Kuopio University Hospital, PO Box 100, 70029, Kuopio, KYS, Finland
| | - Jari Halonen
- School of Medicine, University of Eastern Finland, Kuopio, Finland.,Heart Centre, Kuopio University Hospital, Kuopio, Finland
| | - Ilkka Ojanperä
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Merja Ranta
- Department of Forensic Medicine, University of Helsinki, Helsinki, Finland
| | - Veli-Pekka Ranta
- School of Pharmacy, University of Eastern Finland, Kuopio, Finland
| | | | | | | | - Juha Hartikainen
- School of Medicine, University of Eastern Finland, Kuopio, Finland.,Heart Centre, Kuopio University Hospital, Kuopio, Finland
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Minimally Invasive Extracorporeal Circulation Circuit Is Not Inferior to Off-Pump Coronary Artery Bypass Grafting: Meta-Analysis Using the Bayesian Method. Ann Thorac Surg 2016; 103:342-350. [PMID: 27780561 DOI: 10.1016/j.athoracsur.2016.08.067] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/19/2016] [Revised: 07/12/2016] [Accepted: 08/19/2016] [Indexed: 11/22/2022]
Abstract
The pathophysiologic side effects of cardiopulmonary bypass have already been identified. Minimally invasive extracorporeal circulation technologies (MiECT) and off-pump coronary artery bypass graft surgery (OPCABG) aim to reduce these problems. This meta-analysis provides a comparison of MiECT and OPCABG in randomized and observational studies. A fully probabilistic, Bayesian approach of primary and secondary endpoints was conducted. MiECT does not give inferior results when compared with OPCABG. However, there is a trend to borderline significantly higher blood loss in this group in randomized controlled trials. The question whether MiECT is equivalent to OPCABG can be answered with the affirmative, but long-term follow-up data are needed to detect any advantage over time.
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Pereira SN, Zumba IB, Batista MS, Pieve DD, Santos ED, Stuermer R, Oliveira GPD, Senger R. Comparison of two technics of cardiopulmonary bypass (conventional and mini CPB) in the trans-and postoperative periods of cardiac surgery. Braz J Cardiovasc Surg 2016; 30:433-42. [PMID: 27163417 PMCID: PMC4614926 DOI: 10.5935/1678-9741.20150046] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2015] [Accepted: 06/23/2015] [Indexed: 11/20/2022] Open
Abstract
OBJECTIVE This study aimed to compare the effects of two different perfusion techniques: conventional cardiopulmonary bypass and miniature cardiopulmonary bypass in patients undergoing cardiac surgery at the University Hospital of Santa Maria--RS. METHODS We perform a retrospective, cross-sectional study, based on data collected from the patients operated between 2010 and 2013. We analyzed the records of 242 patients divided into two groups: Group I: 149 patients undergoing cardiopulmonary bypass and Group II - 93 patients undergoing the miniature cardiopulmonary bypass. RESULTS The clinical profile of patients in the preoperative period was similar in the cardiopulmonary bypass and miniature cardiopulmonary bypass groups without significant differences, except in age, which was greater in the miniature cardiopulmonary bypass group. The perioperative data were significant of blood collected for autotransfusion, which were higher in the group with miniature cardiopulmonary bypass than the cardiopulmonary bypass and in transfusion of packed red blood cells, which was higher in cardiopulmonary bypass than in miniature cardiopulmonary bypass. In the immediate, first and second postoperative period the values of hematocrit and hemoglobin were higher and significant in miniature cardiopulmonary bypass than in the cardiopulmonary bypass, although the bleeding in the first and second postoperative days was higher and significant in miniature cardiopulmonary bypass than in the cardiopulmonary bypass. CONCLUSION The present results suggest that the miniature cardiopulmonary bypass was beneficial in reducing the red blood cell transfusion during surgery and showed slight but significant increase in hematocrit and hemoglobin in the postoperative period.
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Affiliation(s)
- Sergio Nunes Pereira
- Centro de Ciências da Saúde, Universidade Federal de Santa Maria, Santa Maria, RS, Brazil
| | | | | | | | | | - Ralf Stuermer
- Hospital Universitário de Santa Maria, Santa Maria, RS, Brazil
| | | | - Roberta Senger
- Hospital Universitário de Santa Maria, Santa Maria, RS, Brazil
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Gursoy M, Hokenek AF, Duygu E, Atay M, Yavuz A. Clinical SYNTAX Score Can Predict Acute Kidney Injury following On-Pump but Not Off-Pump Coronary Artery Bypass Surgery. Cardiorenal Med 2015; 5:297-305. [PMID: 26648946 DOI: 10.1159/000437394] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2015] [Accepted: 07/06/2015] [Indexed: 01/01/2023] Open
Abstract
BACKGROUND The complexity of coronary artery disease is usually a neglected factor in risk stratification systems. We aimed to analyze the discriminative ability of the clinical SYNTAX score (CSS) for acute kidney injury (AKI) following on- and off-pump coronary artery surgery. METHODS A total of 193 patients were reviewed in this study. Patients were divided into two groups according to the surgical procedure (group I: off-pump coronary artery bypass grafting, n = 89; group II: on-pump coronary artery bypass grafting, n = 104). Preoperative demographic data, the CSS and postoperative renal functions were evaluated. The postoperative AKI classification was made using the RIFLE (Risk, Injury, Failure, Loss of function, and End-stage renal disease) criteria. RESULTS Postoperative AKI occurred in 14 of 89 patients (15.7%) in group I and in 29 of 104 patients in group II (27.8%; p = 0.046). The CSS did not vary much between the groups (31.52 ± 13.08 vs. 29.89 ± 15.70; p = 0.638). In group I, the CSS was not different between patients with AKI and those without AKI (30.167 ± 3.93 vs. 31.91± 14.75; p = 0.78). In group II, the CSS was 36.85 ± 18.33 in patients with AKI and 28.02 ± 12.32 in those without, and the difference was significant (p = 0.02). The discriminative ability of the CSS for postoperative AKI using the AUC analysis was 0.500 in group I and 0.840 in group II. CONCLUSION The CSS may be a simple and successful means of risk prediction of postoperative AKI in on-pump coronary artery surgery.
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Affiliation(s)
- Mete Gursoy
- Department of Cardiovascular Surgery, Istanbul, Turkey
| | | | - Egemen Duygu
- Department of Cardiology, Acibadem International Hospital, Istanbul, Turkey
| | - Mehmet Atay
- Department of Cardiovascular Surgery, Karaman State Hospital, Karaman, Turkey
| | - Asuman Yavuz
- Department of Nephrology, Acibadem University, Istanbul, Turkey
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Jacob KA, Leaf DE, Dieleman JM, van Dijk D, Nierich AP, Rosseel PM, van der Maaten JM, Hofland J, Diephuis JC, de Lange F, Boer C, Kluin J, Waikar SS. Intraoperative High-Dose Dexamethasone and Severe AKI after Cardiac Surgery. J Am Soc Nephrol 2015; 26:2947-51. [PMID: 25952257 DOI: 10.1681/asn.2014080840] [Citation(s) in RCA: 67] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/29/2014] [Accepted: 03/06/2015] [Indexed: 12/31/2022] Open
Abstract
Administration of prophylactic glucocorticoids has been suggested as a strategy to reduce postoperative AKI and other adverse events after cardiac surgery requiring cardiopulmonary bypass. In this post hoc analysis of a large placebo-controlled randomized trial of dexamethasone in 4465 adult patients undergoing cardiac surgery, we examined severe AKI, defined as use of RRT, as a primary outcome. Secondary outcomes were doubling of serum creatinine level or AKI-RRT, as well as AKI-RRT or in-hospital mortality (RRT/death). The primary outcome occurred in ten patients (0.4%) in the dexamethasone group and in 23 patients (1.0%) in the placebo group (relative risk, 0.44; 95% confidence interval, 0.19 to 0.96). In stratified analyses, the strongest signal for potential benefit of dexamethasone was in patients with an eGFR<15 ml/min per 1.73 m(2). In conclusion, compared with placebo, intraoperative dexamethasone appeared to reduce the incidence of severe AKI after cardiac surgery in those with advanced CKD.
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Affiliation(s)
- Kirolos A Jacob
- Departments of Anesthesiology and Intensive Care Medicine and Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands;
| | - David E Leaf
- Division of Renal Medicine, the Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
| | - Jan M Dieleman
- Departments of Anesthesiology and Intensive Care Medicine and
| | | | - Arno P Nierich
- Department of Anesthesiology, Isala Klinieken, Zwolle, The Netherlands
| | - Peter M Rosseel
- Department of Anesthesiology Amphia Ziekenhuis, Breda, The Netherlands
| | | | - Jan Hofland
- Department of Anesthesiology Erasmus Medical Center, Rotterdam, The Netherlands
| | - Jan C Diephuis
- Department of Anesthesiology Medisch Spectrum Twente, Enschede, The Netherlands
| | - Fellery de Lange
- Department of Cardiac Anesthesiology Medical Center Leeuwarden, Leeuwarden, The Netherlands; and
| | - Christine Boer
- Department of Anesthesiology Vrije Universiteit University Medical Center, Amsterdam, The Netherlands
| | - Jolanda Kluin
- Cardiothoracic Surgery, University Medical Center Utrecht, Utrecht, The Netherlands
| | - Sushrut S Waikar
- Division of Renal Medicine, the Harvard Medical School, Brigham and Women's Hospital, Boston, Massachusetts
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Buehler AM, Ferri C, Flato UAP, Fernandes JG. Robotically assisted coronary artery bypass grafting: a systematic review and meta-analysis. Int J Med Robot 2014; 11:150-8. [PMID: 25219464 DOI: 10.1002/rcs.1611] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2014] [Revised: 07/25/2014] [Accepted: 07/29/2014] [Indexed: 12/18/2022]
Abstract
BACKGROUND It remains uncertain as to whether robotically assisted coronary bypass surgery (RACBS) is superior to non-robotic procedures. METHODS Literature searches were conducted using MEDLINE, EMBASE and LILACS. Two review authors independently screened citations, assessed trial quality and performed data extraction. RESULTS Three trials met the inclusion criteria. None was randomized. Compared with non-robotic approaches, RACBS was associated with longer surgical times, shorter intensive care unit and hospital stays, higher extubation rates and lower odds for atrial fibrillation as well as myocardial infarction. There were no differences for the odds of stroke and mortality between the interventions. CONCLUSIONS Although robotic-assisted coronary bypass appears to be promising, the study designs were not adequate and may have a high risk of selection bias. There is a need for randomized trials to corroborate the findings and to determine the long-term benefits of RACBS compared with traditional surgical approaches.
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Affiliation(s)
- Anna M Buehler
- Hospital Alemao Oswaldo Cruz, Institute of Health Education and Research, Brazil
| | - Cleusa Ferri
- Hospital Alemao Oswaldo Cruz, Institute of Health Education and Research, Brazil
| | - Uri A P Flato
- Hospital Alemao Oswaldo Cruz, Institute of Health Education and Research, Brazil
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Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adýbelli Z, Giuliani A, Danesi TH, Kim JC, Nayak A, Neri M, Virzi GM, Brocca A, Scalzotto E, Salvador L, Ronco C. Cardiac Surgery-Associated Acute Kidney Injury. Blood Purif 2014; 37 Suppl 2:34-50. [DOI: 10.1159/000361062] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Mao H, Katz N, Ariyanon W, Blanca-Martos L, Adýbelli Z, Giuliani A, Danesi TH, Kim JC, Nayak A, Neri M, Virzi GM, Brocca A, Scalzotto E, Salvador L, Ronco C. Cardiac surgery-associated acute kidney injury. Cardiorenal Med 2013; 3:178-199. [PMID: 24454314 PMCID: PMC3884176 DOI: 10.1159/000353134] [Citation(s) in RCA: 157] [Impact Index Per Article: 14.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Cardiac surgery-associated acute kidney injury (CSA-AKI) is a common and serious postoperative complication of cardiac surgery requiring cardiopulmonary bypass (CPB), and it is the second most common cause of AKI in the intensive care unit. Although the complication has been associated with the use of CPB, the etiology is likely multifactorial and related to intraoperative and early postoperative management including pharmacologic therapy. To date, very little evidence from randomized trials supporting specific interventions to protect from or prevent AKI in broad cardiac surgery populations has been found. The definition of AKI employed by investigators influences not only the incidence of CSA-AKI, but also the identification of risk variables. The advent of novel biomarkers of kidney injury has the potential to facilitate the subclinical diagnosis of CSA-AKI, the assessment of its severity and prognosis, and the early institution of interventions to prevent or reduce kidney damage. Further studies are needed to determine how to optimize cardiac surgical procedures, CPB parameters, and intraoperative and early postoperative blood pressure and renal blood flow to reduce the risk of CSA-AKI. No pharmacologic strategy has demonstrated clear efficacy in the prevention of CSA-AKI; however, some agents, such as the natriuretic peptide nesiritide and the dopamine agonist fenoldopam, have shown promising results in renoprotection. It remains unclear whether CSA-AKI patients can benefit from the early institution of such pharmacologic agents or the early initiation of renal replacement therapy.
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Affiliation(s)
- Huijuan Mao
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Nevin Katz
- Department of Surgery, Johns Hopkins University, Baltimore, Md., USA
| | - Wassawon Ariyanon
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Division of Nephrology, Department of Medicine, Faculty of Medicine, Chulalongkorn University and King Chulalongkorn Memorial Hospital, Thai Red Cross Society, Bangkok, Thailand
- Cardiometabolic Centre, BNH Hospital, Bangkok, Thailand
| | - Lourdes Blanca-Martos
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Nephrology, Hospital Universitario Carlos Haya, Málaga, Spain
| | - Zelal Adýbelli
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Anna Giuliani
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Clinical and Molecular Medicine, Sapienza University, Rome, Italy
| | | | - Jeong Chul Kim
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Akash Nayak
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
- Department of Chemical Engineering and Economics BITS Pilani, Pilani, India
| | - Mauro Neri
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Grazia Maria Virzi
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Alessandra Brocca
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Elisa Scalzotto
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
| | - Loris Salvador
- Department of Cardiac Surgery, Ospedale San Bortolo, Vicenza, Italy
| | - Claudio Ronco
- Department of Nephrology, Ospedale San Bortolo, Vicenza, Italy
- Department of International Renal Research Institute Vicenza (IRRIV), Vicenza, Italy
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Lemma M, Atanasiou T, Contino M. Minimally invasive cardiac surgery-coronary artery bypass graft. Multimed Man Cardiothorac Surg 2013; 2013:mmt007. [PMID: 24413006 DOI: 10.1093/mmcts/mmt007] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
Coronary artery bypass graft (CABG) is among the most common operations performed in the world. Different surgical strategies can be used with different invasiveness. This paper describes a recent development of the technique that merges the advantages resulting from both the adoption of an 'off-pump no-touch aorta operation' and a 'complete arterial revascularization through a left minithoracotomy' in a single procedure. This operation is currently known with the acronym MICS (minimally invasive cardiac surgery)-CABG (minimally invasive cardiac surgery). It is an off-pump operation performed through a minithoracotomy in the fourth or fifth left intercostal space across the midclavicular line. The left internal thoracic artery (LITA) is harvested under direct vision using a special rib-retractor with multiple interchangeable thoracotomy blades, including blades to use with lift systems for proximal artery harvesting, while the right radial artery (RA) is harvested endoscopically. A Y-connection is made between the two arteries. The LITA is used to bypass the left anterior descending coronary artery, while the right RA is used on the obtuse marginal branches and/or the posterior descending coronary artery. A special coronary stabilizer and a heart positioner with a shaft for remote thoracic insertion are needed.
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Affiliation(s)
- Massimo Lemma
- Minimally Invasive Cardiac Surgery Unit, Cardio-Cerebro-Vascular Department, Luigi Sacco University General Hospital, Milan, Italy
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