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Nguyen TD, Morjan M, Ali K, Breitenbach I, Harringer W, El-Essawi A. Influence of minimal invasive extracorporeal circuits on dialysis dependent patients undergoing cardiac surgery. Perfusion 2023:2676591231216794. [PMID: 37977566 DOI: 10.1177/02676591231216794] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2023]
Abstract
INTRODUCTION Cardiac surgery in patients on chronic renal dialysis is associated with significant morbidity and mortality. Minimally invasive extracorporeal circuits (MiECC) have shown a positive impact on patient outcome in different high-risk populations. This retrospective study compares the outcome of these high-risk patients undergoing heart surgery either with a MiECC or a conventional extracorporeal circulation (CECC). METHODS This is a single-center experience including 131 consecutive dialysis dependent patients undergoing cardiac surgery between January 2006 and December 2016. A propensity score matching was employed leaving 30 matched cases in each group. RESULTS After propensity score matching the 30-day mortality was significantly lower in the MiECC group (n = 3 (10%) vs n = 10 (33%) in the CECC group, p = .028). Further, intraoperative transfused units of packed red blood cells were lower in the MiECC group (1.4 ± 1.8 units vs 2.8 ± 1.7, p < .001). CONCLUSIONS There are evident advantages to using MiECC in dialysis dependent patients, especially regarding mortality. These findings necessitate additional research in MiECC usage in high-risk populations.
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Affiliation(s)
- Thai Duy Nguyen
- Clinic for Pediatric & Congenital Heart Surgery, Children's Heart Center, University Hospital RWTH Aachen, Germany
| | - Mohammed Morjan
- Department of Cardiovascular Surgery, University Hospital Düsseldorf, Germany
| | - Khaldoun Ali
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular surgery, Braunschweig Municipal Hospital Germany
| | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular surgery, University Medical Center Göttingen, Germany
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2
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Ishida M, Takahashi S, Okamura H. Comparison of bubble removal performances of five membrane oxygenators with and without a pre-filter. Perfusion 2023; 38:530-538. [PMID: 35105222 DOI: 10.1177/02676591211064960] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
When employing minimal invasive extracorporeal circulation (MiECC), the removal of bubbles in the circuit is important to prevent air embolism. We investigated the bubble removal performance of the FHP oxygenator with a pre-filter and compared it with that of four oxygenators, including the Fusion oxygenator, Quadrox oxygenator, Inspire oxygenator, and FX oxygenator. A closed test circuit filled with an aqueous glycerin solution was used. Air injection (10 mL) was performed prior to the oxygenator, and the number and volume of the bubbles were measured at the inlet and outlet of each oxygenator. At the inlet of the five oxygenators, there were no significant differences in the total number of bubbles detected. At the outlet, bubbles were classified into two groups according to the bubble size: ≥100 μm and <100 μm. Tests were performed at pump flow rates of 4 and 5 L/min. For bubbles ≥100 μm, which are considered clinically detrimental, the FHP was the lowest number and volume of bubbles at both pump flow rates compared to the other oxygenators. Regarding the bubbles <100 μm, the number of bubbles was higher in the FHP than those in others; however, the volume of bubbles was significantly lower at 4 L/min and tended to be lower at 5 L/min. The use of the FHP with the pre-filter removed more bubbles ≥100 μm in the circuit than that by the other oxygenators.
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Affiliation(s)
- Mitsuru Ishida
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Sho Takahashi
- Department of Medical Engineering, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
| | - Homare Okamura
- Department of Cardiovascular Surgery, RinggoldID:%2083943Nerima Hikarigaoka Hospital, Nerima-ku, Japan
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3
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Réhabilitation améliorée après chirurgie cardiaque adulte sous CEC ou à cœur battant 2021. ANESTHÉSIE & RÉANIMATION 2022. [DOI: 10.1016/j.anrea.2022.10.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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4
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Mertes PM, Kindo M, Amour J, Baufreton C, Camilleri L, Caus T, Chatel D, Cholley B, Curtil A, Grimaud JP, Houel R, Kattou F, Fellahi JL, Guidon C, Guinot PG, Lebreton G, Marguerite S, Ouattara A, Provenchère Fruithiot S, Rozec B, Verhoye JP, Vincentelli A, Charbonneau H. Guidelines on enhanced recovery after cardiac surgery under cardiopulmonary bypass or off-pump. Anaesth Crit Care Pain Med 2022; 41:101059. [PMID: 35504126 DOI: 10.1016/j.accpm.2022.101059] [Citation(s) in RCA: 22] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
OBJECTIVE To provide recommendations for enhanced recovery after cardiac surgery (ERACS) based on a multimodal perioperative medicine approach in adult cardiac surgery patients with the aim of improving patient satisfaction, reducing postoperative mortality and morbidity, and reducing the length of hospital stay. DESIGN A consensus committee of 20 experts from the French Society of Anaesthesia and Intensive Care Medicine (Société française d'anesthésie et de réanimation, SFAR) and the French Society of Thoracic and Cardiovascular Surgery (Société française de chirurgie thoracique et cardio-vasculaire, SFCTCV) was convened. A formal conflict-of-interest policy was developed at the onset of the process and enforced throughout. The entire guideline process was conducted independently of any industry funding. The authors were advised to follow the principles of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) system to guide the assessment of the quality of evidence. METHODS Six fields were defined: (1) selection of the patient pathway and its information; (2) preoperative management and rehabilitation; (3) anaesthesia and analgesia for cardiac surgery; (4) surgical strategy for cardiac surgery and bypass management; (5) patient blood management; and (6) postoperative enhanced recovery. For each field, the objective of the recommendations was to answer questions formulated according to the PICO model (Population, Intervention, Comparison, Outcome). Based on these questions, an extensive bibliographic search was carried out and analyses were performed using the GRADE approach. The recommendations were formulated according to the GRADE methodology and then voted on by all the experts according to the GRADE grid method. RESULTS The SFAR/SFCTCV guideline panel provided 33 recommendations on the management of patients undergoing cardiac surgery under cardiopulmonary bypass or off-pump. After three rounds of voting and several amendments, a strong agreement was reached for the 33 recommendations. Of these recommendations, 10 have a high level of evidence (7 GRADE 1+ and 3 GRADE 1-); 19 have a moderate level of evidence (15 GRADE 2+ and 4 GRADE 2-); and 4 are expert opinions. Finally, no recommendations were provided for 3 questions. CONCLUSIONS Strong agreement existed among the experts to provide recommendations to optimise the complete perioperative management of patients undergoing cardiac surgery.
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Affiliation(s)
- Paul-Michel Mertes
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Michel Kindo
- Department of Cardiac Surgery, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Julien Amour
- Institut de Perfusion, de Réanimation, d'Anesthésie de Chirurgie Cardiaque Paris Sud, IPRA, Hôpital Privé Jacques Cartier, Massy, France
| | - Christophe Baufreton
- Department of Cardiovascular and Thoracic Surgery, University Hospital, Angers, France; MITOVASC Institute CNRS UMR 6214, INSERM U1083, University, Angers, France
| | - Lionel Camilleri
- Department of Cardiovascular Surgery, CHU Clermont-Ferrand, T.G.I, I.P., CNRS, SIGMA, UCA, UMR 6602, Clermont-Ferrand, France
| | - Thierry Caus
- Department of Cardiac Surgery, UPJV, Amiens University Hospital, Amiens Picardy University Hospital, Amiens, France
| | - Didier Chatel
- Department of Cardiac Surgery (D.C.), Institut du Coeur Saint-Gatien, Nouvelle Clinique Tours Plus, Tours, France
| | - Bernard Cholley
- Anaesthesiology and Intensive Care Medicine, Hôpital Européen Georges-Pompidou, AP-HP, Université de Paris, INSERM, IThEM, Paris, France
| | - Alain Curtil
- Department of Cardiac Surgery, Clinique de la Sauvegarde, Lyon, France
| | | | - Rémi Houel
- Department of Cardiac Surgery, Saint Joseph Hospital, Marseille, France
| | - Fehmi Kattou
- Department of Anaesthesia and Intensive Care, Institut Mutualiste Montsouris, Paris, France
| | - Jean-Luc Fellahi
- Service d'Anesthésie-Réanimation, Hôpital Universitaire Louis Pradel, Hospices Civils de Lyon, Lyon, France; Faculté de Médecine Lyon Est, Université Claude-Bernard Lyon 1, Lyon, France
| | - Catherine Guidon
- Department of Anaesthesiology and Critical Care Medicine, University Hospital Timone, Aix Marseille University, Marseille, France
| | - Pierre-Grégoire Guinot
- Department of Anaesthesiology and Intensive Care, Dijon University Hospital, Dijon, France; University of Bourgogne and Franche-Comté, LNC UMR1231, Dijon, France; INSERM, LNC UMR1231, Dijon, France; FCS Bourgogne-Franche Comté, LipSTIC LabEx, Dijon, France
| | - Guillaume Lebreton
- Sorbonne Université, INSERM, Unité mixte de recherche CardioMetabolisme et Nutrition, ICAN, AP-HP, Hôpital Pitié-Salpétrière, Paris, France
| | - Sandrine Marguerite
- Department of Anaesthesia and Intensive Care, Hôpitaux Universitaires de Strasbourg, Nouvel Hôpital Civil, FMTS de Strasbourg, Strasbourg, France
| | - Alexandre Ouattara
- CHU Bordeaux, Department of Anaesthesia and Critical Care, Magellan Medico-Surgical Centre, F-33000 Bordeaux, France; Univ. Bordeaux, INSERM, UMR 1034, Biology of Cardiovascular Diseases, F-33600 Pessac, France
| | - Sophie Provenchère Fruithiot
- Department of Anaesthesia, Université de Paris, Bichat-Claude Bernard Hospital, Paris, France; Centre d'Investigation Clinique 1425, INSERM, Université de Paris, Paris, France
| | - Bertrand Rozec
- Service d'Anesthésie-Réanimation, Hôpital Laennec, CHU Nantes, Nantes, France; Université de Nantes, CHU Nantes, CNRS, INSERM, Institut duDu Thorax, Nantes, France
| | - Jean-Philippe Verhoye
- Department of Thoracic and Cardiovascular Surgery, Pontchaillou University Hospital, Rennes, France
| | - André Vincentelli
- Department of Cardiac Surgery, University of Lille, CHU Lille, Lille, France
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Cheng T, Barve R, Cheng YWM, Ravendren A, Ahmed A, Toh S, Goulden CJ, Harky A. Conventional versus miniaturized cardiopulmonary bypass: A systematic review and meta-analysis. JTCVS OPEN 2021; 8:418-441. [PMID: 36004169 PMCID: PMC9390465 DOI: 10.1016/j.xjon.2021.09.037] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/05/2021] [Accepted: 09/24/2021] [Indexed: 11/05/2022]
Abstract
Objective A meta-analysis of randomized controlled trials was performed to compare the effects of miniaturized extracorporeal circulation (MECC) and conventional extracorporeal circulation (CECC) on morbidity and mortality rates after cardiac surgery. Methods A comprehensive literature search was conducted using Ovid, PubMed, Medline, EMBASE, and the Cochrane databases. Randomized controlled trials from the year 2000 with n > 40 patients were considered. Key search terms included variations of “mini,” “cardiopulmonary,” “bypass,” “extracorporeal,” “perfusion,” and “circuit.” Studies were assessed for bias using the Cochrane Risk of Bias tool. The primary outcomes were postoperative mortality and stroke. Secondary outcomes included arrhythmia, myocardial infarction, renal failure, blood loss, and a composite outcome comprised of mortality, stroke, myocardial infarction and renal failure. Duration of intensive care unit, and hospital stay was also recorded. Results The 42 studies eligible for this study included a total of 2154 patients who underwent CECC and 2196 patients who underwent MECC. There were no significant differences in any preoperative or demographic characteristics. Compared with CECC, MECC did not reduce the incidence of mortality, stroke, myocardial infarction, and renal failure but did significantly decrease the composite of these outcomes (odds ratio, 0.64; 95% confidence interval [CI], 0.50-0.81; P = .0002). MECC was also associated with reductions in arrhythmia (odds ratio, 0.67; 95% CI, 0.54-0.83; P = .0003), blood loss (mean difference [MD], –96.37 mL; 95% CI, –152.70 to –40.05 mL; P = .0008), hospital stay (MD, –0.70 days; 95% CI, –1.21 to –0.20 days; P = .006), and intensive care unit stay (MD, –2.27 hours; 95% CI, –3.03 to –1.50 hours; P < .001). Conclusions MECC demonstrates clinical benefits compared with CECC. Further studies are required to perform a cost–utility analysis and to assess the long-term outcomes of MECC. These should use standardized definitions of endpoints such as mortality and renal failure to reduce inconsistency in outcome reporting.
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El-Essawi A, Bauer A, Gröger S, Hausmann H, Gehron J, Böning A, Harringer W. Minimalinvasive extrakorporale Zirkulation. ZEITSCHRIFT FUR HERZ THORAX UND GEFASSCHIRURGIE 2020. [DOI: 10.1007/s00398-019-00349-y] [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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7
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Vives M, Hernandez A, Parramon F, Estanyol N, Pardina B, Muñoz A, Alvarez P, Hernandez C. Acute kidney injury after cardiac surgery: prevalence, impact and management challenges. Int J Nephrol Renovasc Dis 2019; 12:153-166. [PMID: 31303781 PMCID: PMC6612286 DOI: 10.2147/ijnrd.s167477] [Citation(s) in RCA: 73] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2018] [Accepted: 05/29/2019] [Indexed: 12/14/2022] Open
Abstract
Acute kidney injury (AKI) is a major medical problem that is of particular concern after cardiac surgery. Perioperative AKI is independently associated with an increase in short-term morbidity, costs of treatment, and long-term mortality. In this review, we explore the definition of cardiac surgery-associated acute kidney injury (CSA-AKI) and identify diverse mechanisms and risk factors contributing to the renal insult. Current theories of the pathophysiology of CSA-AKI and description of its clinical course will be addressed in this review. Data on the most promising renal protective strategies in cardiac surgery, from well-designed studies, will be scrutinized. Furthermore, diagnostic tools such as novel biomarkers of AKI and their potential utility will be discussed.
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Affiliation(s)
- M Vives
- Department of Anesthesiology & Critical Care, Clinical Research Lead, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Institut d´Investigació Biomédica de Girona (IDIBGI), Girona, Spain
| | - A Hernandez
- Department of Anesthesia & Critical Care, Grupo Policlinica, Ibiza, Spain
| | - F Parramon
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - N Estanyol
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - B Pardina
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - A Muñoz
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - P Alvarez
- Department of Cardiac Surgery, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
| | - C Hernandez
- Department of Anesthesiology & Critical Care Chief, Hospital Universitari Dr Josep Trueta, Universitat de Girona, Girona, Spain
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8
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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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9
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Anastasiadis K, Argiriadou H, Deliopoulos A, Antonitsis P. Minimal invasive extracorporeal circulation (MiECC): the state-of-the-art in perfusion. J Thorac Dis 2019; 11:S1507-S1514. [PMID: 31293801 DOI: 10.21037/jtd.2019.01.66] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
| | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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10
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Sato K, Toda T, Iwata A. Fragility Index in Randomized Controlled Trials of Ischemic Stroke. J Stroke Cerebrovasc Dis 2019; 28:1290-1294. [PMID: 30765294 DOI: 10.1016/j.jstrokecerebrovasdis.2019.01.015] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 01/19/2019] [Indexed: 12/18/2022] Open
Abstract
OBJECTIVE The fragility index (FI), a minimum number of events in 1 arm of a clinical trial required to revert the statistically significant result to nonsignificant, has recently been developed as an easy-to-understand novel metric to evaluate the robustness of randomized controlled trials (RCTs). Here, we evaluated the FI of RCTs in the field of neurology, particularly in studies of ischemic stroke. METHODS Previous literature published between June 1, 2012 and May 31, 2018 were reviewed from the MEDLINE database by the authors. The original article reporting the significant RCT result, of which a dichotomous outcome was set as its primary outcome measure, was included to evaluate the robustness of the result by calculating the FI. In addition, recent studies examining FI in other clinical fields were reviewed and summarized. RESULTS In the 25 eligible RCT studies, the median total number of study participants was 206 (inter quartile range: 144-450) and the median FI was 7 (inter quartile range: 4-15.0). The FI showed a strong negative correlation with the observed P value. There was no significant difference in the FI between RCTs with and without acute settings. Our median FI was higher than the median FI of 2.5 of previous studies examining FI in other clinical fields, as only 20% (5 of 25) of studies included in our study had an FI less than 2.5. CONCLUSION Our results suggest that many RCTs in the field of ischemic stroke have a fair robustness, when compared to those in other clinical fields.
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Affiliation(s)
- Kenichiro Sato
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Tatsushi Toda
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan
| | - Atsushi Iwata
- Department of Neurology, Graduate School of Medicine, The University of Tokyo, Tokyo, Japan.
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11
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Starinieri P, Declercq PE, Robic B, Yilmaz A, Van Tornout M, Dubois J, Mees U, Hendrikx M. A comparison between minimized extracorporeal circuits and conventional extracorporeal circuits in patients undergoing aortic valve surgery: is 'minimally invasive extracorporeal circulation' just low prime or closed loop perfusion ? Perfusion 2017; 32:403-408. [PMID: 28553780 DOI: 10.1177/0267659117691814] [Citation(s) in RCA: 6] [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
INTRODUCTION Even though results have been encouraging, an unequivocal conclusion on the beneficial effect of minimally invasive extracorporeal circulation (MiECC) in patients undergoing aortic valve surgery cannot be derived from previous publications. Long-term outcomes are rarely reported and a significant decrease in operative mortality has not been shown. Most studies have a limited number of patients and are underpowered. They merely report on short-term results of a heterogeneous intraoperative group using different types of ECC system in aortic valve surgery. The aim of the present study was to determine whether MiECC systems are more beneficial than conventional extracorporeal systems (CECC) with regard to mortality, hospital stay and inflammation and with only haemodilution and blood-air interface as differences. METHODS We retrospectively analysed data regarding mortality, hospital stay and inflammation in patients undergoing isolated aortic valve surgery. Forty patients were divided into two groups based on the type of extracorporeal system used; conventional (n=20) or MiECC (n=20). RESULTS Perioperative blood product requirements were significantly lower in the MiECC group (MiECC: 0.2±0.5 units vs CECC: 0.9±1.2 units, p=0.004). No differences were seen postoperatively regarding mortality (5% vs 5%, p=0.99), total length of hospital stay (10.6±7.2 days (MiECC) vs 12.1±5.9 days (CECC), p=0.39) or inflammation markers (CRP: MiECC: 7.09±13.62 mg/L vs CECC: 3.4±3.2 mg/L, p=0.89). CONCLUSION MiECC provides circulatory support that is equally safe and feasible as conventional extracorporeal circuits. No differences in mortality, hospital stay or inflammation markers were observed.
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Affiliation(s)
| | - Peter E Declercq
- 2 Department of Laboratory Medicine, Jessa Hospital, Belgium.,3 University of Leuven, Faculty of Pharmaceutical Sciences, Leuven, Belgium
| | - Boris Robic
- 4 Department of Cardio-thoracic Surgery, Jessa Hospital, Belgium.,5 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
| | - Alaaddin Yilmaz
- 4 Department of Cardio-thoracic Surgery, Jessa Hospital, Belgium
| | | | | | - Urbain Mees
- 4 Department of Cardio-thoracic Surgery, Jessa Hospital, Belgium
| | - Marc Hendrikx
- 4 Department of Cardio-thoracic Surgery, Jessa Hospital, Belgium.,5 Faculty of Medicine and Life Sciences, Hasselt University, Hasselt, Belgium
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Abstract
INTRODUCTION Cardiopulmonary bypass has undoubtedly been the cornerstone in the rapid development of cardiac surgery, allowing even the performance of procedures beyond the scope of cardiothoracic surgery. Its use however, is associated with significant complications that arise from the mechanical effects of the circuit on circulating blood components as well as the contact of blood with non-endothelial surfaces. Miniature cardiopulmonary bypass systems have been developed in an attempt to minimize these complications. Areas covered: Herein clinical outcomes from the most recent studies in adult cardiac surgery are discussed. The main benefits of miniaturisation as well as potential areas of further application are described. Expert commentary: Data is critically appraised in the context of current guidelines. Finally the need for further basic science in addition to large multi-centre randomized controlled trial data is highlighted.
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Affiliation(s)
- Ioannis Dimarakis
- a Department of Cardiothoracic Surgery , Wythenshawe Hospital , Manchester , UK
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13
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Anastasiadis K, Antonitsis P, Vranis K, Kleontas A, Asteriou C, Grosomanidis V, Tossios P, Argiriadou H. Effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing coronary artery bypass grafting: a randomized pilot study. Interact Cardiovasc Thorac Surg 2016; 23:740-747. [PMID: 27378790 DOI: 10.1093/icvts/ivw213] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2015] [Revised: 05/01/2016] [Accepted: 05/10/2016] [Indexed: 11/14/2022] Open
Abstract
OBJECTIVES Perioperative low cardiac output syndrome occurs in 3-14% of patients undergoing isolated coronary artery bypass grafting (CABG), leading to significant increase in major morbidity and mortality. Considering the unique pharmacological and pharmacokinetic properties of levosimendan, we conducted a prospective, double-blind, randomized pilot study to evaluate the effectiveness of prophylactic levosimendan in patients with impaired left ventricular function undergoing CABG. METHODS Thirty-two patients undergoing CABG with low left ventricular ejection fraction (LVEF ≤ 40%) were randomized to receive either a continuous infusion of levosimendan at a dose of 0.1 μg/kg/min for 24 h without a loading dose or a placebo. The primary outcome of the study was the change in the LVEF assessed with transthoracic echocardiography on the seventh postoperative day. Secondary outcomes included the physiological and clinical effects of levosimendan. RESULTS All patients tolerated preoperative infusion of levosimendan well. The LVEF improved in both groups; this increase was statistically significant in the levosimendan group (from 35.8 ± 5% preoperatively to 42.8 ± 7.8%, P = 0.001) compared with the control group (from 37.5 ± 3.4% preoperatively to 41.2 ± 8.3%, P = 0.1). The cardiac index, SvO2, pulmonary capillary wedge pressure and right ventricular stroke work index showed a similar trend, which was optimized in patients treated with levosimendan. Moreover, an increase in extravascular lung water was noticed in this group during the first 24 h after surgery. CONCLUSIONS This pilot study shows that prophylactic levosimendan infusion is safe and effective in increasing the LVEF postoperatively in patients with impaired cardiac function undergoing coronary surgery. This finding may be translated to 'optimizing' patients' status before surgery.
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MESH Headings
- Cardiac Output, Low/etiology
- Cardiotonic Agents/administration & dosage
- Coronary Artery Bypass/adverse effects
- Coronary Artery Disease/complications
- Coronary Artery Disease/diagnosis
- Coronary Artery Disease/surgery
- Dose-Response Relationship, Drug
- Double-Blind Method
- Female
- Finland/epidemiology
- Follow-Up Studies
- Humans
- Hydrazones/administration & dosage
- Incidence
- Infusions, Intravenous
- Male
- Middle Aged
- Pilot Projects
- Postoperative Complications/epidemiology
- Postoperative Complications/prevention & control
- Prospective Studies
- Pyridazines/administration & dosage
- Simendan
- Stroke Volume/drug effects
- Stroke Volume/physiology
- Survival Rate/trends
- Tomography, Emission-Computed, Single-Photon
- Ventricular Dysfunction, Left/complications
- Ventricular Dysfunction, Left/drug therapy
- Ventricular Dysfunction, Left/physiopathology
- Ventricular Function, Left/drug effects
- Ventricular Function, Left/physiology
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14
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Anastasiadis K, Antonitsis P, Kostarellou G, Kleontas A, Deliopoulos A, Grosomanidis V, Argiriadou H. Minimally invasive extracorporeal circulation improves quality of life after coronary artery bypass grafting. Eur J Cardiothorac Surg 2016; 50:1196-1203. [PMID: 27307483 DOI: 10.1093/ejcts/ezw210] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2015] [Revised: 05/02/2016] [Accepted: 05/08/2016] [Indexed: 12/20/2022] Open
Abstract
OBJECTIVES The effect on postoperative health-related quality of life (HRQoL) after coronary artery bypass grafting (CABG) surgery with conventional cardiopulmonary bypass (cCPB) and off-pump surgery has been investigated extensively; however, there are no studies focusing on HRQoL after surgery with minimally invasive extracorporeal circulation (MiECC). Therefore, we sought to prospectively investigate the effect of MiECC on postoperative HRQoL when compared with cCPB in patients undergoing CABG over a short-term (3-month) follow-up period. METHODS Sixty patients scheduled for elective CABG surgery were randomly assigned into two groups: those who had surgery on MiECC system (n = 30) and those who underwent CABG using cCPB (n = 30). Quality-of-life assessment was performed preoperatively (baseline-T0), at first postoperative month (T1) and at 3-month follow-up (T3). The RAND SF-36 scale was used for data collection, which included both sociodemographic and clinical characteristics of patients. The primary outcome of the study was quantitative measurement of postoperative HRQoL at 3-month follow-up. RESULTS Both groups were balanced in terms of demographic, socio-economic and operative characteristics. At 3-month follow-up, mean SF-36 component and summary scores in each group were higher in absolute values than the respective mean baseline scores, apart from role-physical score in patients operated with cCPB. Patients operated on MiECC showed uniformly significantly higher values in all individual and summary domains, whereas patients operated on cCPB showed significant improvement in 6/8 individual domains. Patients operated on MiECC showed a more pronounced increase in SF-36 individual domain scores from the first to the third postoperative month when compared with cCPB, which was statistically significant regarding physical functioning (P = 0.001), role-physical (P < 0.001), vitality (P = 0.01) and role-emotional (P = 0.004). This resulted in a significant improvement in physical (P = 0.002) and mental (P = 0.01) summary scores. CONCLUSIONS The current study proves that MiECC significantly improves HRQoL after coronary surgery compared with cCPB. This finding, combined with results from large-scale studies showing superior clinical outcomes from its use, enhances the role of MiECC as a dominant technique in coronary revascularization surgery.
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Affiliation(s)
| | | | | | | | | | | | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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Kowalewski M, Pawliszak W, Raffa GM, Malvindi PG, Kowalkowska ME, Zaborowska K, Kowalewski J, Tarelli G, Taggart DP, Anisimowicz L. Safety and efficacy of miniaturized extracorporeal circulation when compared with off-pump and conventional coronary artery bypass grafting: evidence synthesis from a comprehensive Bayesian-framework network meta-analysis of 134 randomized controlled trials involving 22 778 patients. Eur J Cardiothorac Surg 2015; 49:1428-40. [DOI: 10.1093/ejcts/ezv387] [Citation(s) in RCA: 33] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/07/2015] [Accepted: 09/30/2015] [Indexed: 11/12/2022] Open
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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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Anastasiadis K, Antonitsis P, Argiriadou H, Deliopoulos A, Grosomanidis V, Tossios P. Modular minimally invasive extracorporeal circulation systems; can they become the standard practice for performing cardiac surgery? Perfusion 2015; 30:195-200. [DOI: 10.1177/0267659114567555] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Minimally invasive extracorporeal circulation (MiECC) has been developed in an attempt to integrate all advances in cardiopulmonary bypass technology in one closed circuit that shows improved biocompatibility and minimizes the systemic detrimental effects of CPB. Despite well-evidenced clinical advantages, penetration of MiECC technology into clinical practice is hampered by concerns raised by perfusionists and surgeons regarding air handling together with blood and volume management during CPB. We designed a modular MiECC circuit, bearing an accessory circuit for immediate transition to an open system that can be used in every adult cardiac surgical procedure, offering enhanced safety features. We challenged this modular circuit in a series of 50 consecutive patients. Our results showed that the modular AHEPA circuit design offers 100% technical success rate in a cohort of random, high-risk patients who underwent complex procedures, including reoperation and valve and aortic surgery, together with emergency cases. This pilot study applies to the real world and prompts for further evaluation of modular MiECC systems through multicentre trials.
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Affiliation(s)
- K Anastasiadis
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - P Antonitsis
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - H Argiriadou
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - A Deliopoulos
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - V Grosomanidis
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - P Tossios
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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Long DM, Jenkins E, Griffith K. Perfusionist techniques of reducing acute kidney injury following cardiopulmonary bypass: an evidence-based review. Perfusion 2014; 30:25-32. [DOI: 10.1177/0267659114544395] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Cardiac surgery utilizing cardiopulmonary bypass has come a long way since its introduction nearly 60 years ago. In the early days, end-organ damage was linked to contact of the blood with the extracorporeal circuit. One potential cardiac surgery complication known to result in significant morbidity and mortality is acute kidney injury (AKI). Causes of AKI are multifaceted, but most of them are associated with techniques that perfusionists employ during extracorporeal circuit management. These can cause patients to either go on dialysis or renal replacement therapy. Patients with AKI have longer lengths of stay and consume significant resources beyond those with normal kidney function. Few current evidence-based markers determine if the kidneys are adequately protected during surgery. Most relevant literature does not address perfusion-specific techniques that reduce the incidence of AKI. This paper reviews the pathophysiology of the kidney and focuses on perfusion techniques that may reduce the incidence of AKI.
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Affiliation(s)
- DM Long
- Perfusion Services, NorthShore University Health System, Evanston, IL, USA
| | - E Jenkins
- Cardiovascular Center-Perfusion Services, University of Michigan Hospitals, Ann Arbor, MI, USA
| | - K Griffith
- Cardiovascular Center-Perfusion Services, University of Michigan Hospitals, Ann Arbor, MI, USA
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