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Angelini GD, Reeves BC, Culliford LA, Maishman R, Rogers CA, Anastasiadis K, Antonitsis P, Argiriadou H, Carrel T, Keller D, Liebold A, Ashkaniani F, El-Essawi A, Breitenbach I, Lloyd C, Bennett M, Cale A, Gunaydin S, Gunertem E, Oueida F, Yassin IM, Serrick C, Murkin JM, Rao V, Moscarelli M, Condello I, Punjabi P, Rajakaruna C, Deliopoulos A, Bone D, Lansdown W, Moorjani N, Dennis S. Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS). Perfusion 2024:2676591241258054. [PMID: 38832503 DOI: 10.1177/02676591241258054] [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: 06/05/2024]
Abstract
INTRODUCTION The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. METHODS This is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis. RESULTS The trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250). CONCLUSIONS MiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.
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Affiliation(s)
| | | | | | | | - Chris A Rogers
- Bristol Medical School, University of Bristol, Bristol, UK
| | | | | | - Helena Argiriadou
- Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | | | | | | | | | | | | | - Clinton Lloyd
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Mark Bennett
- University Hospitals Plymouth NHS Trust, Plymouth, UK
| | - Alex Cale
- Hull University Teaching Hospitals NHS Trust, Hull, UK
| | - Serdar Gunaydin
- Numune Training and Research Hospital in Ankara, Ankara, Turkey
| | - Eren Gunertem
- Numune Training and Research Hospital in Ankara, Ankara, Turkey
| | - Farouk Oueida
- Saud Al-Babtain Cardiac Centre, Dammam, Saudi Arabia
| | | | | | | | - Vivek Rao
- University Health Network, Toronto, ON, Canada
| | | | | | | | - Cha Rajakaruna
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
| | | | - Daniel Bone
- University Hospitals Bristol NHS Foundation Trust, Bristol, UK
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Zhang S, Chou YT, Zhang J, Chen J, Xiong Y, Lu J, Chen C, Xu Y, Liu Y. Experience in applied veno-arterial extracorporeal membrane oxygenation to support catheter ablation of malignant ventricular tachycardia. IJC HEART & VASCULATURE 2023; 49:101283. [PMID: 37908623 PMCID: PMC10613908 DOI: 10.1016/j.ijcha.2023.101283] [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: 07/26/2023] [Revised: 10/08/2023] [Accepted: 10/14/2023] [Indexed: 11/02/2023]
Abstract
Background An electrical storm due to malignant ventricular tachycardia (VT) is a life-threatening condition that requires catheter ablation (CA). Most VT arrhythmias evolve over time after acute myocardial infarction, coronary artery bypass grafting, or chronic heart failure. Clinically, only radiofrequency ablation can identify and block all arrhythmia origin points. The procedure necessitates continuous VT induction in patients, resulting in hemodynamic instability; therefore, extracorporeal membrane oxygenation (ECMO) support is required. Earlier studies have reported substantial mortality rates; however, our results are significantly more favorable. In this study, we combined the minimally invasive extracorporeal circulation (MiECC) approach with ECMO to preserve an appropriate ECMO flow rate, thus reducing intraoperative left heart afterload. We report 21 cases illustrating the usefulness of modified veno-arterial (VA)-ECMO in this scenario. Methods Data of 21 patients supported by the modified VA-ECMO system (MiECC approach combined with the ECMO system) during VT CA in the Wuhan Asia Heart Hospital between June 2020 and July 2021 were reviewed retrospectively. Results Successful ablation was achieved in 20 out of 21 patients (95%). The median time for ECMO implantation was 206 min. Only two patients experienced complications post-treatment. All patients made complete recovery and were discharged. All patients were alive at the 1-year-follow-up. Conclusions Our modified VA-ECMO system helped restore systemic circulation in patients experiencing an electrical storm, thus achieving greater electrical stability during VT CA. Pre-insertion of VA-ECMO can achieve even better results.
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Affiliation(s)
| | - Yueh-ting Chou
- Wuhan Asia Heart Hospital, Wuhan, China
- National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
| | | | - Jin Chen
- Wuhan Asia Heart Hospital, Wuhan, China
| | | | - Juan Lu
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Chao Chen
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Yue Xu
- Wuhan Asia Heart Hospital, Wuhan, China
| | - Yan Liu
- Wuhan Asia Heart Hospital, Wuhan, China
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Gkiouliava A, Argiriadou H, Antonitsis P, Goulas A, Papapostolou E, Sarridou D, Karapanagiotidis GT, Anastasiadis K. Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery on minimal invasive extracorporeal circulation; A prospective randomized study. Perfusion 2023:2676591231204284. [PMID: 37776194 DOI: 10.1177/02676591231204284] [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: 10/02/2023]
Abstract
INTRODUCTION Individualized heparin and protamine management is increasingly used as a strategy to reduce coagulation activation and bleeding complications. While it is associated with increased heparin requirements during Cardiopulmonary Bypass (CPB), the impact on protamine administration remains controversial. We aim to investigate the effect of heparin level-guided monitoring on protamine dosing during cardiac surgery where low-anticoagulation protocols are implemented. METHODS This is a prospective, randomized, controlled trial. A total of 132 patients undergoing elective full-spectrum cardiac surgery with Minimal Invasive Extracorporeal Circulation (MiECC) were recruited. All patients were managed by the same anaesthetic, surgical and perfusion team. Patients were randomly allocated in two groups; the individualized heparin-protamine titration (IHPT) group and the conventional heparinization and reversal group by using ACT (cACT) with a 0.75:1, protamine: heparin ratio. Titration was accomplished with the Hepcon HMS Plus (Medtronic, Minneapolis, MN) system. The primary outcome of the study was the total protamine dose used. Secondary outcomes comprised of the total heparin dose, the percentage of patients achieving target ACT, 24-h transfusion requirements, postoperative bleeding, duration of mechanical ventilation, major morbidity and length of hospital stay. Patients in each group were divided in two subgroups according to the target ACT; those operated for coronary artery bypass grafting (CABG) using a target ACT >300 s and the rest (non-CABG) patients operated with a target ACT >400 s, respectively. RESULTS Protamine requirements were significantly reduced when IHPT was implemented; CABG (118 ± 24 mg vs 163 ± 61 mg; p < 0.001) and non-CABG cases (151 ± 46 mg vs 197 ± 45 mg; p < 0.001). Moreover, heparin requirements were significantly higher in the non-CABG subgroup managed with IHPT (34,539 ± 7658 IU vs 29,893 ± 9037 IU; p = 0.02). In overall, no significant differences were detected with respect to postoperative bleeding, transfusion of RBC or other blood products. CONCLUSIONS Individualized heparin monitoring and management reduces protamine requirements in cardiac surgery with MiECC implementing reduced anticoagulation strategy. TRIAL REGISTRATION clinicaltrials.gov; NCT04215588.
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Affiliation(s)
- Anna Gkiouliava
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Helena Argiriadou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Antonis Goulas
- First Laboratory of Pharmacology, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Evangelia Papapostolou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Despoina Sarridou
- Department of Anesthesiology and Intensive Care, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Georgios T Karapanagiotidis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
| | - Kyriakos Anastasiadis
- Cardiothoracic Department, AHEPA University Hospital, Aristotle University of Thessaloniki School of Medicine, Thessaloniki, Greece
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Carrel T. Reduced Invasiveness of Cardiopulmonary Bypass: The Mini-Circuit and the Micro-Cardioplegia. J Cardiovasc Dev Dis 2023; 10:290. [PMID: 37504545 PMCID: PMC10380229 DOI: 10.3390/jcdd10070290] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2023] [Revised: 07/04/2023] [Accepted: 07/05/2023] [Indexed: 07/29/2023] Open
Abstract
The aim of cardiopulmonary bypass is the maintenance of a sufficient whole body perfusion and gas exchange during open or closed heart surgery procedure (coronary artery bypass grafting, valve repair and replacement, surgical intervention on the ascending aorta and/or aortic arch, repair of congenital malformations, and finally implantation of ventricular assist devices or cardiac transplantation). The main components of cardiopulmonary bypass are the pump that supplies the circulation and the oxygenator that regulates gas exchange. However, even though this technology has been extensively developed and improved over the last decades, one of the major drawbacks-which is the fact that blood has to flow through tubing systems with foreign surfaces-persists so far. Nevertheless, interesting innovations have been made more recently in order to better control the side-effects that culminate into a major activation of the coagulation and inflammatory systems: among them, miniaturization of the circuits, together with reduction of the priming volume and a simplified cardioplegia concept. All of these lead to a significant decrease of hemodilution and thereby a significant reduction of volume overload during surgery. In this brief review we will present some of these most interesting topics around minimized circuits and the simplified low-volume cardioplegia and discuss their potential benefits on the clinical outcome.
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Affiliation(s)
- Thierry Carrel
- Departement of Cardiac Surgery, University of Zürich, CH-8006 Zürich, Switzerland
- Department of Cardiac Surgery, University Hospital Basel, CH-4052 Basel, Switzerland
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Condello I. Anticoagulation in Emergency Cardiac Surgery - The Rationale for Modular Minimally Invasive Extracorporeal Circulation Use. Braz J Cardiovasc Surg 2023; 38:209-210. [PMID: 35244368 PMCID: PMC10010715 DOI: 10.21470/1678-9741-2020-0481] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/27/2023] Open
Affiliation(s)
- Ignazio Condello
- Department of Cardiac Surgery, Anthea Hospital, GVM Care & Research, Bari, Italy
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Ellam S, Räsänen J, Hartikainen J, Selander T, Juutilainen A, Halonen J. Impact of minimal invasive extracorporeal circulation on perioperative intravenous fluid management in coronary artery bypass surgery. Perfusion 2023; 38:135-141. [PMID: 34479461 PMCID: PMC9841459 DOI: 10.1177/02676591211043232] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/24/2023]
Abstract
OBJECTIVE Compare the use of blood products and intravenous fluid management in patients scheduled for coronary artery bypass surgery and randomized to minimal invasive extracorporeal circulation (MiECC) and conventional extracorporeal circulation (CECC). METHODS A total of 240 patients who were scheduled for their first on-pump CABG, were randomized to MiECC or CECC groups. The study period was the first 84 hours after surgery. Hemoglobin <80 g/l was used as transfusion trigger. RESULTS Red blood cell transfusions intraoperatively were given less often in the MiECC group (23.3% vs 9.2%, p = 0.005) and the total intravenous fluid intake was significantly lower in the MiECC group (3300 ml [2950-4000] vs 4800 ml [4000-5500], p < 0.001). Hemoglobin drop also was lower in the MiECC group (35.5 ± 8.9 g/l vs 50.7 ± 9 g/l, p < 0.001) as was hemoglobin drop percent (25.3 ± 6% vs 35.3 ± 5.9%, p < 0.001). Chest tube drainage output was higher in the MiECC group (645 ml [500-917.5] vs 550 ml [412.5-750], p = 0.001). Particularly, chest tube drainage in up to 600 ml category, was in benefit of CECC group (59.1% vs 40.8%, p = 0.003). ROC curve analysis showed that patients with hemoglobin level below 95 g/l upon arrival to intensive care unit was associated with increased risk of developing postoperative atrial fibrillation (POAF) (p = 0.002, auc = 0.61, cutoff <95, sensitivity = 0.47, positive predictive value = 0.64). CONCLUSION MiECC reduced the intraoperative need for RBC transfusion and intravenous fluids compared to the CECC group, also reducing hemoglobin drop compared to the CECC group in CABG surgery patients. Postoperative hemoglobin drop was a predictor of POAF.
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Affiliation(s)
- Sten Ellam
- Department of Anesthesiology and
Operative Services, Kuopio University Hospital, Kuopio, Finland,Sten Ellam, Department of Anesthesiology
and Operative Services, Kuopio University Hospital, PO Box 100, Kuopio 70029,
Finland.
| | - Jenni Räsänen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland
| | - Juha Hartikainen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland,Heart Center, Kuopio University
Hospital, Kuopio, Finland
| | - Tuomas Selander
- Research Support Services, Kuopio
University Hospital, Kuopio, Finland
| | - Auni Juutilainen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland
| | - Jari Halonen
- School of Medicine, University of
Eastern Finland, Kuopio, Finland,Heart Center, Kuopio University
Hospital, Kuopio, Finland
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Santavy P, Kubickova V, Sima M, Urbanek K. Population pharmacokinetics of three alternative prophylactic antibiotics during cardiac surgery with extracorporeal circulation. Biomed Pap Med Fac Univ Palacky Olomouc Czech Repub 2022. [PMID: 35775358 DOI: 10.5507/bp.2022.033] [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: 11/23/2022] Open
Abstract
AIMS The aim of this pharmacokinetic study was to describe and quantify population pharmacokinetics of three antibiotics, cefazolin, ampicillin, and ciprofloxacin, used as antibacterial prophylaxis during cardiovascular surgery with the use of extracorporeal circulation (ECC). METHODS Adult patients undergoing cardiac surgery with ECC were enrolled to this prospective, pharmacokinetic study. An intravenous bolus of 2 g of ampicillin, 2 g of cefazolin or 400 mg of ciprofloxacin was administered 60-30 min before surgery. Blood samples were collected at 15, 30, 45, 60, 120 and 180 min after the administration and at the end of the surgery. Plasma concentrations of the antibiotics were measured using HPLC methods. Serum concentration-time profiles were analyzed using nonlinear mixed-effects modeling approach. RESULTS A total of 54 patients were enrolled into the study, 20 with ampicillin, 25 cefazolin and 9 ciprofloxacin. For all antibiotics, population pharmacokinetic models have been successfully developed. CONCLUSION We identified estimated glomerular filtration rate (eGFR) as the main factor determining the achievement of the pharmacokinetic/pharmacodynamic (PK/PD) target in ampicillin or cefazolin and body weight in ciprofloxacin prophylaxis during cardiac surgery with ECC support.
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Affiliation(s)
- Petr Santavy
- Department of Cardiac Surgery, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Vendula Kubickova
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
| | - Martin Sima
- Department of Pharmacology, First Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Karel Urbanek
- Department of Pharmacology, Faculty of Medicine and Dentistry, Palacky University Olomouc and University Hospital Olomouc, Czech Republic
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Anastasiadis K, Antonitsis P, Asteriou C, Deliopoulos A, Argiriadou H. Modular minimally invasive extracorporeal circulation ensures perfusion safety and technical feasibility in cardiac surgery; a systematic review of the literature. Perfusion 2021; 37:852-862. [PMID: 34137323 DOI: 10.1177/02676591211026514] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/04/2023]
Abstract
INTRODUCTION Despite extensive evidence that shows clinical of superiority of MiECC, worldwide penetration remains low due to concerns regarding air handling and volume management in the context of a closed system. The purpose of this study is to thoroughly investigate perfusion safety and technical feasibility of performing all cardiac surgical procedures with modular (hybrid) MiECC, as experienced from the perfusionist's perspective. METHODS We retrospectively reviewed perfusion charts of consecutive adult patients undergoing all types of elective, urgent, and emergency cardiac surgery under modular MiECC. The primary outcome measure was perfusion safety and technical feasibility, as evidenced in the need for conversion from a closed to an open circuit. A systematic review of the literature was conducted aiming to ultimately clarify whether there are any safety issues regarding MiECC technology. RESULTS We challenged modular MiECC use in a series of 403 consecutive patients of whom a significant proportion (111/403; 28%) underwent complex surgery including reoperations (4%), emergency repair of acute type A aortic dissection and composite aortic surgery (1.7%). Technical success rate was 100%. Conversion to an open circuit was required in 18/396 patients (4.5%), excluding procedures performed under circulatory arrest. Open configuration accounted for 40% ± 21% of total procedural perfusion time and was related to significant hemodilution and increase in peak lactate levels. Systematic review revealed that safety of the procedure challenged originated from a single report, while no clinical adverse event related to MiECC was identified. CONCLUSIONS Use of modular MiECC secures safety and ensures technical feasibility in all cardiac surgical procedures. It represents a type III active closed system, while its stand-by component is reserved for a small (<5%) proportion of procedures and for a partial procedural time. Thus, it eliminates any safety concern regarding air handling and volume management, while it overcomes any unexpected intraoperative scenario.
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Affiliation(s)
- Kyriakos Anastasiadis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Christos Asteriou
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Apostolos Deliopoulos
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Helena Argiriadou
- Cardiothoracic Department, School of Medicine, Aristotle University of Thessaloniki, Thessaloniki, Greece
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Anastasiadis K, Antonitsis P, Deliopoulos A, Argiriadou H. From less invasive to minimal invasive extracorporeal circulation. J Thorac Dis 2021; 13:1909-1921. [PMID: 33841979 PMCID: PMC8024827 DOI: 10.21037/jtd-20-1830] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
Development of minimally invasive cardiac surgery (MICS) served the purpose of performing surgery while avoiding the surgical stress triggered by a full median sternotomy. Minimizing surgical trauma is associated with improved cosmesis and enhanced recovery leading to reduced morbidity. However, it has to be primarily appreciated that the extracorporeal circulation (ECC) stands for the basis of nearly all MICS procedures. With some fundamental modification and advancement in perfusion techniques, the use of ECC has become the enabling technology for the development of MICS. Less invasive cardiopulmonary bypass (CPB) techniques are based on remote cannulation and optimization of perfusion techniques with assisted venous drainage and use of centrifugal pump, so as to facilitate the demanding surgical maneuvers, rather than minimizing the invasiveness of the CPB. This is reflected in the increased duration of CPB required for MICS procedures. Minimal invasive Extracorporeal Circulation (MiECC) represents a major breakthrough in perfusion. It integrates all contemporary technological advancements that facilitate best applying cardiovascular physiology to intraoperative perfusion. Consequently, MiECC use translates to improved end-organ protection and clinical outcome, as evidenced in multiple clinical trials and meta-analyses. MICS performed with MiECC provides the basis for developing a multidisciplinary intraoperative strategy towards a "more physiologic" cardiac surgery by combining small surgical trauma with minimum body's physiology derangement. Integration of MiECC can advance MICS from non-full sternotomy for selected patients to a "more physiologic" surgery, which represents the real face of modern cardiac surgery in the transcatheter era.
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Affiliation(s)
| | | | | | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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10
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Argiriadou H, Antonitsis P, Gkiouliava A, Papapostolou E, Deliopoulos A, Anastasiadis K. Minimal invasive extracorporeal circulation preserves coagulation integrity. Perfusion 2021; 37:257-265. [PMID: 33637025 DOI: 10.1177/0267659121998544] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Coagulopathy after cardiac surgery is a serious multifactorial complication that results in postoperative bleeding requiring transfusion of red blood cells and procoagulant products. Use of cardiopulmonary bypass represents the major contributing factor affecting coagulation. We sought to prospectively investigate the effect of contemporary minimal invasive extracorporeal circulation (MiECC) on coagulation parameters using point-of-care (POC) rotational thromboelastometry and the relation to postoperative bleeding. METHODS Patients undergoing elective cardiac surgery on MiECC were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level-guided protamine titration. Rotational thromboelastometry testing was performed before induction of anesthesia and after aortic cross-clamp release. A strict POC-guided transfusion protocol was implemented. The primary endpoint was the assessment of viscoelastic properties of the coagulating blood at the end of surgery compared to preoperative values and the relation to postoperative bleeding and 24-hour transfusion requirements. RESULTS Fifty patients were included in the study with a significant proportion having complex surgery. Thirteen patients (26%) required blood transfusion (mean rate: 0.5 ± 1 units per patient), 5/50 (10%) received coagulation factors while no patient received fresh frozen plasma, platelets or fibrinogen. Thromboelastometry analysis showed that the major derangement was CT EXTEM > 100 seconds in 28/50 (56%) and A10 EXTEM < 40 mm in one (2%) patient without clinical significance. Platelet function was preserved throughout surgery. A10-FIBTEM was found predictive of postoperative bleeding at 12 hours. CONCLUSIONS MiECC preserves clot quality throughout surgery acting in both key determinants of clot strength; fibrinogen and platelets. This is clinically translated into minimal postoperative bleeding and restricted use of blood products and coagulation factors.
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Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Anna Gkiouliava
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Evangelia Papapostolou
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Apostolos Deliopoulos
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
| | - Kyriakos Anastasiadis
- Cardiothoracic Department, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, Greece
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Conventional versus minimally invasive extracorporeal circulation in patients undergoing cardiac surgery: protocol for a randomised controlled trial (COMICS). Perfusion 2020; 36:388-394. [PMID: 32781894 PMCID: PMC8167910 DOI: 10.1177/0267659120946731] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
Introduction: Despite low mortality, cardiac surgery patients may experience serious life-threatening post-operative complications, often due to extracorporeal circulation and reperfusion. Miniaturised cardiopulmonary bypass (minimally invasive extracorporeal circulation) has been developed aiming to reduce the risk of post-operative complications arising with conventional extracorporeal circulation. Methods: The COMICS trial is a multi-centre, international, two-group parallel randomised controlled trial testing whether type II, III or IV minimally invasive extracorporeal circulation is effective and cost-effective compared to conventional extracorporeal circulation in patients undergoing elective or urgent coronary artery bypass grafting, aortic valve replacement or coronary artery bypass grafting + aortic valve replacement. Randomisation (1:1 ratio) is concealed and stratified by centre and surgical procedure. The primary outcome is a composite of 12 serious complications, objectively defined or adjudicated, 30 days after surgery. Secondary outcomes (at 30 days) include other serious adverse events (primary safety outcome), use of blood products, length of intensive care and hospital stay and generic health status (also at 90 days). Status of the trial: Two centres started recruiting on 08 May 2018; 10 are currently recruiting and 603 patients have been randomised (11 May 2020). The recruitment rate from 01 April 2019 to 31 March 2020 was 40-50 patients/month. About 80% have had coronary artery bypass grafting only. Adherence to allocation is good. Conclusions: The trial is feasible but criteria for progressing to a full trial were not met on time. The Trial Steering and Data Monitoring Committees have recommended that the trial should currently continue.
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12
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Ellam S, Hartikainen J, Korvenoja P, Pitkänen O, Tyrväinen E, Valtola A, Halonen J. Impact of minimal invasive extracorporeal circulation on atrial fibrillation after coronary artery bypass surgery. Artif Organs 2020; 44:1176-1183. [PMID: 32557731 DOI: 10.1111/aor.13756] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/14/2020] [Revised: 06/02/2020] [Accepted: 06/05/2020] [Indexed: 01/04/2023]
Abstract
Postoperative atrial fibrillation (POAF) is the most common arrhythmia after cardiac surgery with an incidence between 15% and 50% and pathophysiology not fully known. By choosing the method of extracorporeal circulation with focus on the reduction of systemic inflammatory response, one can potentially decrease the risk of POAF. In this prospective, randomized trial, we compared minimal invasive extracorporeal circulation (MiECC) with conventional extracorporeal circulation (CECC) in the prevention of POAF after coronary artery bypass surgery (CABG). A total of 240 patients who were scheduled for their first on-pump CABG, were randomized to MiECC or CECC. The primary outcome measure was the incidence of first POAF during the first 84 hours after surgery. POAF occurred in 42/120 (35.0%) MiECC patients and 43/120 (35.8%) CECC patients with nonsignificant difference between the groups (OR 1.043, 95% CI 0.591-1.843, P = .884). The first postoperative creatine kinase-MB mass (CK-MBm) value was lower in the MiECC group, 13.95 [10.5-16.7] (median [IQR]) than in the CECC group, 15.30 [11.4-18.9] (P = .036), whereas the use of perioperative dobutamine was higher in the MiECC group, 18/120 (15.0%), than in the CECC group 8/120 (6.7%) (P = .038). The incidence of a stroke, perioperative myocardial infarction, and resternotomy caused by bleeding did not differ in the MiECC and CECC groups. Age (OR 1.08, 95% CI 1.04-1.13, P = .000) and peak postoperative CK-MBm (OR 1.57, 95% CI 1.06-2.37, P = .026) were independent predictors of POAF. MiECC compared to CECC was not effective in reducing the incidence of POAF in patients undergoing CABG.
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Affiliation(s)
- Sten Ellam
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Pekka Korvenoja
- Acute Care, South Karelia Central Hospital, Lappeenranta, Finland
| | - Otto Pitkänen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Esko Tyrväinen
- Department of Anesthesiology and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Antti Valtola
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jari Halonen
- Heart Center, Kuopio University Hospital, and School of Medicine, University of Eastern Finland, Kuopio, Finland
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El-Essawi A, Follis M, Brouwer R, Breitenbach I, Groeger S, Anssar M, Harringer W. Is aortic valve replacement with a minimally invasive extracorporeal circuit a contemporary option for octogenarians? Interact Cardiovasc Thorac Surg 2020; 31:56-62. [DOI: 10.1093/icvts/ivaa066] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2019] [Revised: 03/08/2020] [Accepted: 03/15/2020] [Indexed: 01/19/2023] Open
Abstract
Abstract
OBJECTIVES
Minimally invasive extracorporeal circuits have been introduced to cardiac surgery in an attempt to reduce the negative effects of cardiopulmonary bypass on patient outcome. On the other hand, transcatheter aortic valve replacement (TAVR) provides an excellent option to replace the aortic valve without the need for cardiopulmonary bypass. Several studies have compared TAVR to surgical aortic valve replacement (SAVR) but none have utilized a minimally invasive extracorporeal circuit.
METHODS
We retrospectively analysed the results of both procedures among octogenarians operated in our department from 2003 to 2016. Excluded were patients with an active endocarditis, a history of previous cardiac surgery, as well as those who had a minimally invasive surgical approach. This yielded 81 and 142 octogenarians in the SAVR and TAVR groups, respectively. To compensate for a lack of randomization, we performed a propensity score analysis, which yielded 68 patient pairs for the final analysis.
RESULTS
The 30-day postoperative mortality was lower in the SAVR group (1.5% vs 5.9%) but not statistically significant (P = 0.4). In contrast, the incidence of postoperative atrial fibrillation was lower in the TAVR group (13% vs 29%) but also non-significant (P = 0.2). Finally, the incidence of paravalvular leakage was in favour of the SAVR group (2.9% vs 52%; P = 0.001) while the transfusion requirement was significantly lower in the TAVR group (29% vs 72%; P < 0.001).
CONCLUSIONS
SAVR utilizing a minimally invasive extracorporeal circuit improves the quality of patient care and can offer an alternative to TAVR in octogenarians.
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Affiliation(s)
- Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Marco Follis
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - René Brouwer
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Ingo Breitenbach
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Steffen Groeger
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Marcel Anssar
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
| | - Wolfgang Harringer
- Department of Thoracic and Cardiovascular Surgery, Braunschweig Clinic, Braunschweig, Germany
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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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15
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Argiriadou H, Antonitsis P, Gkiouliava A, Papapostolou E, Deliopoulos A, Anastasiadis K. Minimal invasive extracorporeal circulation preserves platelet function after cardiac surgery: a prospective observational study. Perfusion 2019; 35:138-144. [DOI: 10.1177/0267659119866289] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Introduction: Cardiac surgery on conventional cardiopulmonary bypass induces a combination of thrombocytopenia and platelet dysfunction which is strongly related to postoperative bleeding. Minimal invasive extracorporeal circulation has been shown to preserve coagulation integrity, though effect on platelet function remains unclear. We aimed to prospectively investigate perioperative platelet function in a series of patients undergoing cardiac surgery on minimal invasive extracorporeal circulation using point-of-care testing. Methods: A total of 57 patients undergoing elective cardiac surgery on minimal invasive extracorporeal circulation were prospectively recruited. Anticoagulation strategy was based on individualized heparin management and heparin level–guided protamine titration performed in all patients with a specialized point-of-care device (Hemostasis Management System – HMS Plus; Medtronic, Minneapolis, MN, USA). Platelet function was evaluated with impedance aggregometry using the ROTEM platelet (TEM International GmbH, Munich, Germany). ADPtest and TRAPtest values were assessed before surgery and after cardiopulmonary bypass. Results: ADPtest value was preserved during surgery on minimal invasive extracorporeal circulation (58.2 ± 20 U vs. 53.6 ± 21 U; p = 0.1), while TRAPtest was found significantly increased (90 ± 27 U vs. 103 ± 38 U; p = 0.03). Postoperative ADPtest and TRAPtest values were inversely related to postoperative bleeding (correlation coefficient: −0.29; p = 0.03 for ADPtest and correlation coefficient: −0.28; p = 0.04 for TRAPtest). The preoperative use of P2Y12 inhibitors was identified as the only independent predictor of a low postoperative ADPtest value (OR = 15.3; p = 0.02). Conclusion: Cardiac surgery on minimal invasive extracorporeal circulation is a platelet preservation strategy, which contributes to the beneficial effect of minimal invasive extracorporeal circulation in coagulation integrity.
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Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
| | | | - Anna Gkiouliava
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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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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17
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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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18
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Argiriadou H, Antonitsis P, Deliopoulos A, Anastasiadis K. Point-of-care coagulation management during surgery with minimal invasive extracorporeal circulation. J Thorac Dis 2019; 11:S1519-S1524. [PMID: 31293803 PMCID: PMC6586579 DOI: 10.21037/jtd.2019.02.53] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 02/18/2019] [Indexed: 01/08/2023]
Affiliation(s)
- Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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19
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Ellam S, Pitkänen O, Lahtinen P, Musialowicz T, Hippeläinen M, Hartikainen J, Halonen J. Impact of minimal invasive extracorporeal circulation on the need of red blood cell transfusion. Perfusion 2019; 34:605-612. [PMID: 31027452 DOI: 10.1177/0267659119842811] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
OBJECTIVE Minimal invasive extracorporeal circulation may decrease the need of packed red blood cell transfusions and reduce hemodilution during cardiopulmonary bypass. However, more data are needed on the effects of minimal invasive extracorporeal circulation in more complex cardiac procedures. We compared minimal invasive extracorporeal circulation and conventional extracorporeal circulation methods of cardiopulmonary bypass. METHODS A total of 424 patients in the minimal invasive extracorporeal circulation group and 844 patients in the conventional extracorporeal circulation group undergoing coronary artery bypass grafting and more complex cardiac surgery were evaluated. Age, sex, type of surgery, and duration of perfusion were used as matching criteria. Hemoglobin <80 g/L was used as red blood cell transfusion trigger. The primary endpoint was the use of red blood cells during the day of operation and the five postoperative days. Secondary endpoints were hemodilution (hemoglobin drop after the onset of perfusion) and postoperative bleeding from the chest tubes during the first 12 hours after the operation. RESULTS Red blood cell transfusions were needed less often in the minimal invasive extracorporeal circulation group compared to the conventional extracorporeal circulation group (26.4% vs. 33.4%, p = 0.011, odds ratio 0.72, 95% confidence interval 0.55-0.93), especially in coronary artery bypass grafting subgroup (21.3% vs. 35.1%, p < 0.001, odds ratio 0.50, 95% confidence interval 0.35-0.73). Hemoglobin drop after onset of perfusion was also lower in the minimal invasive extracorporeal circulation group than in the conventional extracorporeal circulation group (24.2 ± 8.5% vs. 32.6 ± 12.6%, p < 0.001). Postoperative bleeding from the chest tube did not differ between the groups (p = 0.808). CONCLUSION Minimal invasive extracorporeal circulation reduced the need of red blood cell transfusions and hemoglobin drop when compared to the conventional extracorporeal circulation group. This may have implications when choosing the perfusion method in cardiac surgery.
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Affiliation(s)
- Sten Ellam
- Department of Anesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Otto Pitkänen
- Department of Anesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Pasi Lahtinen
- Department of Anesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Tadeusz Musialowicz
- Department of Anesthesia and Operative Services, Kuopio University Hospital, Kuopio, Finland
| | - Mikko Hippeläinen
- Heart Center, Kuopio University Hospital and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Juha Hartikainen
- Heart Center, Kuopio University Hospital and School of Medicine, University of Eastern Finland, Kuopio, Finland
| | - Jari Halonen
- Heart Center, Kuopio University Hospital and School of Medicine, University of Eastern Finland, Kuopio, Finland
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20
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Pasechnik IN, Dvoryanchikova VA, Tsepenshchikov VA. [Extracorporeal circulation in cardiac surgery: state of the problem]. Khirurgiia (Mosk) 2017. [PMID: 28638019 DOI: 10.17116/hirurgia2017672-78] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Affiliation(s)
- I N Pasechnik
- Central State Medical Academy of the Presidential Administration of the Russian Federation, Moscow
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21
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Modular minimal invasive extracorporeal circuits: another step toward universal applicability? Perfusion 2017; 32:598-605. [DOI: 10.1177/0267659117712404] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Introduction: Safety concerns have been one of the main reasons opposing a wider acceptance of minimal invasive extracorporeal circuits (MiECC). Following an extensive experience and a multitude of modifications, we have set out to employ a modular MiECC as a universal extracorporeal circuit. Methods: A total of 129 cardiac surgical procedures were performed by a single surgeon in 2013. Excluding procedures done under circulatory arrest or with the potential need of such, the MiECC was utilized in almost 90% of surgeries. Of sixty-two (simple procedures) patients who underwent coronary artery bypass grafting (CABG), aortic valve replacement (AVR) or CABG + AVR, 82% were non-elective, 10% had a left ventricular ejection fraction (EF) <30% and most had an impaired renal function. Thirty-eight patients had more complex surgeries (complex procedures), 37% of which were urgent, 15% had an EF <30% and the majority had renal dysfunction. Results: The 30-day mortality was 5% in simple procedures and 2.5% in complex procedures. The incidence of postoperative atrial fibrillation was 13% and 16%, respectively. Optimum outcome was defined as a freedom from all complications and blood transfusions and was achieved in 52% and 42%, respectively. Conclusions: This report shows that modular MiECC can be employed with a high safety margin in cardiac surgery. Furthermore, it emphasizes the impact that minimal invasive philosophy could have in improving patient care.
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Anastasiadis K, Antonitsis P, Deliopoulos A, Argiriadou H. A multidisciplinary perioperative strategy for attaining "more physiologic" cardiac surgery. Perfusion 2017; 32:446-453. [PMID: 28692337 DOI: 10.1177/0267659117700488] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
BACKGROUND Cardiac surgery is, by definition, a "non-physiologic" intervention associated with systemic adverse effects. Despite advances in surgical technique, cardiopulmonary bypass (CPB) technology as well as anaesthesia management and patient care, there is still significant morbidity and subsequent mortality. AIM We consider that the contemporary demand for further improving patient outcome mandates the upgrade from optimal perfusion during the procedure as the gold standard to the concept of a "more physiologic" cardiac surgery. Our policy is a multidisciplinary perioperative strategy based on goal-directed perfusion throughout surgery incorporating in-line monitoring. This translates to "prevent rather than correct" malperfusion through real-time adjustment rather than correction of derangement detected late by incremental evaluation. METHOD The strategy is based on continuous monitoring of cardiac index, SvO2, DO2i, DO2i/VCO2i and rSO2. Data acquisition is followed by action when needed; this includes stepwise: transfusion, increase of cardiac output and initiation of inotropic/vasoactive support. Moreover, implementation of minimally invasive extracorporeal circulation (MiECC) is considered as a fundamental component of physiologic perfusion when on-CPB, providing improved circulatory support and end-organ protection. CONCLUSION We consider that, with this strategy which establishes optimal perfusion perioperatively, we attain the goal of a "more physiologic" cardiac surgery.
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Affiliation(s)
| | | | | | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
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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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Quantification of Operational Learning in Minimal Invasive Extracorporeal Circulation. Artif Organs 2016; 41:628-636. [DOI: 10.1111/aor.12813] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Revised: 06/17/2016] [Accepted: 06/30/2016] [Indexed: 12/15/2022]
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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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26
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Anastasiadis K, Murkin J, Antonitsis P, Bauer A, Ranucci M, Gygax E, Schaarschmidt J, Fromes Y, Philipp A, Eberle B, Punjabi P, Argiriadou H, Kadner A, Jenni H, Albrecht G, van Boven W, Liebold A, de Somer F, Hausmann H, Deliopoulos A, El-Essawi A, Mazzei V, Biancari F, Fernandez A, Weerwind P, Puehler T, Serrick C, Waanders F, Gunaydin S, Ohri S, Gummert J, Angelini G, Falk V, Carrel T. Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS). Interact Cardiovasc Thorac Surg 2016; 22:647-62. [PMID: 26819269 DOI: 10.1093/icvts/ivv380] [Citation(s) in RCA: 106] [Impact Index Per Article: 13.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/11/2015] [Accepted: 11/25/2015] [Indexed: 12/11/2022] Open
Abstract
Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.
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Affiliation(s)
| | - John Murkin
- Department of Anesthesiology and Perioperative Medicine, University of Western Ontario, London, Canada
| | | | - Adrian Bauer
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Marco Ranucci
- Department of Anaesthesia and Intensive Care, Policlinico S. Donato, Milan, Italy
| | - Erich Gygax
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Jan Schaarschmidt
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | - Yves Fromes
- University Pierre and Marie Curie (Paris 06), Paris, France
| | | | - Balthasar Eberle
- Department of Anesthesiology and Pain Therapy, University of Bern, Bern, Switzerland
| | - Prakash Punjabi
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK
| | - Helena Argiriadou
- Cardiothoracic Department, AHEPA University Hospital, Thessaloniki, Greece
| | - Alexander Kadner
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Hansjoerg Jenni
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
| | - Guenter Albrecht
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | - Wim van Boven
- Department of Cardiothoracic Surgery, Amsterdam Medical Center, Amsterdam, Netherlands
| | - Andreas Liebold
- Department of Cardiothoracic and Vascular Surgery, Ulm University, Ulm, Germany
| | | | - Harald Hausmann
- Department of Cardiothoracic Surgery, MediClin Heart Centre Coswig, Coswig, Germany
| | | | - Aschraf El-Essawi
- Department of Thoracic and Cardiovascular Surgery, Braunschweig, Germany
| | - Valerio Mazzei
- Department of Adult Cardiac Surgery, Mater Dei Hospital, Bari, Italy
| | - Fausto Biancari
- Department of Cardiac Surgery, Oulu University Hospital, Oulu, Finland
| | - Adam Fernandez
- Department of Surgery, Sidra Medical & Research Centre, Doha, Qatar
| | - Patrick Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Centre, Maastricht, Netherlands
| | - Thomas Puehler
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | | | | | - Serdar Gunaydin
- Department of Cardiovascular Surgery, Medline Hospitals, Adana, Turkey
| | - Sunil Ohri
- Department of Cardiothoracic Surgery, Wessex Cardiac Centre, University Hospital Southampton, Hampshire, UK
| | - Jan Gummert
- Department of Thoracic and Cardiovascular Surgery, University Hospital of the Rhine University Bochum, Bad Oeynhausen, Germany
| | - Gianni Angelini
- Department of Cardiothoracic Surgery, Hammersmith Hospital, London, UK Department of Cardiac Surgery, Bristol Heart Institute, Bristol, UK
| | - Volkmar Falk
- Department of Cardiothoracic Surgery, German Heart Centre, Berlin, Germany
| | - Thierry Carrel
- Department of Cardiovascular Surgery, University of Bern, Bern, Switzerland
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27
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Affiliation(s)
- Kyriakos Anastasiadis
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
| | - Polychronis Antonitsis
- Cardiothoracic Department, Aristotle University of Thessaloniki, AHEPA University Hospital, Thessaloniki, Greece
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