Cardiopulmonary Bypass Research Articles

Haemodynamic monitoring after paediatric cardiac surgery using echocardiography and PiCCO.

Haemodynamic instability is common after surgical repair of CHDs in infants and children. Monitoring cardiac output in addition to traditional circulation parameters could improve the postoperative care of these patients. Echocardiography and transpulmonary thermodilution are the two most common methods for measuring cardiac output in infants. To compare the results of cardiac output measurements using echocardiography and a transpulmonary thermodilution setup after paediatric cardiac surgery. Forty children, scheduled for elective repair of a ventricular septal defect or of an atrio-ventricular septal defect using cardiopulmonary bypass, were enrolled in this prospective, observational study. Cardiac output was simultaneously measured using echocardiography and a commercially available transpulmonary thermodilution method (PiCCO™) at 18 h after the end of surgery. At 18 h after surgery, PiCCO™ gave a mean of 3.0% higher cardiac output than echocardiography. This difference was not statistically significant. 95% of the observations fell within -50.0 to 82.6%. The methods were found to have a good agreement on average, with no statistically significant difference between them. However, the spread of the results was large. It is questionable whether the methods can be used interchangeably in clinical practice.

Platelet-sparing properties of aprotinin

BACKGROUND Cardiac surgery involving cardiopulmonary bypass (CPB) is associated with the risk of acquired coagulopathy, including dysregulated fibrinolysis, which can result in life-threatening bleeding complications. Aprotinin, an antifibrinolytic agent, has been recommended for the prevention of these complications. Its effectiveness has been attributed to its ability to nonspecifically inhibit various serine proteases involved in the coagulation and fibrinolysis cascade. Additionally, aprotinin may protect platelets from CPB-induced dysfunction through a platelet-sparing effect, further enhancing its efficacy. OBJECTIVES The biochemical pathways underlying aprotinin's platelet-sparing effect remain unclear. Furthermore, it is uncertain to what extent this effect contributes to reducing blood loss and need for transfusion. DESIGN A scoping review DATA SOURCES MEDLINE, Embase and Cochrane were searched from inception until 21 December 2023. ELIGIBILITY CRITERIA Studies in which a platelet-sparing effect of aprotinin was investigated. These included systematic reviews; experimental, and observational studies describing healthy humans, patients, or animals undergoing any type of surgery; studies in which donated blood was used for in-vitro studies. RESULTS Sixty-four studies were deemed eligible, the majority of which observed a platelet-sparing effect, attributing it to the inhibition of platelet aggregation (via protection of glycoprotein (GP) IIb/IIIa receptors), platelet adhesion (by protection of GP Ib receptors), both aggregation and adhesion receptors, proteolysis of protease-activated receptor 1 receptors, platelet activation (by inhibition of plasmin) and platelet activation (by inhibition of thrombin). A dose-dependency of the platelet-sparing effect was investigated in both in-vitro studies and randomised controlled trials, yielding mixed results. No studies have explored the relative contribution of aprotinin's platelet-sparing effect and its antifibrinolytic effect in reducing blood loss and need for transfusion. CONCLUSIONS This review elucidated current knowledge on how aprotinin influences platelets and exerts its platelet-sparing effect, while highlighting gaps in the existing literature.

Clinical Assessment of the Utility of Pulsatile Over Nonpulsatile Flow for Neonatal and Pediatric Cardiopulmonary Bypass Procedures Using Multidisciplinary Translational Research at a Tertiary Care Center.

Clinical Assessment of the Utility of Pulsatile Over Nonpulsatile Flow for Neonatal and Pediatric Cardiopulmonary Bypass Procedures Using Multidisciplinary Translational Research at a Tertiary Care Center.

Surgical Closure of Multiple Muscular Ventricular Septal Defects in Children Using 3D-Printed Models.

Multiple muscular ventricular septal defects (VSDs) are often difficult to visualize and access surgically. The main challenge is identifying all defects intraoperatively, without which residual defects are inevitable. Patient-specific three-dimensional (3D) printed models can help accurately demonstrate intracardiac anatomy. We present our experience using this technology to surgically close multiple muscular VSDs . Data of all patients with multiple VSDs in whom a 3D-printed model was used to aid surgical planning between September 2021 and July 2023 was collected retrospectively. Our approach involved generating a 3D model from a preoperative computerized tomography scan for each patient, which was then used to precisely identify the location of the multiple VSDs and plan surgical intervention. Six patients underwent closure of multiple VSDs using a 3D model. The mean age at surgery was 3.5 years (SD ± 2.8 years). Five (83.3%) patients had previously undergone pulmonary artery banding. The VSDs were approached through the right atrium in three (50%) and the right ventricle in three (50%) patients. Mean cardiopulmonary bypass and myocardial ischemia times were 185.2 min (SD ± 94.8 min) and 147.5 min (SD ± 86 min), respectively. There was no postoperative heart block or a hemodynamically significant residual VSD. All six patients had normal biventricular function at a median follow-up duration of 1.7 months (interquartile range: 1.2-7.4 months). 3D printing to aid closure of multiple VSDs is safe, reliable, and reproducible. We recommend adding 3D printing to surgeons' armamentarium when faced with the challenge of closing multiple muscular VSDs in children.

Early arrhythmia after cardiac surgery in children with congenital heart disease

Objective. To analyze the frequency and risk factors for arrhythmia in children with congenital heart disease in the early period after cardiac surgery. Materials and methods. A retrospective analysis of the incidence and risk factors for arrhythmia in 285 children who underwent cardiac surgery in the Department of Surgical Treatment of Congenital Heart Diseases in Newborns and Young Children at the Amosov National Institute of Cardiovascular Surgery of the National Academy of Medical Sciences of Ukraine for the period from 2021 to 2023 was performed. There were 202 children under the age of 18. Results. In the early postoperative period, heart rhythm disturbances occurred in 53 (26.2%) of 202 patients: 28 had supraventricular tachycardia, 16 had bradyarrhythmia (atrioventricular block), 6 had ventricular tachycardia, and 3 had nodal ectopic tachycardia. It was found that plastic surgery of the interventricular and atrial septal defect in isolation or in combination with interventions for other defects (Fallot's tetrad, transposition of the great vessels, atrioventricular communication) and bidirectional and total cavopulmonary anastomoses are associated with a high risk of arrhythmia. Statistically significant (p < 0.05) risk factors for arrhythmia were: lactate level of more than 2 mmol/L, duration of cardiopulmonary bypass more than 185 minutes, duration of aortic clamping more than 67 minutes. Conclusions. Arrhythmia often complicates the course of the early period after cardiac surgery in children and requires timely and correct action. Prolonged cardiopulmonary bypass, aortic constriction, and lactatidosis are risk factors for arrhythmia. Plastic surgery of the interventricular and atrial septal defects, as well as palliative reconstructive heart surgery, are associated with frequent cardiac arrhythmias in the early postoperative period.

Methylprednisolone for acute type A aortic dissection patients undergoing total arch replacement: Design and rationale of the Medal trial

BackgroundThe mortality and morbidity of emergency total aortic arch replacement (TAAR) for acute type A aortic dissection (ATAAD) is high, which is partly due to the excessively activated systemic inflammatory response. Methylprednisolone, an anti-inflammatory agent, might suppress the systemic inflammatory response and lead to improved outcomes. However, the protective effects of methylprednisolone on TAAR for ATAAD were not clarified. The usage and dosage varied in different centers across the world. Methods and resultsThe Medal trial is a prospective, multicenter, randomized, double-blind, placebo-controlled, parallel-group trial to evaluate whether 500 mg methylprednisolone IV before cardiopulmonary bypass could reduce the incidence of postoperative major organ injury, compared to placebo. Adult patients with the diagnosis with ATAAD, awaiting emergency total aortic arch replacement with hypothermic circulatory arrest and selective cerebral perfusion will be included in the trial. A total of 340 eligible subjects from nine large cardiovascular centers will be randomized in a 1:1 ratio to recieve 500mg methylprednislone or placebo before cardiopulmonary bypass. The primary outcome is postoperative major adverse outcome [defined as all-cause death or postoperative neurological deficit or KDIGO II -III acute kidney injury or respiratory syndrome (tracheal intubation> 72 hours, tracheostomy or re-intubation) until postoperative day 30 or patient discharge]. The study has received approval from the local Ethics Committees of the nine participating centers, and enrolled its first subject in June 24, 2022. As of September 5,2024, 323 subjects have been enrolled. Results of the Medal trial will be published once data collection and analysis have been completed. ConclusionsThe Medal trial will determine the effectiveness of 500 mg methylprednisolone on the outcomes of patients with ATAAD undergoing TAAR. RegistrationURL https://www.chictr.org.cn/searchprojEN.html (Chinese Clinical Trial Registry). Unique identifier: ChiCTR2200059286

Impact of Intraoperative Blood Transfusion on Cerebral Injury in Pediatric Patients Undergoing Congenital Septal Heart Defect Surgery

Background: The components of donor blood themselves have the potential to initiate a systemic inflammatory response and exacerbate neuroinflammation, resulting in subsequent cerebral injury. The aim of this study was to establish the role of transfusion in the development of cerebral injury during the correction of congenital heart defects in children. Material and Methods: A total of 78 patients aged from 1 to 78 months, with body weights ranging from 3.3 to 21.5 kg, were investigated. Biomarkers of cerebral injury and systemic inflammatory response were studied at three time points. First: prior to the surgical intervention. Second: after the completion of cardiopulmonary bypass. Third: 16 h after the conclusion of the surgery. Results: The strongest correlation was found for S-100-β protein with the volume of transfusion at the second (Rho = 0.48, p = 0.00065) and third time points (Rho = 0.36, p = 0.01330). Neuron-specific enolase demonstrated a similar trend: Rho = 0.41 and p = 0.00421 after the completion of cardiopulmonary bypass. Conclusions: The use of red blood cell suspension and its dosage per kilogram of body weight correlated with the biomarkers of cerebral injury and systemic inflammatory response with moderate to significant strength.

Therapeutic results of three-dimensional aortic valve anatomic repair for regurgitant bicuspid aortic valve

Objective: To explore the surgical technique and results of three-dimensional aortic valve anatomic repair for bicuspid aortic valve (BAV) with aortic regurgitation (AR). Methods: This is a retrospective case series study. From August 2021 to December 2023, 130 consecutive patients with BAV-AR underwent aortic valve anatomic repair at the Department of Cardiothoracic Surgery, Zhongshan Hospital, Fudan University,and the data were retrospectively analyzed. There were 115 males and 15 females, aged (38.6±11.7) years (range: 15 to 67 years). All patients received modified aortic root reconstruction, to do three-dimensional root remodeling, including the basal ring, sinus of Valsalva and sino-tubular junction simultaneously. Perioperative and follow-up data were collected and analyzed. Comparisons between groups were performed using independent samples t-test, Wilcoxon paired signed-rank test, or χ² test. Results: No patient transferred to valve replacement during the operation. The cardiopulmonary bypass time (M(IQR)) was 109 (34) minutes (range:67 to 247 minutes), and the aortic cross-clamp time was 76 (26) minutes (range: 32 to 158 minutes). Preoperative transesophageal echocardiography showed 123 patients (94.6%) presented with moderate or severe regurgitation. Immediately postoperative transesophageal echocardiography showed no regurgitation in 22 patients (16.9%), trace regurgitation in 81 patients (62.3%) and mild regurgitation in 27 patients (20.8%). Follow up was complete in all patients, with a follow-up of 5.5 (9.4) months (range: 0.1 to 27.6 months). No mortality was observed during follow-up. Echocardiography was obtained in 112 patients at the latest follow-up, including no regurgitation in 4 patients (3.6%), trace regurgitation in 58 patients (51.8%), mild regurgitation in 45 patients (40.2%), moderate regurgitation in 4 patients (3.6%), and severe regurgitation in 1 patient (0.9%). Conclusion: For patients with BAV-AR who have good valve quality and no severe aortic sinus dilation, the recent outcomes of three-dimensional anatomical repair technique, focusing on overall remodeling of the aortic root, are satisfactory.

Evaluation of FiO2 Adjustment Habits of Perfusionists in Turkey During Cardiopulmonary Bypass

Evaluation of FiO2 Adjustment Habits of Perfusionists in Turkey During Cardiopulmonary Bypass

Outcomes of the Modified Warden Procedure for Partial Anomalous Pulmonary Venous Connection Drainage to a High Location in the Superior Vena Cava

To report the safety and effectiveness of a modified Warden procedure. Twenty-six (26) patients underwent modified Warden surgery at our centre from September 2017 to September 2021. In all patients, the superior vena cava (SVC) was reconstructed by turning the atrial wall in the main body of the right atrium upwards and applying fresh autologous pericardial patches. There were 13 male patients and 13 female patients, and the median age of the patients was 7.0 (range, 0.3-47.0) years. The median follow-up time after surgery was 47.0 (range, 32.0-80.0) months. The aortic cross-clamp time was 108.50±34.72 minutes, the cardiopulmonary bypass time was 154.81±41.65 minutes, the median postoperative mechanical ventilation time was 8.5 (range, 0.0-91.0) hours, the median intensive care unit stay was 43.5 (range, 15.0-352.0) hours, and the median length of postoperative hospital stay was 7.0 (range, 6.0-19.0) days. All patients were safely and successfully discharged from the hospital. No deaths or sinus node dysfunction occurred during the follow-up period. The mean gradient of the reconstructed SVC and/or the right pulmonary vein (PV) increased in eight patients and decreased to less than 1 mmHg in six patients. One (1) adult patient had already undergone two vascular interventions, and one child had persistent stenosis but did not undergo reoperation at the time of the study. In addition, two patients were subjected to pericardial windowing. A modified Warden technique using a right atrial flap and autologous pericardium effectively corrected the high-plane connection between the PVs and SVC. This technique effectively avoids sinus node dysfunction; however, a short-term increase in the differential pressure of the re-established SVC or PV after the procedure is acceptable, and reintervention is required only in rare cases.

Prediction of Successful Liberation from Continuous Renal Replacement Therapy Using a Novel Biomarker in Patients with Acute Kidney Injury after Cardiac Surgery-An Observational Trial.

An acute kidney injury (AKI) is the most common complication following cardiac surgery, and can lead to the initiation of continuous renal replacement therapy (CRRT). However, there is still insufficient evidence for when patients should be liberated from CRRT. Proenkephalin A 119-159 (PENK) is a novel biomarker that reflects kidney function independently of other factors. This study investigated whether PENK could guide successful liberation from CRRT. Therefore, we performed a prospective, observational, single-center study at the Medical University of Vienna between July 2022 and May 2023, which included adult patients who underwent cardiac surgery for a cardiopulmonary bypass; patients on preoperative RRT were excluded. The PENK levels were measured at the time of AKI diagnosis and at the initiation of and liberation from CRRT, and were subsequently compared to determine whether the patients were successfully liberated from CRRT. We screened 61 patients with postoperative AKI; 20 patients experienced a progression of AKI requiring CRRT. The patients who were successfully liberated from CRRT had mean PENK levels of 113 ± 95.4 pmol/L, while the patients who were unsuccessfully liberated from CRRT had mean PENK levels of 290 ± 175 pmol/L (p = 0.018). For the prediction of the successful liberation from CRRT, we found an area under the curve of 0.798 (95% CI, 0.599-0.997) with an optimal threshold value of 126.7 pmol/L for PENK (Youden Index = 0.53, 95% CI, 0.10-0.76) at the time of CRRT liberation (sensitivity = 0.64, specificity = 0.89). In conclusion, PENK is a novel biomarker that has the potential to predict the successful liberation from CRRT for patients with AKI after cardiac surgery.

The Crucial Triad: Endothelial Glycocalyx, Oxidative Stress, and Inflammation in Cardiac Surgery-Exploring the Molecular Connections.

Since its introduction, the number of heart surgeries has risen continuously. It is a high-risk procedure, usually involving cardiopulmonary bypass, which is associated with an inflammatory reaction that can lead to perioperative and postoperative organ dysfunction. The extent of complications following cardiac surgery has been the focus of interest for several years because of their impact on patient outcomes. Recently, numerous scientific efforts have been made to uncover the complex mechanisms of interaction between inflammation, oxidative stress, and endothelial dysfunction that occur after cardiac surgery. Numerous factors, such as surgical and anesthetic techniques, hypervolemia and hypovolemia, hypothermia, and various drugs used during cardiac surgery trigger the development of systemic inflammatory response and the release of oxidative species. They affect the endothelium, especially endothelial glycocalyx (EG), a thin surface endothelial layer responsible for vascular hemostasis, its permeability and the interaction between leukocytes and endothelium. This review highlights the current knowledge of the molecular mechanisms involved in endothelial dysfunction, particularly in the degradation of EG. In addition, the major inflammatory events and oxidative stress responses that occur in cardiac surgery, their interaction with EG, and the clinical implications of these events have been summarized and discussed in detail. A better understanding of the complex molecular mechanisms underlying cardiac surgery, leading to endothelial dysfunction, is needed to improve patient management during and after surgery and to develop effective strategies to prevent adverse outcomes that complicate recovery.

Sanguineous cardiopulmonary bypass prime accelerates the inflammatory response during pediatric cardiac surgery.

The inflammatory response to cardiopulmonary bypass (CPB) in pediatric patients remains an unresolved challenge. Sanguineous CPB prime, composed of allogenic blood products, is one potentially important stimulus. This study aims to identify specific inflammatory mediators active in sanguineous CPB prime and their impact on the inflammatory response at CPB initiation. In a post-hoc analysis of a prospective observational cohort study (NCT05154864), where pediatric patients undergoing cardiac surgery with CPB were enrolled after informed consent, patients were grouped by CPB prime type (sanguineous vs crystalloid). Arterial samples were collected post-sternotomy as a baseline and again at CPB initiation from all patients. In the sanguineous group, CPB prime samples were also collected after buffered ultrafiltration but before CPB initiation. Luminex® measured concentrations of 24 inflammatory mediators for comparison between groups. Statistical analyses were by Mann-Whitney test and Wilcoxon signed-rank test. Data are presented as median [IQR]. Forty consecutive pediatric patients participated. The sanguineous group (n = 26) was younger (4.0 [0.2 - 6.0] vs 48.5 [39.0 - 69.5] months; p = 2.6 × 10-7) and smaller (4.9 [34 - 6.6] vs 17.2 [14.9 - 19.6] kg; p = 2.6 × 10-7) than the crystalloid group (n = 14). Despite this, baseline concentrations of 20 complement and cytokine concentrations were comparable between groups (p > 0.05) while four showed differences between groups (p < 0.05). The sanguineous prime contained supraphysiologic concentrations of complement mediators: C2, C3, C3a, C3b, and C5a. Correspondingly, upon CPB initiation, patients receiving sanguineous prime exhibited a significantly larger burden of C2, C3, C3b, C5, and C5a (p < 0.001) relative to the crystalloid group. Cytokine and chemokine mediators were present at trace levels in the sanguineous prime. Sanguineous prime contains activated complement that accelerates the inflammatory response at CPB initiation in neonates and infants. Immunomodulatory interventions targeting complement during CPB prime preparation could offer substantial benefits for these vulnerable patients.

Extracorporeal Blood Purification and Acute Kidney Injury in Cardiac Surgery

Cardiac surgery-associated acute kidney injury (CSA-AKI) remains a significant problem following cardiopulmonary bypass (CPB). Various strategies are proposed to attenuate CSA-AKI, including extracorporeal blood purification (EBP), but little is known about the effect of EBP through an acrylonitrile-sodium methallylsulfonate/polyethyleneimine membrane during CPB. To determine whether the use of an EBP device in a nonemergent cardiac surgery population reduces CSA-AKI after CPB. This double-blind, randomized clinical trial was conducted in 2 tertiary hospitals in Spain. Patients 18 years or older undergoing nonemergent cardiac surgery who were at high risk for CSA-AKI were enrolled from June 15, 2016, through November 5, 2021, with follow-up data through February 5, 2022. Of 1156 patients assessed, 343 patients were randomized (1:1) to either receive EBP or standard care. Nonselective EBP device connected to the CPB circuit. The primary outcome was the rate of CSA-AKI in the 7 days after randomization. Among 343 patients randomized (169 to receive EBP and 174 to receive usual care), the mean (SD) age was 69 (9) years and 119 were females. The rate of CSA-AKI was 28.4% (95% CI, 21.7%-35.8%) in the EBP group vs 39.7% (95% CI, 32.3%-47.3%) in the standard care group (P = .03), with an adjusted difference of 10.4% (95% CI, 2.3%-18.5%) using a log-binomial model (P = .01). No significant differences (P > .05) were observed in most of the predefined clinical secondary end points or post hoc exploratory end points. In a sensitivity analysis, EBP was found to be more effective in terms of CSA-AKI reduction in patients with chronic kidney disease, diabetes, hypertension, low left ventricular ejection fraction (<40%), and lower body mass index (<30). No differences were observed between the groups in adverse events tracking. The use of a nonselective EBP device connected to the CPB circuit in a nonemergent population of patients undergoing cardiac surgery was associated with a significant reduction of CSA-AKI in the first 7 days after surgery. ClinicalTrials.gov Identifier: NCT02518087.

Efficacy and Safety of Esmolol in Neonatal Cardiac Surgery with Cardiopulmonary Bypass (CPB) for d-Transposition of the Great Arteries (d-TGA).

D-Transposition of the great arteries (d-TGA) is the most common congenital heart disease requiring surgical correction within the neonatal period. Sinus tachycardia often persists postoperatively, potentially affecting cardiac function. This study aimed to investigate the efficacy and safety of the short-acting beta-1-selective beta-blocker esmolol in controlling heart rate in neonatal cardiac surgery with cardiopulmonary bypass (CPB). A retrospective cohort study was conducted on neonates undergoing surgery for d-TGA. The study cohort included 112 patients, divided into an esmolol intervention group (n = 57) and a control group (n = 55). Baseline characteristics, hemodynamic parameters and outcome measures were assessed. In the esmolol group, median heart rate at ICU admission was significantly higher compared to the control group (155 vs. 147bpm, p = 0.018). After a median time of 11h, heart rate was lower among the esmolol patients (135 vs. 144bpm, p < 0.001). There were no differences in other hemodynamic parameters between the two groups. Patients treated with esmolol required longer catecholamine support while no difference regarding survival, duration of invasive ventilation and ICU stay were noticed. No relevant hemodynamic difference was seen between neonates treated with perioperative esmolol and the control group and outcome did not differ. This indicates non-inferiority of perioperative betablocker therapy in young age. Prospective and placebo-controlled assessment of perioperative esmolol therapy in neonates is needed.

Clinical Outcomes in Patients with Phosphate Abnormalities After Cardiac Surgery: A Retrospective Cohort Study.

The clinical significance and incidence of phosphate abnormalities in cardiac surgery have not been investigated extensively. We hypothesize that phosphate abnormalities are associated with a longer time to tracheal extubation. This was a single-center, retrospective cohort study in patients who underwent nontransplant cardiac surgery with cardiopulmonary bypass between August 2009 and December 2020. Serum phosphate levels were measured within 6 hours of arrival to the intensive care unit (ICU). Select clinical outcomes were extracted from an intramural database: time to tracheal extubation, hospital length of stay, and in-hospital mortality. The lactate level within 6 hours of arrival to the ICU was extracted as well. A total of 2659 patients were included. There were 502 (18.9%) patients who were found to be hypophosphatemic (phosphate <2.5 mg/dL), 1905 (71.6%) had normal phosphate levels (phosphate 2.5-4.5 mg/dL), and 252 (9.5%) were hyperphosphatemic (phosphate >4.5 mg/dL). Hyperphosphatemia was associated with 26% longer time to tracheal extubation (incident rate ratio, 1.26, 95% confidence interval [CI], 10%, 44%, P = .001), 37% longer hospital length of stay (acceleration factor = 0.63, 95% CI, -43% to -30%); P < .001), and increased in-hospital mortality (odds ratio, 4.0; 95% CI, 2.3-7.1; P < .001) when compared to patients with normal phosphate levels. These associations were not found for hypophosphatemia. Hyperphosphatemia in the immediate postoperative period after cardiac surgery is associated with adverse clinical outcomes. Future studies will need to investigate if actively correcting the phosphate level has an impact on clinical outcomes.

Totally 3D endoscopic aortic valve replacement: initial results and experience from a single center.

This study aimed to evaluate the feasibility and initial outcomes of totally endoscopic aortic valve replacement (TEAVR) performed via a single working port at the fourth intercostal space (ICS) utilizing a 3D endoscopic system. A retrospective observational study was conducted on 35 consecutive patients who underwent TEAVR over a six-month period from December 2023 to June 2024. Patient selection was based on the presence of isolated aortic valve disease without the need for ascending aorta replacement or aortic root enlargement. A 4 cm single working port was created at the 4th ICS, extending from the right mid-axillary to the anterior axillary line. A 10-mm trocar for a 3D endoscope was placed at the right anterior-axillary line. Peripheral cardiopulmonary bypass (CPB) was established. The primary outcomes investigated included the success rate of the procedure, in-hospital mortality, and perioperative complications. The mean age of the patients was 58.7 ± 12.8 years, with 22.9% being female. The majority of patients (77.1%) presented with aortic stenosis, often accompanied by severe calcification. The medianCPB time was 210 ± 43 min, and the median aortic cross-clamp time was 132 ± 41 min. The procedure was successfully completed in all patients using the endoscopic approach, with no conversions to full sternotomy. Two mortalities were recorded, attributed to postoperative complications including bleeding and cerebral infarctions. The early (30-day) mortality rate was 5.7%. Prolonged mechanical ventilation (>48 h) was required in 17.1% of patients, and reoperation for bleeding was necessary in 2.9% of patients. TEAVR is a feasible procedure with the potential to replace the traditional sternotomy approach for aortic valve replacement.

Factors associated with acute kidney injury after on-pump coronary artery bypass grafting

BackgroundAcute kidney injury (AKI) frequently occurs as a complication of cardiac surgery and cardiopulmonary bypass (CPB). Its prevalence and severity are determined by various preoperative and intraoperative factors. The aim of this study was to examine the risk factors for AKI following on-pump coronary artery bypass grafting (CABG).MethodsA retrospective analysis of clinical records from a single medical center was performed. The primary determinant for AKI analysis was the creatinine-level changes within the first 48 h after surgery. Records of 120 patients from a prospective cohort study were examined.ResultsAn AKI incidence of 26% occurred in the study cohort. The univariate analysis revealed that patients who developed AKI had notably higher EuroSCORE II values (2.00 ± 0.98 vs. 1.49 ± 0.74, p = 0.006) and higher initial levels of urea (7.62 ± 2.94 vs. 6.12 ± 1.71, p = 0.002) and creatinine (0.108 ± 0.039 vs. 0.091 ± 0.016, p = 0.003). Additionally, they exhibited a more frequent occurrence of initial albumin levels below 40 g/l (9 (34.6%) vs. 11 (14.9%) cases, p = 0.030) and a lower initial hemoglobin level (137.8 ± 13.2 g/l vs. 146.6 ± 13.6 g/l, p = 0.005) in comparison to patients without this complication. Moreover, those with AKI had a significantly longer hospital stay duration (14.3 ± 5.45 days vs. 12.6 ± 3.05 days, p = 0.048). Logistic regression indicated one risk factor, oxygen delivery during CPB, that correlated with the onset of AKI in the early postoperative period.ConclusionThe prevalence of AKI was higher among patients with a higher EuroSCORE II, lower preoperative hemoglobin, increased preoperative levels of creatinine and urea, infrequent albumin levels below 40 g/L, diminished oxygen delivery during CPB, and greater need for RBC transfusion and furosemide, but it did not correlate with the duration of CPB.

Comparative outcomes of cardioplegic arrest versus beating heart in pediatric undergoing extracardiac total cavopulmonary connection

BackgroundTotal cavopulmonary connection (TCPC) is a definitive palliative procedure for functionally univentricular congenital heart disease. The study aims to compare the impact of on-pump cardioplegic arrest and on-pump beating heart cardiopulmonary bypass (CPB) on the prognosis of pediatric patients undergoing extracardiac TCPC.MethodsThe medical data of patients (< 18 years) who underwent extracardiac TCPC with CPB between January 2008 and December 2020 in the cardiac surgery center were retrospectively analyzed. Depending on CPB strategies, the patients were assigned to the beating-heart (BH) and cardioplegic arrest (CA) groups. Data including baseline characteristics, intra/postoperative variables, and clinical outcomes were collected for analysis with 1:1 propensity score matching and multivariable stepwise logistic regressions.ResultsFifty-seven matched patient pairs were obtained. No significant difference existed between the two groups in the in-hospital mortality (3.5% vs. 1.8%, P = 1) and one-year survival rate (100% vs. 96.4%, P = 0.484). The BH group had significantly less intraoperative platelet transfusion (10 mL vs. 150 mL, P = 0.019) and blood loss (100 mL vs. 150 mL, P = 0.033) than the CA group. The CA group had significantly higher vasoactive-inotropic scores (P < 0.05) and longer postoperative ICU stays (2.0 d vs. 3.7 d, P = 0.017). No significant difference existed between the two groups in the incidence of postoperative adverse events.ConclusionAlthough both CPB strategies are safe and feasible for extracardiac TCPC, the BH technique would cause less intraoperative platelet transfusion and blood loss, and achieve faster early-term postoperative recovery.

Perioperative assessment of diaphragmatic dysfunction in cardiac surgery patients and its effect on outcome; a prospective observational study

Objectives: While the assessment of the diaphragm in different clinical scenarios is quite frequent, there remains a scarcity of studies focused on assessing diaphragm dysfunction using ultrasound in cardiac surgery patients. We investigated the impact of cardiopulmonary bypass (CPB) surgery on diaphragm function and evaluated its effects on mechanical ventilation. Methodology: A prospective cohort study, on 100 consecutive adult cardiac surgery patients, was conducted at National Heart Institute. Diaphragmatic displacement (DD) or excursion and diaphragmatic thickening fraction (DTF) were measured using motion-mode ultrasound during quite normal breathing pre-operatively (the day before surgery) and post-operatively on mechanical ventilation, while the patient was fully conscious and spontaneously breathing on continuous positive airway pressure (CPAP) mode + pressure support 10 cmH2O. Then, the results were correlated to CBP time and important patient outcomes. Results: Post-operative DD was significantly less as compared to the pre-operative reading; (1.39 ± 0.42 cm vs. 2.3 ± 0.52 cm; P &lt; 0.001), as was DTF (23% ± 10% vs. 40% ± 13%; P &lt; 0.001). The incidence of diaphragmatic dysfunction post-cardiac surgery was 17% by the definition of DD &lt; 1 cm, and 49% by the definition of DTF ≤ 20%. DD was positively correlated with CBP time, as well as total ventilation time and ICU stay, indicating a negative impact on overall patient outcomes. Conclusion: The results suggest that diaphragmatic dysfunction is positively correlated with CPB time, total ventilation time and ICU stay, underscoring the importance of monitoring diaphragmatic function in post-operative patients, who are difficult to wean from mechanical ventilation with apparently normal chest X-ray, particularly those with prolonged CPB time. Keywords: cardiac surgery; cardiopulmonary bypass; diaphragm dysfunction; diaphragmatic displacement; diaphragm ultrasound; mechanical ventilation. Citation: Omara ISM, Nagi HK, Mohamed KAA, Abd El Haq HH, Awdallah FF. Perioperative assessment of diaphragmatic dysfunction in cardiac surgery patients and its effect on outcome; a prospective observational study. Anaesth. pain intensive care 2024;28(5):816−823; DOI: 10.35975/apic.v28i5.2555 Received: June 28, 2024; Reviewed: September 04, 2024; Accepted: September 06, 2024