Cardiothorac Vasc Anesth Research Articles

Simultaneous Use of Two Defibrillators for the Conversion of Refractory Ventricular Fibrillation

T?>HE SIMULTANEOUS use of two defibrillators to deliver higher energy levels for the treatment of refractory arrhythmias is currently not a component of standard advanced cardiac life support (ACLS) guidelines. 1 Field J.M. Hazinski M.F. Sayre M.R. et al. Part 1: Executive summary: 2010 American Heart Association Guidelines for Cardiopulmonary Resuscitation and Emergency Cardiovascular Care. Circulation. 2010; 122: S640-S656 Crossref PubMed Scopus (773) Google Scholar As a result, it is an underappreciated and underutilized therapy, despite case reports and series demonstrating its efficacy and safety in refractory atrial and ventricular arrhythmias. 2 Bjerregaard P. El-Shafei A. Janosik D.L. et al. Double external direct-current shocks for refractory atrial fibrillation. Am J Cardiol. 1999; 83 (A10): 972-974 Abstract Full Text Full Text PDF PubMed Scopus (34) Google Scholar , 3 Chang A.K. Lent G.S. Grinberg D. Double-dose external cardioversion for refractory unstable atrial fibrillation in the ED. Am J Emerg Med. 2008; 26 (e1-e3): 385 Abstract Full Text Full Text PDF PubMed Scopus (6) Google Scholar , 4 Hoch D.H. Batsford W.P. Greenberg S.M. et al. Double sequential external shocks for refractory ventricular fibrillation. J Am Coll Cardiol. 1994; 23: 1141-1145 Abstract Full Text PDF PubMed Scopus (59) Google Scholar , 5 Kabukcu M. Demircioglu F. Yanik E. et al. Simultaneous double external DC shock technique for refractory atrial fibrillation in concomitant heart disease. Jpn Heart J. 2004; 45: 929-936 Crossref PubMed Scopus (18) Google Scholar , 6 Marrouche N.F. Bardy G.H. Frielitz H.J. et al. Quadruple pads approach for external cardioversion of atrial fibrillation. Pacing Clin Electrophysiol. 2001; 24: 1321-1324 Crossref PubMed Scopus (25) Google Scholar , 7 Saliba W. Juratli N. Chung M.K. et al. Higher energy synchronized external direct current cardioversion for refractory atrial fibrillation. J Am Coll Cardiol. 1999; 34: 2031-2034 Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar This brief report describes the utility of double-dose defibrillation in refractory ventricular fibrillation (VF) and further publicizes its efficacy. Erratum to “Simultaneous Use of Two Defibrillators for the Conversion of Refractory Ventricular Fibrillation” J Cardiothorac Vasc Anesth 29(2015):369-378Journal of Cardiothoracic and Vascular AnesthesiaVol. 29Issue 4PreviewIt was discovered that the original online version of the above article contained errors that were not the fault of the author(s). The Publisher decided to ‘resupply’ (repost and replace) the XML and online PDF of the article. Unfortunately the discovery of the errors was too late to correct the printed issue. Full-Text PDF

Perioperative management of antiplatelet therapy

Worldwide, cardiovascular events represent the major cause of morbidity and mortality. A key role in the pathogenesis of these events is played by platelets. Interventional procedures, with placement of coronary and vascular stents, often represent the preferred therapeutic strategy. Antiplatelet medications are considered first-line therapy in preventing cardiovascular thrombotic events. A wide array of antiplatelet agents is available, each with different pharmacological properties. When patients on antiplatelet agents present for surgery, the perioperative team must design an optimal strategy to manage antiplatelet medications. Each patient is stratified according to risk of developing a cardiovascular thrombotic event and inherent risk of surgical bleeding. After risk stratification analysis, various therapeutic pathways include continuing or discontinuing all antiplatelet agents or maintaining one antiplatelet agent and discontinuing the other. This review focuses on the pharmacological and pharmacokinetic properties of both older and novel antiplatelet drugs, and reviews current literature and guidelines addressing options for perioperative antiplatelet management.

CASE 8—2014Anesthetic Management of Bilateral Lung Transplantation From Donor Lungs Managed by the Organ Care System

A 57-YEAR-OLD MAN with medical history significant for end-stage lung disease and pulmonary arterial hypertension secondary to nonspecific interstitial pneumonia and progressive limited systemic sclerosis presented for bilateral lung transplantation. Previous management included mycophenolate, prednisone, treprostinil, and sildenafil. His pretransplant transthoracic echocardiogram revealed a preserved left ventricular ejection fraction of 65% with high estimated right ventricular systolic pressures between 109-116 mmHg. Cardiac catheterization confirmed elevated pulmonary arterial (PA) pressures, 102/40/63 mmHg, with a pulmonary artery occlusion pressure of 11 mmHg and a cardiac index of 2.3 L/min/m2. There was no significant coronary artery disease. The patient was randomized to be transplanted with donor lungs managed by the Organ Care System (OCS) (TransMedics Inc, Andover, MA), the first such transplantation in the United States. Erratum to the August 2014 issue of the Journal of Cardiothoracic and Vascular Anesthesia: J Cardiothorac Vasc Anesth 28(4), 2015Journal of Cardiothoracic and Vascular AnesthesiaVol. 29Issue 4PreviewIt was discovered that the original online version of the issue contained errors in pagination. The Publisher decided to ‘resupply’ (repost and replace) the XML and online PDF of the issue. The print version of the issue contained the correct folios at the time of printing. Full-Text PDF

Noninvasive Ventilation Practice in Cardiac Surgery Patients: Insights From a European Survey

Noninvasive Ventilation Practice in Cardiac Surgery Patients: Insights From a European Survey

Prasugrel-related Late Cardiac Tamponade After Coronary Artery Bypass Surgery in a Patient With a Recently Implanted Bare Metal Stent

1. Patel PA, Lane B, Augoustides JG: Progress in Platelet Blockers: The Target is the P2Y12 Receptor. J Cardiothorac Vasc Anesth 27: 620-624, 2013 2. Hansson EC, Dellborg M, Lepore V, et al: Prevalence, indications and appropriateness of antiplatelet therapy in patients operated for acute aortic dissection: Associations with bleeding complications and mortality. Heart 99:116-121, 2013 3. Gurbel PA, Bliden KP, Butler K, et al: Randomized double-blind assessment of the ONSET and OFFSET of the antiplatelet effects of ticagrelor versus clopidogrel in patients with stable coronary artery disease: The ONSET/OFFSET study. Circulation 120:2577-2585, 2009 4. Held C, Asenblad N, Bassand JP, et al: Ticagrelor versus clopidogrel in patients with acute coronary syndromes undergoing coronary artery bypass surgery: results from the PLATO (Platelet Inhibition and Patient Outcomes) trial. J Am Coll Cardiol 57:672-684, 2011 5. van der Linden J, Lindvall G, Sartipy U: Aprotinin decreases postoperative bleeding and number of transfusions in patients on clopidogrel undergoing coronary artery bypass graft surgery: A double-blind, placebo-controlled, randomized clinical trial. Circulation 112:I276-I280, 2005

Bullet Embolization From the Right Internal Jugular Vein to the Right Ventricle

I read with great interest the case report by Soong et al entitled “Transesophageal Echocardiography in the Management of Right Ventricular Bullet Embolization from the Left Brachiocephalic Vein”.1 We encountered a similar case. A 24-year-old man was transferred to our trauma unit with penetrating injuries. He had gunshot wounds to the posterior aspect of his neck, right shoulder, and right thigh. He was hemodynamically stable, breathing spontaneously, and neurologically intact. X-rays from the referring hospital showed a radioopaque object overlying the cardiac silhouette (Fig 1). Computed tomography (CT), at our institution, of the head and neck showed soft tissue injury of the posterior aspect of the neck, small fragments of radioopaque material scattered from the right scapular tip to around the right carotid sheath, and a hematoma in the right sternocleidomastoid muscle. Chest CT revealed a radioopaque object within the tip of the right ventricle without associated hemothorax or pneumothorax (Fig 2). Transthoracic echocardiography (TTE) and transesophageal echocardiography (TEE) (Fig 3, Fig 4, Fig 5) showed the bullet lodged in the apex of the right ventricle. There was no pericardial effusion, right ventricular wall penetration, or damage to the papillary muscles or tricuspid valve. Cardiovascular surgery opted for conservative management, and he was sent home after an uneventful 6-day stay. He was recovering well one month post-discharge and was lost to further followup.Fig 2CT of the chest.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 3TTE—bright echodensity (1cm x 0.7 cm) in the apex of the right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 4TEE—four-chamber view showing bright echodense structure in the apex of the right ventricle.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Fig 5TEE—transgastric view of the right ventricle showing bright echodense structure.View Large Image Figure ViewerDownload Hi-res image Download (PPT) The best therapeutic approach of a stable patient with a bullet embolized to the heart is controversial. Some authors strongly urge immediate exploration,1Soong W. Beckmann A.K. Lin L. et al.Transesophageal echocardiography in the management of right ventricular bullet embolization from the left brachiocephalic vein.J Cardiothorac Vasc Anesth. 2012; 26: 459-461Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar, 2Howanitz E.P. Murray K.D. Galbraith T.A. et al.Peripheral venous bullet embolization to the heart. Case report and review of the literature.J Vasc Surg. 1988; 8: 55-58Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholar while others advocate conservative management.3Gandhi S.K. Marts B.C. Mistry B.M. et al.Selective management of embolized intracardiac missiles.Ann Thorac Surg. 1996; 62: 290-292Abstract Full Text PDF PubMed Scopus (33) Google Scholar Because the bullet was determined to be lodged in the apex of the right ventricle and not resting freely in the cardiac chamber, we decided to treat our patient conservatively. We believe the management should be individualized to each patient. In conclusion, we agree with Soong et al1Soong W. Beckmann A.K. Lin L. et al.Transesophageal echocardiography in the management of right ventricular bullet embolization from the left brachiocephalic vein.J Cardiothorac Vasc Anesth. 2012; 26: 459-461Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar that echocardiography is a useful imaging modality. It was vital in locating the bullet and defining the extent of cardiac trauma to guide treatment in our case.

The Problems of Using Unreliable Evidence in Consensus Group Decision-Making

Landoni and colleagues report the work of an International Consensus Group and present evidence-based non-surgical recommendations to reduce perioperative mortality.1Landoni G. Rodseth R.N. Santini F. Ponschab M. Ruggeri L. Székely A. et al.Randomized evidence for reduction of perioperative mortality.J Cardiothorac Vasc Anesth. 2012; 26: 764-772Abstract Full Text Full Text PDF PubMed Scopus (84) Google Scholar The International Consensus Group has recommended that aprotinin should not be used in cardiac surgery and cites as evidence the significant increase in mortality associated with aprotinin compared to the lysine analogues that was reported in the BART study.2Fergusson D.A. Hébert P.C. Mazer D. et al.A comparison of aprotinin and lysine analogues in high-risk cardiac surgery.NEJM. 2008; 358: 2319-2331Crossref PubMed Scopus (830) Google Scholar Ultimately, the quality of any recommendation depends on the quality of the evidence upon which it is made, and evidence from the BART study may be unreliable. Health Canada reviewed and re-analyzed the data from the BART study and, subsequently, so did the European Medicines Agency (EMA). Both drug regulatory agencies found concerning limitations to the published results regarding mortality.3Health Canada. Final report – expert advisory panel on Trasylol (aprotinin) 2011. Available from http://www.hc-sc.gc.ca/dhp-mps/medeff/advise-consult/eap-gce_trasylol/final_rep-rap-eng.php (accessed 9 Oct 2012)Google Scholar, 4European Medicines Agency. European Medicines Agency recommends lifting suspension of aprotinin 2012. Available from http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2012/02/WC500122914.pdf (accessed 9 Oct 2012)Google Scholar After randomization, there had been an unexplained exclusion of 137 patients from the statistical analysis.3Health Canada. Final report – expert advisory panel on Trasylol (aprotinin) 2011. Available from http://www.hc-sc.gc.ca/dhp-mps/medeff/advise-consult/eap-gce_trasylol/final_rep-rap-eng.php (accessed 9 Oct 2012)Google Scholar Most importantly, the mortality trend of these excluded patients was opposite to that of the included patients.3Health Canada. Final report – expert advisory panel on Trasylol (aprotinin) 2011. Available from http://www.hc-sc.gc.ca/dhp-mps/medeff/advise-consult/eap-gce_trasylol/final_rep-rap-eng.php (accessed 9 Oct 2012)Google Scholar Reanalysis of the data including these originally excluded patients, reduced the mortality signal for aprotinin to statistically nonsignificant.3Health Canada. Final report – expert advisory panel on Trasylol (aprotinin) 2011. Available from http://www.hc-sc.gc.ca/dhp-mps/medeff/advise-consult/eap-gce_trasylol/final_rep-rap-eng.php (accessed 9 Oct 2012)Google Scholar Furthermore, the findings of the BART study have not been replicated; when data from other RCTs were analysed together with exclusion of data from the BART study, aprotinin was not associated with a higher risk of death compared with other antifibrinolytics.4European Medicines Agency. European Medicines Agency recommends lifting suspension of aprotinin 2012. Available from http://www.ema.europa.eu/docs/en_GB/document_library/Press_release/2012/02/WC500122914.pdf (accessed 9 Oct 2012)Google Scholar Given the major inaccuracies in the published paper that have been identified by Health Canada and the EMA, the International Consensus Group should not have considered the BART study to assess aprotinin as it has perversely influenced their decision making. Consensus groups and any other bodies making recommendations about clinical practice need to ensure that they use evidence of a reliable quality. Reply: Summarizing Randomized Evidence With Clinically Relevant Outcomes Performed in the Perioperative PeriodJournal of Cardiothoracic and Vascular AnesthesiaVol. 27Issue 3PreviewWe thank Drs Alston and McMullan1 for their comments and for the opportunity to better explain some aspects of the innovative2 paper that we recently published in JCVA.3 Full-Text PDF Randomized Evidence for Reduction of Perioperative MortalityJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 5PreviewWith more than 220 million major surgical procedures performed annually, perioperative interventions leading to even minor mortality reductions would save thousands of lives per year. This international consensus conference aimed to identify all nonsurgical interventions that increase or reduce perioperative mortality as suggested by randomized evidence. Full-Text PDF

Quadriplegia After Off-Pump Coronary Artery Bypass Surgery: Look Before You Place the Neck in an Extended Position

Quadriplegia After Off-Pump Coronary Artery Bypass Surgery: Look Before You Place the Neck in an Extended Position

The Vasoactive-Inotropic Score and Levosimendan: Time for LVIS?

Three recent randomized controlled trials1Momeni M. Rubay J. Matta A. et al.Levosimendan in congenital cardiac surgery: A randomized, double-blind clinical trial.J Cardiothorac Vasc Anesth. 2011; 25: 419-424Abstract Full Text Full Text PDF PubMed Scopus (63) Google Scholar, 2Ricci Z. Garisto C. Favia. I et al.Levosimendan infusion in newborns after corrective surgery for congenital heart disease: Randomized controlled trial.Intensive Care Med. 2012; 38: 1198-1204Crossref PubMed Scopus (43) Google Scholar, 3Lechner E. Hofer A. Leitner-Peneder G. et al.Levosimendan versus milrinone in neonates and infants after corrective open-heart surgery: A pilot study.Pediatr Crit Care Med. 2012; ([Epub ahead of print])PubMed Google Scholar evaluated the safety and efficacy of levosimendan in children with congenital heart disease undergoing cardiac surgery. All these papers concluded that levosimendan was safe and contributed to improvement of cardiac function and inotropic support optimization. From these initial experiences following levosimendan use in adult critically ill patients, indications for this drug in the pediatric setting is expected to increase. Recently, Davidson et al4Davidson J. Tong S. Hancock H. et al.Prospective validation of the vasoactive-inotropic score and correlation to short-term outcomes in neonates and infants after cardiothoracic surgery.Intensive Care Med. 2012; 38: 1184-1190Crossref PubMed Scopus (123) Google Scholar prospectively compared the vasoactive-inotropic score (VIS) and inotrope score in infants after cardiovascular surgery, as mathematical measures for evaluating vasoactive drug administration, and, consequently, the hemodynamic condition of patients. At all assessed time points, VIS was shown to be more predictive of poor short-term outcome than inotrope score. Interestingly, the authors observed that from a clinical perspective, a high VIS at 48 hours postoperatively achieved the best performance as a predictor for poor outcome. VIS is calculated as dopamine dose (mcg/kg/min)+dobutamine dose (mcg/kg/min)+100×epinephrine dose (mcg/kg/min)+10×milrinone dose (mcg/kg/min)+10,000×vasopressin dose (U/kg/min)+100×norepinephrine dose (mcg/kg/min). We noticed that levosimendan is not currently included in the VIS calculation. In our opinion, the time has come for a modified version of VIS also including levosimendan input in the formula (levosimendan VIS [LVIS]). It should be mentioned that the hypothetical application of levosimendan to the VIS formula should be prolonged for a week (3 or 4 days after the drug infusion has been stopped, due to its prolonged metabolite activity). We propose to include levosimendan with a factor of 50 (to achieve a contribution to VIS similar to milrinone); milrinone 0.5 to 1 mcg/kg/min has a VIS weight from 5 to 10. Similarly, a levosimendan dose of 0.1 to 0.2 mcg/kg/min would achieve a LVIS formula weight of 5 to 10. We tried to apply this concept to a recent study from our group2Ricci Z. Garisto C. Favia. I et al.Levosimendan infusion in newborns after corrective surgery for congenital heart disease: Randomized controlled trial.Intensive Care Med. 2012; 38: 1198-1204Crossref PubMed Scopus (43) Google Scholar and found that the significant VIS differences between the levosimendan group and controls would change dramatically; significant LVIS differences are not present between the 2 groups (Fig 1A and B). We suggest authors and reviewers take into account the following LVIS in future pediatric papers dealing with levosimendan: LVIS = dopamine dose (mcg/kg/min)+dobutamine dose (mcg/kg/min)+100×epinephrine dose (mcg/kg/min)+10×milrinone dose (mcg/kg/min)+10,000×vasopressin dose (U/kg/min)+100×norepinephrine dose (mcg/kg/min)+50×levosimendan dose (mcg/kg/min).

Perioperative Management of Patients With Left Ventricular Assist Devices Undergoing Noncardiac Surgery

ACCORDING TO THE American Heart Association 2010 update, more than 5.7 million people in the United States suffer from heart failure. 1 Lloyd Jones D. Adams R. Brown T. et al. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1380) Google Scholar , 2 Lloyd Jones D. Adams R. Carnethon M. et al. Heart disease and stroke statistics—2009 update: A report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation. 2009; 119: e21-e181 Crossref PubMed Scopus (2096) Google Scholar , 3 Ammar K.A. Jacobsen S.J. Mahoney D.W. et al. Prevalence and prognostic significance of heart failure stages: Application of the American College of Cardiology/American Heart Association heart failure staging criteria in the community. Circulation. 2007; 115: 1563-1570 Crossref PubMed Scopus (324) Google Scholar The prevalence of heart failure in the United States has been rising with the aging population. The annual number of heart failure–related hospitalizations has risen to more than 1 million and has resulted in combined direct and indirect costs approximating $40 billion. 1 Lloyd Jones D. Adams R. Brown T. et al. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1380) Google Scholar , 2 Lloyd Jones D. Adams R. Carnethon M. et al. Heart disease and stroke statistics—2009 update: A report from the American Heart Association statistics committee and stroke statistics subcommittee. Circulation. 2009; 119: e21-e181 Crossref PubMed Scopus (2096) Google Scholar Despite advancements in the pharmacologic management of heart failure, mortality rates have remained relatively unchanged. After a diagnosis of heart failure, the 1-year mortality rate is 20%, 1 Lloyd Jones D. Adams R. Brown T. et al. Heart disease and stroke statistics—2010 update: A report from the American Heart Association. Circulation. 2010; 121: e46-e215 Crossref PubMed Scopus (1380) Google Scholar and once a patient has American College of Cardiology/American Heart Association stage D heart failure (ie, end-stage heart failure), the 2-year mortality rate approaches 75%. 4 Thunberg C.A. Gaitan B.D. Arabia F.A. et al. Ventricular assist devices today and tomorrow. J Cardiothorac Vasc Anesth. 2010; 24: 656-680 Abstract Full Text Full Text PDF PubMed Scopus (72) Google Scholar Although cardiac transplantation has excellent results for the treatment of end-stage heart failure, this option is limited severely by the number of available donor organs, with the annual number of heart transplants having plateaued at approximately 2,300 over the last 15 years. In 1991, since the landmark Randomized Evaluation of Mechanical Assistance of Chronic Heart Failure (REMATCH) trial showed improved 1- and 2-year survival rates in the mechanical circulatory support group versus the medical management group, 5 Rose E.A. Gelijns A.C. Moskowitz A.J. et al. Long-term use of a left ventricular assist device for end-stage heart failure. N Engl J Med. 2001; 345: 1435-1443 Crossref PubMed Scopus (3294) Google Scholar left ventricular assist devices (LVADs) have taken a more prominent role in the management of heart failure. Since 2006 when the Interagency Registry for Mechanically Assisted Circulatory Support started collecting data on mechanical circulatory support devices, more than 3,000 primary adult LVADs have been implanted. 6 Kirklin J.K. Naftel D.C. Kormos R.L. et al. Third INTERMACS annual report: The evolution of destination therapy in the united states. J Heart Lung Transplant. 2011; 30: 115-123 Abstract Full Text Full Text PDF PubMed Scopus (276) Google Scholar Parides et al 7 Parides M.K. Moskowitz A.J. Ascheim D.D. et al. Progress versus precision: Challenges in clinical trial design for left ventricular assist devices. Ann Thorac Surg. 2006; 82: 1140-1146 Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar estimated that between 20,000 and 60,000 patients could benefit from LVAD therapy annually.

Response to Rodriguez and Feltracco: Effectiveness of Noninvasive Ventilation: The Mystery Is in the Bottom Line

Response to Rodriguez and Feltracco: Effectiveness of Noninvasive Ventilation: The Mystery Is in the Bottom Line

Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going?

Fibrinogen Supplementation in Cardiac Surgery: Where Are We Now and Where Are We Going?

Magnesium

Magnesium

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

High Transvalvular Gradients Across a Prosthetic Valve in the Mitral Position: Not Ignoring the Bigger Picture

Comment on the “Update on Blood Conservation for Cardiac Surgery”

We would like to comment on the “Update on Blood Conservation for Cardiac Surgery” published in the February 2012 issue of the Journal of Cardiothoracic and Vascular Anesthesia.1Nalla B.P. Freedman J. Hare G.M.T. et al.Update on blood conservation for cardiac surgery.J Cardiothorac Vasc Anesth. 2012; 26: 117-133Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar While we applaud the extensive and thoughtful work that went into this publication, we would like to raise several issues that we believe are oversights in the section pertaining to topical hemostatic agents. The discussion of fibrin sealants should include EVICEL® (Ethicon, Inc, Somerville, NJ) Fibrin Sealant (Human). EVICEL is a fibrin sealant marketed in the United States, with a general hemostasis indication, and is the only fibrin sealant that is both aprotinin free and tranexemic acid free. One of the 3 pivotal trials for EVICEL to gain a general hemostasis indication was in vascular surgery, which showed safety and efficacy for use at anastomotic sites.2Chalmers R.T. Darling III, R.C. Wingard J.T. et al.Safety and effectiveness of a tranexamic acid-free fibrin sealant during vascular surgical procedures: Results of a randomised multicentre study.Br J Surg. 2010; 97: 1784-1789Crossref PubMed Scopus (42) Google Scholar With regard to flowable gelatin topical hemostatic agents, we believe these should be considered as a class. Only Floseal is mentioned by name although that class includes SURGIFLO (Ethicon, Inc) Hemostatic Matrix, a flowable gelatin. SURGIFLO is a flowable form of SURGIFOAM (Ethicon, Inc) Absorbable Gelatin Sponge. Data from a multicenter prospective, randomized, controlled clinical trial for SURGIFOAM, which included vascular anastomoses, was accepted by the Food and Drug Administration for the purposes of approving SURGIFLO. Because this gelatin product can be constituted as a pad, powder, or flowable, they are, in effect, viewed as the same agent. Notably, the pivotal randomized controlled trial for EVITHROM (Ethicon, Inc) thrombin using SURGIFOAM as a carrier also included cardiovascular patients.3Doria C. Fischer C.P. Wood C.G. et al.Phase 3, randomized, double-blind study of plasma-derived human thrombin versus bovine thrombin in achieving hemostasis in patients undergoing surgery.Curr Med Res Opin. 2008; 24: 785-794Crossref PubMed Scopus (38) Google Scholar Finally, SURGIFLO, which may be used with or without thrombin, is derived from porcine gelatin. Because Floseal's bovine origin is a potential concern, SURGIFLO should be considered as an alternative. In the section on thrombin, mention is made that concerns over the formation of bovine-induced antithrombin antibodies lead to the development of recombinant human thrombin. We would like to point out that the Food and Drug Administration approved EVITHROM thrombin in 2007, the first human-derived thrombin available in the United States. We hope this letter will contribute to the document as an addendum. We thank the multiple authors of this document for their efforts and dedication to promoting the conservation of blood products in cardiovascular surgery and improving the quality of care for all patients. Update on Blood Conservation for Cardiac SurgeryJournal of Cardiothoracic and Vascular AnesthesiaVol. 26Issue 1PreviewPATIENTS UNDERGOING CARDIAC SURGERY are at risk of excessive bleeding, leading to increased usage of allogeneic blood and hemostatic blood products. Although this patient population represents a relatively small proportion of surgical patients, cardiac surgery consumes about 20% of the available blood supply in the United States,1 with similar numbers reported worldwide.2,3 The potential for beneficial effects of transfusing blood to maintain tissue oxygen perfusion and prevent organ ischemia may be greatest in patients with cardiovascular disease. Full-Text PDF

Management of Hypotension Associated With Angiotensin-Axis Blockade and General Anesthesia Administration

YPOTENSION, SOMETIMES REFRACTORY, is a well-recognized phenomenon associated with the administration of general anesthesia in patients who have angiotensin-axis blockade (AAB) because of the administration of either angiotensin-converting enzyme inhibitors (ACEIs) or angiotensin-receptor blockers (ARBs). 1 Hypotension in such patients usually occurs within 30 minutes of the induction of anesthesia2,3 and is more frequent in patients also receiving diuretics. 4 There is an ongoing debate as to whether ACEIs and ARBs should be discontinued before surgery. 2,3,5-9 Although omitting these agents before general anesthesia may avoid hypotension,3,8,10 some argue that their discontinuation is not required because the associated hypotension is easily treatable 6,11 and subsequent hypertension may occur perioperatively requiring antihypertensive therapy. 9 Furthermore, the discontinuation of ACEIs and ARBs might remove the potential beneficial effect of AAB on myocardial protection 9,12-14 Adding to this debate, preoperative therapy with ACEIs in cardiac surgery 5 and ACEIs and ARBs in vascular surgery 15 have been found to be associated with an increased risk of mortality. In contrast, in cardiac surgery, ACEIs may confer renal protection16 ; and in

Pulmonary Gas Embolism as a Potential Cause of Hypoxia Immediately After Cardiopulmonary Bypass

THE DEVELOPMENT OF HYPOXIA is not uncommon during cardiac surgery. 1 Yende S. Wunderink R. Causes of prolonged mechanical ventilation after coronary artery bypass surgery. Chest. 2002; 122: 245-252 Crossref PubMed Scopus (50) Google Scholar Causes of hypoxia include cardiogenic and/or noncardiogenic pulmonary edema, atelectasis, pneumonia, surgical trauma of pulmonary vasculatures, and increased ventilation-perfusion (VA/Q) mismatch from vasodilators. 1 Yende S. Wunderink R. Causes of prolonged mechanical ventilation after coronary artery bypass surgery. Chest. 2002; 122: 245-252 Crossref PubMed Scopus (50) Google Scholar , 2 Wan S. LeClerc J.L. Vincent J.L. Inflammatory response to cardiopulmonary bypass. Chest. 1997; 112: 676-692 Crossref PubMed Scopus (776) Google Scholar , 3 Gale G.D. Teasdale S.J. Saunders D.E. et al. Pulmonary atelectasis and other respiratory complications after cardiopulmonary bypass and investigation of aetiological factors. Can Anaesth Soc J. 1979; 26: 15-21 Crossref PubMed Scopus (62) Google Scholar , 4 Möllhoff T. Van Aken H. Mulier J.P. et al. Effects of urapidil, ketanserin and sodium nitroprusside on venous admixture and arterial oxygenation following coronary artery bypass grafting. Br J Anaesth. 1990; 64: 493-497 Crossref PubMed Scopus (20) Google Scholar , 5 Franke A. Lante W. Fackeldey V. et al. Pro-inflammatory cytokines after different kinds of cardiothoracic surgical procedures: Is what we see what we know?. Eur J Cardiothorac Surg. 2005; 28: 569-575 Crossref PubMed Scopus (144) Google Scholar , 6 Prondzinsky R. Knüpfer A. Loppnow H. et al. Surgical trauma affects the pro-inflammatory status after cardiac surgery to a higher degree than cardiopulmonary bypass. J Thorac Cardiovasc Surg. 2005; 129: 760-766 Abstract Full Text Full Text PDF PubMed Scopus (87) Google Scholar , 7 Spies B.D. Transfusion of blood products affects outcome in cardiac surgery. Semin Cardiothorac Vasc Anesth. 2004; 8: 267-281 Crossref PubMed Scopus (120) Google Scholar , 8 Bux J. Transfusion-related acute lung injury (TRALI): A serious adverse event of blood transfusion. Vox Sang. 2005; 89: 1-10 Crossref PubMed Scopus (191) Google Scholar Pulmonary gas embolism (PGE) by air or medical gases potentially can occur in cardiac surgery involving opening of the right heart because it is impossible to remove all traces of air from the cardiac chambers before closing the heart. 9 Lumb A.B. Pulmonary vascular disease. in: “Nunn’s” Applied Respiratory Physiology Sixth Edition. Elsevier, Philadelphia, Pennsylvania2005: 387-398 Google Scholar However, PGE has not been mentioned often as a cause of hypoxia during cardiac surgery. An adult patient who underwent corrective surgery for incomplete endocardial cushion defect (ECD) and developed severe hypoxia immediately after cardiopulmonary bypass (CPB), in which case the authors hypothesized PGE as a possible cause, is presented.

Asymptomatic Carotid Artery Stenosis and Cognitive Outcomes After Coronary Artery Bypass Grafting

Conclusion: Asymptomatic >50% carotid stenosis is a risk factor for cognitive decline after coronary artery bypass grafting (CABG). Summary: Patients anticipate CABG will improve their quality of life (Koch CG et al, Semin Cardiothorac Vasc Anesth 2008;12:203-17). Preservation and improvement of psychologic emotional well-being enhances quality of life. Neuropsychologic disorders are being more frequently addressed in the care of the postoperative patient. Cerebrovascular disease and coronary artery disease potentially put patients at risk for cognitive decline. In this report, the authors correlate asymptomatic carotid stenosis with cognitive decline after coronary artery bypass grafting (CABG). They sought to detect the incidence of cognitive decline after CABG, identify risk factors associated with such cognitive decline, and investigate a possible link between cognitive performance and asymptomatic carotid stenosis. The authors studied 127 patients who underwent CABG. The patients underwent a neuropsychologic examination that included seven cognitive tests and two scales for evaluation of mood disorders. The patients were tested the day before surgery and before discharge from the hospital. Testing revealed that early postoperative decline was common and was detected in 46% of patients. Postoperative cognitive decline was associated with low cardiac output syndrome perioperatively (P < .05), postoperative bleeding (P = .03), longer duration of surgery (P = .02), and longer intensive care unit stay and postoperative mechanical ventilation time (P < .05). Multivariate regression analysis indicated carotid artery stenosis of >50% was a strong independent predictor of postoperative cognitive decline (odds ratio, 26.9; 95% confidence interval, 6.44-112.34). Comment: The authors' data indicate an association between cognitive decline after CABG and the presence of >50% carotid stenosis. One cannot, however, derive from this data that the carotid stenosis itself leads to cognitive decline after CABG. Indeed, we know that repair of asymptomatic carotid stenosis before CABG has minimal, if any, impact on more obvious clinical end points such as stroke and death after CABG. This study did not have cerebral imaging before and after CABG to correlate with the neurophysiologic testing. At this time, it seems more likely the carotid stenosis is more of a marker for more advanced preexisting intracranial vascular disease potentially associated with cognitive decline after CABG than a potential target for intervention to decrease cognitive decline after CABG.

Pro: Continuous Cardiac Output and SvO2 Monitoring Should Be Routine During Off-Pump Coronary Artery Bypass Graft Surgery

OFF-PUMP CORONARY ARTERY bypass surgery (OPCAB) has gained popularity in recent years as a technique of surgical myocardial revascularization. In the United States, about 20% to 25% of coronary artery bypass graft (CABG) surgeries are performed off-pump. 1 Parolari A. Pesce L.L. Trezzi M. et al. Performance of EuroSCORE in CABG and off-pump coronary artery bypass grafting: Single institution experience and meta-analysis. Eur Heart J. 2009; 30: 297-304 Crossref PubMed Scopus (60) Google Scholar The clinical advantages of OPCAB are the avoidance of the cross-clamping of the aorta and the reduced systemic inflammatory effects of cardiopulmonary bypass (CPB), which have been shown to reduce postoperative morbidity in low-risk and high-risk patients as well as in comparison with patients who underwent percutaneous coronary intervention. 2 Demaria R.G. Carrier M. Fortier S. et al. Reduced mortality and strokes with off-pump coronary artery bypass grafting surgery in octogenarians. Circulation. 2002; 106: I5-I10 PubMed Google Scholar , 3 Cheng D.C. Bainbridge D. Martin J.E. et al. Does off-pump coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with conventional coronary artery bypass? A meta-analysis of randomized trials. Anesthesiology. 2005; 102: 188-203 Crossref PubMed Scopus (385) Google Scholar , 4 Bainbridge D. Cheng D. Martin J. et al. Does off-pump or minimally invasive coronary artery bypass reduce mortality, morbidity, and resource utilization when compared with percutaneous coronary intervention? A meta-analysis of randomized trials. Thorac Cardiovasc Surg. 2007; 133: 623-631 Abstract Full Text Full Text PDF Scopus (34) Google Scholar Nevertheless, abrupt manipulations of the heart during OPCAB surgery presents unique challenges to the cardiac anesthesiologist. 5 Grow M.P. Singh A. Fleming N.W. et al. Cardiac output monitoring during off-pump coronary artery bypass grafting. J Cardiothorac Vasc Anesth. 2004; 18: 43-46 Abstract Full Text Full Text PDF PubMed Scopus (12) Google Scholar

Pharmacologic Management of Coagulopathy in Cardiac Surgery: An Update

THERE ARE ABOUT 1.5 million adult cardiac surgical procedures performed in the United States every year, 1 Herbertson M. Recombinant activated factor VII in cardiac surgery. Blood Coagul Fibrinolysis. 2004; 15: S31-S32 Crossref PubMed Scopus (54) Google Scholar enabled by the use of extracorporeal circulation (ECC). The nature of the procedure and the underlying disease subject the cardiovascular patient population to different hematologic insults. Despite a heightened awareness of the various adverse effects of blood product transfusions, 2 Koch C.G. Li L. Sessler D.I. et al. Duration of red-cell storage and complications after cardiac surgery. N Engl J Med. 2008; 358: 1229-1239 Crossref PubMed Scopus (1138) Google Scholar the publication of national transfusion guidelines, 3 Ferraris V.A. Brown J.R. Despotis G.J. et al. 2011 update to the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists blood conservation clinical practice guidelines. Ann Thorac Surg. 2011; 91: 944-982 Abstract Full Text Full Text PDF PubMed Scopus (1003) Google Scholar and an acceptance of lower transfusion thresholds, allogeneic blood product usage remains as high as 50% in cardiac surgical patients. 4 Bennett-Guerrero E. Song H.K. Zhao Y. et al. Temporal changes in the use of blood products for coronary artery bypass graft surgery in North America: An analysis of the Society of Thoracic Surgeons Adult Cardiac Database. J Cardiothorac Vasc Anesth. 2010; 24: 814-816 Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar