Conventional Cardiopulmonary Bypass Research Articles

Comparison of outcomes between off-pump and on-pump coronary artery bypass graft surgery using collaborative targeted maximum likelihood estimation

There are some discrepancies about the superiority of the off-pump coronary artery bypass grafting (CABG) surgery over the conventional cardiopulmonary bypass (on-pump). The aim of this study was estimating risk ratio of mortality in the off-pump coronary bypass compared with the on-pump using a causal model known as collaborative targeted maximum likelihood estimation (C-TMLE). The data of the Tehran Heart Cohort study from 2007 to 2020 was used. A collaborative targeted maximum likelihood estimation and targeted maximum likelihood estimation, and propensity score (PS) adjustment methods were used to estimate causal risk ratio adjusting for the minimum sufficient set of confounders, and the results were compared. Among 24,883 participants (73.6% male), 5566 patients died during an average of 8.2 years of follow-up. The risk ratio estimates (95% confidence intervals) by unadjusted log-binomial regression model, PS adjustment, TMLE, and C-TMLE methods were 0.86 (0.78–0.95), 0.88 (0.80–0.97), 0.88 (0.80–0.97), and 0.87(0.85–0.89), respectively. This study provides evidence for a protective effect of off-pump surgery on mortality risk for up to 8 years in diabetic and non-diabetic patients.

“Con: Is Minimal Invasive Extracorporeal Circulation Superior to Conventional Cardiopulmonary Bypass in Cardiac Surgery?”

“Con: Is Minimal Invasive Extracorporeal Circulation Superior to Conventional Cardiopulmonary Bypass in Cardiac Surgery?”

Unusual severe hypoxemia due to unilateral pulmonary edema after conventional cardiopulmonary bypass salvaged by veno-venous extracorporeal membrane oxygenation: a case report

BackgroundWe report a case in which veno-venous extracorporeal membrane oxygenation (V-V ECMO) saved the life of a patient who developed severe hypoxemia due to unusual unilateral pulmonary edema (UPE) after cardiopulmonary bypass (CPB).Case presentationA 69-year-old man underwent aortic valve replacement and coronary artery bypass grafting. Following uneventful weaning off CPB, he developed severe hypoxemia. The ratio of arterial oxygen tension to inspired oxygen fraction (PaO2/FiO2) decreased from 301 mmHg 5 min after CPB to 42 mmHg 90 min after CPB. A chest X-ray revealed right-sided UPE. Immediately established V-V ECMO increased PaO2/FiO2 to 170 mmHg. Re-expansion pulmonary edema (REPE) was likely, as the right lung remained collapsed during CPB following the accidental opening of the right chest cavity during graft harvesting.ConclusionsV-V ECMO was effective in improving oxygenation and saving the life of a patient who had fallen into unilateral REPE unusually developing after conventional CPB.

Effect of different coronary artery revascularization procedures on cognition: A systematic review

Coronary revascularization interventions have been associated with post-intervention cognitive decline. Hence, this systematic review aims to compare the long-term effects of different coronary revascularization interventions on cognition. The Cochrane Library and MEDLINE databases were searched for articles published between January 2009 and January 2023. Articles on clinical trials and cohort studies that compared at least two different interventions with a minimum three months follow up were included to evaluate the consequences of different intervention techniques on cognition. Each selected study was evaluated using a revised tool to assess the risk of bias in randomized trials (RoB 2), and Risk of Bias In Non-Randomized Studies - of Interventions(ROBINS-1) was used for evaluating non-randomized studies. Five eligible studies, with four different comparisons, were included. Out of these studies, three RCTs and two cohort studies were included A participants gone through different procedures; on-pump and off-pump coronary artery bypass grafting (CABG), Percutaneous coronary intervention (PCI conventional cardiopulmonary bypass (CCPB), the miniaturized cardiopulmonary bypass (MCPB) and endoscopic coronary artery bypass grafting (Endo-CABG). These comparisons showed that different interventions have different effects on cognition; however, there is no solid evidence of correlations between them. Thus, the results of this review suggest that there should be greater focus on comparing interventions and that a reasonable follow-up duration should be set to avoid the influence of confounders. There is also a need to determine the effect of long-term cognitive decline while reducing interference by other variables.

Comparison of the effects of minimally invasive cardiopulmonary bypass and conventional cardiopulmonary bypass on atrial fibrillation after coronary artery bypass grafting and application of magnetic nanoparticles chemiluminescence immunoassay to detect serum indexes

To compare the effects of minimally invasive cardiopulmonary bypass coronary artery bypass grafting (MICB-CABG) and conventional cardiopulmonary bypass (CCPB)-CABG on the occurrence of atrial fibrillation (AF), in this research, totally 86 patients with CABG, admitted in our hospital from March 2020 to October 2021, were selected and divided equally into MICB-CABG and CCPB-CABG groups, according to the random number table method. The incidence of AF and left atrial volume index (LAVI) were compared between the two groups. In total, 104 patients with symptoms such as chest tightness, breathlessness, chest pain, and precordial discomfort were included in the study. All patients were examined by nano-CT and coronary angiography. However, time of ventilator use and time of fever were shorter in the MICB-CABG group. AF is closely related to LAVI, and levels of inflammatory factors, such as high-sensitivity (hs)-CRP, IL-6, and tumor necrosis factor-α (TNF-α), in the CCPB-CABG group were significantly higher than those in the MICB-CABG group. Taking the results of selective coronary angiography as the gold standard, the sensitivity and specificity of nano-CT in detecting coronary artery abnormalities were 99.17% and 97.93%, respectively, suggesting that nano-CT can display coronary artery variations precisely. Compared with the CCPB-CABG group, the incidence of AF after surgery and the risk indicators related to the occurrence of AF were significantly lower in the MICB-CABG group. Compared with traditional CCPB-CABG, MICB-CABG interferes less with the physiological functions of the body, reduces atrium damage, and improves the therapeutic effect. In addition, magnetic nanoparticle CLIA can meet the clinical need for detecting serum indexes and has good potential for clinical use.

Cardiopulmonary bypass in neonates and infants: advantages of high flow high hematocrit bypass strategy-clinical practice review.

Cardiopulmonary bypass is an integral and indispensable part of surgical repair of congenital heart defects. While the complications and morbidity secondary to the use of cardiopulmonary bypass has decreased considerably, there remains a significant incidence of clinically relevant renal and neurological injury. To provide more physiological delivery of oxygenated blood to the end-organs, our center has been successfully using a high-flow, high hematocrit cardiopulmonary bypass strategy since 2006. The essential components of this strategy include maintaining high flows (typically 200 mL/kg/min in neonates, 150-175 mL/kg/min in older infants weighing <10 kg, and 2.6 L/min/m2 in older children) throughout the duration of cardiopulmonary bypass irrespective of patient temperature, as well as maintaining a hematocrit of at least 32% on cardiopulmonary bypass. The incidence of post-operative acute kidney injury (around 3%) and clinical acute neurological events (<1%) with this strategy is considerably less when compared to other contemporary publications using the conventional cardiopulmonary bypass strategy. In this review, we discuss the rationale behind our approach and present evidence to support the high-flow, high-hematocrit strategy. We also discuss the practical aspects of our strategy and describe the adjuncts we use to derive additional benefits. These adjuncts include the use of a hybrid pH/alpha stat strategy during cooling/rewarming, aggressive use of conventional ultrafiltration during cardiopulmonary bypass, a terminal hematocrit of 40-45%, and avoidance of milrinone and albumin in the early peri-operative period. This results in a very low incidence of post-operative bleeding, facilitates chest closure in the operating room even in most neonates, helps in reducing the need for post-operative blood product transfusion and helps in achieving a favorable post-operative fluid balance early after surgery.

Coagulation after paediatric miniaturised versus conventional cardiopulmonary bypass: Retrospective cohort study.

Cardiopulmonary bypass (CPB) causes coagulation disorders after surgery. This study aimed to compare the coagulation parameters after congenital cardiac surgery with miniaturised CPB (MCPB) versus conventional CPB (CCPB). We gathered information about children who underwent cardiac surgery between 1/1/2016 and 12/31/2019. Using propensity score-matched data, we compared the coagulation parameters and postoperative outcomes of the MCPB and CCPB groups. A total of 496 patients (327 with MCPB, 169 withCCPB) underwent congenital cardiac surgery, and 160 matched pairs in each group were enrolled in the analysis. Compared with CCPB children, MCPB children had a lowermean prothrombin time (14.9 ± 2.0 vs 16.4 ± 4.1; p < 0.001)and international normalised ratio (1.3 ± 0.2 vs. 1.4 ± 0.3; p < 0.001), but higher thrombin time (23.4 ± 20.4 vs 18.2 ± 4.4; p = 0.002). The CCPB group had greaterperioperative changes inprothrombin time, international normalised ratio, fibrinogen, and antithrombin III activity (all p < 0.01) but lower perioperative changesin thrombin time (p = 0.001) thanthe MCPB group. Ultra-fasttrack extubation and blood transfusionrates, postoperative blood loss, and intensive care unitlength of stay were considerably decreased in the MCPB group. There were no considerable intergroup differences in the activated partial thromboplastin time or platelet count. Compared with CCPB, MCPB was associated with lower coagulation changes and better early outcomes, including shorter intensive care unit stay and less postoperative blood loss.

Modified cardiopulmonary bypass with low priming volume for blood conservation in cardiac valve replacement surgery

BackgroundThe adverse effects of cardiopulmonary bypass during open cardiac surgery, including hemodilution, seem to be inevitable, especially for patients who generally have a relatively lower BMI with relatively small blood volumes. This study reports the modification and use of a cardiopulmonary bypass (CPB) system to reduce priming volume and hemodilution.MethodsThis is a retrospective study of 462 adult patients who underwent cardiac valve replacement surgery from January 2019 to September 2021 at the General Hospital of Western Theater Command. The modified group consisted of 212 patients undergoing modified CPB. The control group included 250 patients receiving conventional CPB. Evaluated indices included fluid intake and output volumes during CPB, intraoperative indices related to CPB operation, usage of blood products during the peri-CPB period, and postoperative outcomes.ResultsThe modified group displayed a significant reduction in the crystalloid (200 mL vs. 600 mL, P < 0.05) and colloid priming volumes (450 mL vs. 1100 mL, P < 0.05), and ultrafiltration solution volume (750 mL vs. 1200 mL, P < 0.05). Furthermore, the modified group had a significantly lower rate of defibrillation (30.2% vs. 41.2%, P < 0.05). The intraoperative urine volume (650 mL vs. 500 mL, P < 0.05) and intraoperative hematocrit (Hct) (26% vs. 24%, P < 0.05) of the modified CPB group were also higher than in the control group. The modified group required a lower infusion volume of packed red blood cells (250 mL vs. 400 mL, P < 0.05) and lower infusion rates of packed red blood cells (17.9% vs. 25.2%, P < 0.05) and fresh frozen plasma (1.41% vs. 5.2%, P < 0.05). In addition, the modified group showed significantly improved indices related to postoperative recovery.ConclusionsThe modified CPB system effectively conserves blood and shows noteworthy potential for application in cardiac valve replacement surgery.

Abdominal and Peripheral Tissue Oxygen Supply during Selective Lower Body Perfusion for the Surgical Repair of Congenital Heart Disease: A Pilot Study.

Lower body perfusion (LBP) may be a strategy for maintaining organ perfusion during congenital heart disease surgery. It is hypothesized that renal and lower limb oxygen supply during LBP is superior to off-pump surgery and comparable to that of a standard cardiopulmonary bypass (CPB). in this prospective single-center study, patients aged &lt;1 year were recruited if they were scheduled for a correction of aortic arch anomalies using antegrade cerebral perfusion and LBP (group 1), a repair of coarctation during aortic cross-clamping (group 2), or surgery under whole-body CPB (group 3). Renal (prefix "r") and peripheral (prefix "p") oxygen saturation (SO2), hemoglobin amount (Hb), blood velocity (Velo), and blood flow (Flow) were measured noninvasively. A total of 23 patients were included (group 1, n = 9; group 2, n = 5; group 3, n = 9). Compared to the baseline values, rSO2 and pSO2 decreased significantly in group 2 compared to groups 1 and 3. Conversely, rHB significantly increased in group 2 compared to groups 1 and 3, reflecting abdominal venous stasis. Compared to group 3, group 1 showed a significantly lower pFlow during CPB; however, rFlow, pFlow, and pVelo did not differ. according to these observations, LBP results in an improved renal oxygen supply compared to off-pump surgery and may prove to be a promising alternative to conventional CPB.

Use of cardiopulmonary bypass machine in intensive care unit as a short term mechanical circulatory support for recovery of cardiac function.

Extracorporeal Membrane Oxygenation (ECMO) is used as a bridge to recovery of cardiac function following completion of congenital cardiac surgeries where there is failure to wean from cardiopulmonary bypass (CPB) or severe low cardiac output states in the post operative periods. Although ECMO is a well-established form of mechanical circulatory support, the associated cost can be a huge financial burden on families. We are an ECMO center and use the same in post operative congenital cardiac surgeries for mechanical cardiovascular support if needed. However, a significant proportion of the children, whom we operate, are funded by government aides. The resources are limited in such circumstances. If needed, we use the same CPB circuit and cannulae used in the Operating Room (OR) and support them at a significantly lower cost compared to ECMO. We report our experience of using conventional CPB machine as a short-term bridge to recovery of cardiac function in Intensive Care Unit where there was limitation of funds. Essentially same CPB circuit with roller pump is retained, by omitting cardiotomy suckers. We use D901 Lilliput 1 Oxygenator (Sorin, Italy) for children <5kg and D902 Lilliput 2 (Sorin, Italy) Oxygenator for children >5Kg. We supported nine patients on CPB between March 2019 and December 2021. During this time, 1392 congenital cardiac surgeries were performed. We could wean off three patients (33.3%) and discharge two patients (22.2%). Our support time ranged from 21h to 60h with a median of 48h. Beyond 48h of support, we experienced several CPB induced complications in our cohort. In resource-limited settings, conventional CPB machines can be used for short-term cardiac support. Although results may not be comparable to using ECMO, some patients can be definitely salvaged, who would otherwise die in the absence of institution of mechanical circulatory support.

The application of modular multifunctional left heart bypass circuit system integrated with ultrafiltration in thoracoabdominal aortic aneurysm repair.

Open thoracoabdominal aortic aneurysm (TAAA) repair is a complex and challenging operation with a high incidence of serious complications, and high perioperative mortality and morbidity. Left heart bypass (LHB) is a circulatory support system used to perfuse the distal aorta during TAAA operation, and the advantages of LHB include guaranteeing distal perfusion, reducing the use of heparin, and diminishing the risk of bleeding and postoperative neurological deficits. In China, the circuit for TAAA repair is deficient, and far from the perfusion requirements. We designed a modular multifunctional LHB circuit for TAAA repair. The modular circuit consisted of cannulation pipelines, functional consumables connection pipelines, and accessory pipelines. The accessory pipelines make up lines for selective visceral perfusion and kidney perfusion, suckers and rapid infusion. The circuit can be assembled according to surgical requirements. The ultrafilter and heat exchanger are integrated into the circuit to fulfill the basic demands of LHB. The LHB circuit also has pipelines for selective visceral perfusion to the celiac artery and superior mesenteric artery and renal perfusion pipelines. Meanwhile, the reserved pipelines facilitate the quick switch from LHB to conventional cardiopulmonary bypass (CPB). The reserved pipelines reduce the time of reassembling the CPB circuit. Moreover, the rapid infusion was integrated into the LHB circuit, which can rapid infusion when massive hemorrhage during the open procedures such as exposure and reconstruction of the aorta. The ultrafiltration can diminish the consequent hemodilution of hemorrhage and rapid infusion. A hemoperfusion cartridge also can be added to reduce the systemic inflammatory during operation. The circuit can meet the needs of LHB and quickly switch to conventional CPB. No oxygenator was required during LHB, which reduce the use of heparin and reduce the risk of bleeding. The heat exchanger contributes to temperature regulation; ultrafiltration, arterial filter, and rapid-infusion facilitated the blood volume management and are useful to maintain hemodynamic stability. This circuit made the assembly of the LHB circuit more easily, and more efficient, which may contribute to the TAAA repair operation performed in lower volume centers easily. 26 patients who received TAAA repair under the modular multifunctional LHB from January 2018-March 2022 were analyzed, and we achieved acceptable clinical outcomes. The in-hospital mortality and 30-day postoperative mortality were 15.4%, and the postoperative incidences of paraparesis (4%), stroke (4%), and AKI need hemodialysis (12%) were not particularly high, based on the limited patients sample size in short research period duration.

Use of roller pump in venovenous extracorporeal membrane oxygenation as an emergency rescue procedure.

A 41 years old male patient, having acute respiratory distress syndrome (ARDS) due to viral pneumonia, was put on venovenous (VV) extracorporeal membrane oxygenation (ECMO). After 3 h of initiation, the ECMO pump malfunctioned. The patient was initially managed on a hand crank for 5 h. However, as another machine would be available after 12–24 h, we decided to use a roller pump with a conventional cardiopulmonary bypass (CPB) circuit. We successfully manage this crisis with this technique without any complications. This technique can be lifesaving in catastrophic situations such as ECMO console or pump failures when there are neither backup machines nor service engineers available.

Minimized Extracorporeal Circulation Is Associated with Reduced Plasma Levels of Free-Circulating Mitochondrial DNA Compared to Conventional Cardiopulmonary Bypass: A Secondary Analysis of an Exploratory, Prospective, Interventional Study.

The use of minimized extracorporeal circulation (MiECC) during cardiac surgery is associated with a reduced inflammatory reaction compared to conventional cardiopulmonary bypass (cCPB). Since it is unknown if MiECC also reduces the amount of free-circulating mitochondrial DNA (mtDNA), this study aims to compare MiECC-induced mtDNA release to that of cCPB as well as to identify potential relations between the plasma levels of mtDNA and an adverse outcome. Overall, 45 patients undergoing cardiac surgery with either cCPB or MiECC were included in the study. MtDNA encoding for NADH dehydrogenase 1 was quantified with quantitative polymerase chain reaction. The plasma amount of mtDNA was significantly lower in patients undergoing cardiac surgery with MiECC compared to cCPB (MiECC: 161.8 (65.5–501.9); cCPB 190.8 (82–705.7); p < 0.001). Plasma levels of mtDNA showed comparable kinetics independently of the study group and peaked during CPB (MiECC preoperative: 68.2 (26.5–104.9); MiECC 60 min after start of CPB: 536.5 (215.7–919.6); cCPB preoperative: 152.5 (80.9–207.6); cCPB 60 min after start of CPB: 1818.0 (844.2–3932.2); all p < 0.001). Patients offering an mtDNA blood concentration of >650 copies/µL after the commencement of CPB had a 5-fold higher risk for postoperative atrial fibrillation independently of the type of cardiopulmonary bypass. An amount of mtDNA being higher than 650 copies/µL showed moderate predictive power (AUROC 0.71 (0.53–071)) for the identification of postoperative atrial fibrillation. In conclusion, plasma levels of mtDNA were lower in patients undergoing cardiac surgery with MiECC compared to cCPB. The amount of mtDNA at the beginning of the CPB was associated with postoperative atrial fibrillation independent of the type of cardiopulmonary bypass.

Minimal Invasive Extracorporeal Circulation (MiECC) in Car-diac Surgery: A Narrative Review

The heart remained a mystery for many years and was considered surgically untouchable. With the use of extracorporeal circulation, there has been a revolution in this area. Due to its mechanical components and interactions with blood, cardiopulmonary bypass (CPB) can cause significant changes in the body. Factors such as contact between artificial materials and blood, continuous flow, hemodilution, hypothermia and anticoagulation affect all organs during CPB, and may result in various complications. The minimally invasive extracorporeal circulation (MiECC) system was developed to minimize the contact of blood with air and foreign surfaces during conventional CPB. In addition, the biocompatibility of the components that make up the MiECC circuits increased, which reduced the inflammatory response. The absence of a venous reservoir and shorter lines allow the prime volume to be used to decrease, which also reduces the damage to the blood elements, and consequently, the need for blood transfusion. The MiECC system also has its downsides, the most important one being the difficulty in removing the air that can enter through the venous line, the impairment of the pump function, and embolization. During the use of these systems, perfusion safety and communication with the whole team must be at the highest level. In line with this information, the use of these systems can become standard in cardiac surgery with new technological additions.

The Efficacy of Resin Hemoperfusion Cartridge on Inflammatory Responses during Adult Cardiopulmonary Bypass

Aim: This study aimed to evaluate the efficacy of the resin hemoperfusion device (HA380 hemoperfusion cartridge) on inflammatory responses during adult cardiopulmonary bypass (CPB). Methods: Sixty patients undergoing surgical valve replacement were randomized into the HP group (n = 30) with an HA380 hemoperfusion cartridge in the CPB circuit or the control group (n = 30) with the conventional CPB circuit. The results of routine blood tests, blood biochemical indexes, and inflammatory factors were analyzed at V0 (pre-CPB), V1 (CPB 30 min), V2 (ICU 0 h), V3 (ICU 6 h), and V4 (ICU 24 h). Results: The HP group had significantly lower levels of IL-6, IL-8, and IL-10. Significant estimation of group differences in the generalized estimating equation (GEE) models was also observed in IL-6 and IL-10. The HP group had significantly lower levels of creatinine (Cr), aminotransferase (AST), and total bilirubin (TBil) compared to the control group. The estimation of differences of Cr, AST, and TBil all reached statistical significance in GEE results. The HP group had significantly less vasopressor requirement and shorter mechanical ventilation time and ICU stay time as compared to the control group. Conclusion: The HA380 hemoperfusion cartridge could effectively reduce the systemic inflammatory responses and improve postoperative recovery of patients during adult CPB.

The effect of using the minimized cardio-pulmonary bypass Systems for Coronary Artery Bypass Grafting in diabetic patients

IntroductionMultiple studies have shown a decrease in the inflammatory response with minimized bypass circuits leading to less complications and mortality rate. On the other hand, some other studies showed that there is no difference in post-operative outcomes. So, the aim of this study is to investigate the clinical benefits of using the Minimized cardiopulmonary Bypass system in Coronary Artery Bypass Grafting and its effect on postoperative morbidity and mortality in diabetic patients as one of the high-risk groups that may benefit from these systems.MethodsThis is a retrospective study that included 114 diabetic patients who underwent Coronary artery bypass grafting (67 patients with conventional cardiopulmonary bypass system and 47 with Minimized cardiopulmonary bypass system). The patients’ demographics, intra-operative characteristics and postoperative complications were compared between the two groups.ResultsCoronary artery bypass grafting was done on a beating heart less commonly in the conventional cardiopulmonary bypass group (44.78% vs. 63.83%, p = 0.045). There was no difference between the two groups in blood loss or transfusion requirements. Four patients in the conventional cardiopulmonary bypass group suffered perioperative myocardial infarction while no one had perioperative myocardial infarction in the Minimized cardiopulmonary bypass group. On the other hand, less patients in the conventional group had postoperative Atrial Fibrillation (4.55% vs. 27.5%, p = 0.001). The requirements for Adrenaline and Nor-Adrenaline infusions were more common the conventional group than the Minimized group.ConclusionThe use of conventional cardiopulmonary bypass for Coronary Artery Bypass Grafting in diabetic patients was associated with higher use of postoperative vasogenic and inotropic support. However, that did not translate into higher complications rate or mortality.

A 22 Year Old Female Case Scenario: Veno-venous Extracorporeal Membrane Oxygenation

ECMO (Extracorporeal membrane oxygenation) is one of the epic innovations of medical science to support the life of a human, in various conditions of lung failure, where it is difficult to maintain oxygenation of the body. ECMO was considered a very good option for conventional cardiopulmonary bypass technique and evolved into treatment of severe acute respiratory distress syndrome (ARDS) during the 1970s. Many kinds of research have been done on a similar topic. The initial reports on the utilisation of ECMO in ARDS patients were very exciting, and afterwards, ECMO proved to be certainly advantageous in infants having acute respiratory failure with a survival rate of almost 80%. There were two large randomised controlled trials, done during the period of 1979-1994 in adults with ARDS, that showed the failure of ECMO, with the survival rate range between 10% to 33%in the ECMO groups. Since then, ECMO treatment for ARDS patients has undergone further advancements by combining with lung-protective ventilation strategies and further by applying heparin-coated equipment, membranes, and tubings. Many healthcare facilities have used this advanced ECMO technology and achieved survival rates of more than 50%. However, whether improved ECMO can really challenge the advanced conventional treatment of adult ARDS is still a matter of debate and needs further studies.It was seen that acute respiratory failure requires intensive care. In few cases where ventilator support doesn’t prove effective, only the option of V-V ECMO remains. The present article describes the case of a 22-year-old female patient who was admitted with severe acute respiratory distress syndrome with associated multiple organ failure. The patient was admitted to the emergency of the Fortis Hospital with suspected acute kidney injury of unknown aetiology. After the initial 4 days of diagnostics at the ward, the patient required a further 24 days of hospital treatment and spent 16 days at the Intensive Care Unit. There, she underwent ECMO V-V therapy, lasting 14 days, which resulted initially in the improvement of his arterial blood gas parameters and clinical condition but later on, she developed pneumothorax and her condition worsened day by day gradually becoming critical.

Upper mini-sternotomy versus right mini-thoracotomy approach in mitral valve surgery

Background: Full median sternotomy has been a standard surgical approach for heart surgery for more than 50 years. Several advantages increasing the use of less invasive approaches to the mitral valve surgery including, cosmetic, blood product use, respiratory, and pain advantages over conventional surgery. Parasternal incision, right mini-thoracotomy and partial sternotomy are described approaches for less invasive cardiac surgery. Objective: Comparing the less invasive approaches via upper partial sternotomy vs right mini-thoracotomy in mitral valve surgery. Methods: Sixty patients, underwent mitral valve surgery in NHI, were enrolled in this study and divided into two equal groups, and randomly assigned into two equal groups: group upper mini-sternotomy (UMS group, n = 30) or group RMT group (n = 30).The preoperative characteristics, operative variables, mortality, and morbidity were analyzed prospectively. Results: No difference were found between the two groups as regards the mortality. However, in Group UMS, blood loss was significantly higher, also cross clamp time and total bypass time were significantly longer. RMT group showed less time on mechanical ventilation, ICU stay and total hospital stay. In Group UMS, two patients (7%) developed deep sternal wound infection, and one patient (3%) suffered unstable sternum and one patient (3%) required permanent pacemaker. Conclusion: Both approaches upper partial sternotomy and right mini thoracotomy are considered a safe alternative for mitral valve replacement and can provide adequate exposure for mitral valve. In Upper partial sternotomy, conventional cardiopulmonary bypass, no specific instruments or endoscope were needed. In right mini thoracotomy, a longer learning curve and special instruments were required, however, it carried better outcome considering patient satisfaction for pain and cosmetic outcome the hospital stay and short return to activity.

Retrograde autologous priming method reduces plasma free hemoglobin level in aortic surgery.

Background:Although conventional cardiopulmonary bypass (cCPB) is still the most widely used method in open heart surgery, methods such as retrograde autologous priming (RAP) are increasingly popular in terms of limiting hemodilution. Our hypothesis is that the use of the RAP method in aortic surgery may result in a limitation of hemodilution and a decrease in fHb levels. For this purpose, plasma free hemoglobin (fHb) levels were investigated in adult open aortic arch repair with axillary artery cannulation patients using cCPB and rRAP methods.Materials and Methods:In this study, a total of 36 patients undergoing aortic surgery using rRAP and standard cCPB were investigated. Measurements were performed at five time points: After induction of anesthesia, 5th minute of CPB, 10th minute of antegrade cerebral perfusion, 30th minute after declamping of aorta, and at sternum closure. Besides hemodynamic variables, arterial blood gas analysis and postoperative variables, patients were assessed for fHb levels.Results:The rRAP group had a significantly lower increase in fHb levels in T3, T4, and T5 time points, when compared to the cCPB group (p = 0.002, 0.047, 0.009, respectively). There was no significant difference between the rRAP and cCPB groups in other intraoperative, and postoperative variables. Also, it was observed that rRAP did not make a difference in terms of blood and blood product transfusion.Conclusion:In this study, in patients undergoing aortic surgery, a reduction in the increase of fHb was observed with the rRAP method which is a simple procedure that does not require high cost or advanced technology.

Extension of cardiopulmonary bypass outside the operating room as a short-term bridge to recovery "the poor man's ECMO".

This report describes the use of conventional cardiopulmonary bypass (CPB) circuit beyond the operating room to the critical care unit to provide cardiopulmonary support for patients requiring emergent resuscitation as well as short-term support for rest and recovery of the heart. We modified the CPB circuit and created a closed extra corporeal membrane oxygenation (ECMO) circuit using a conventional oxygenator excluding the venous reservoir. We believe that this technique provides a short-term mechanical support and also acts as a bridge to recovery, or a bridge to decision, in very limited resource settings.