Doses Of Inotropes Research Articles

The Impact of Intraoperative Hyperlactatemia on Weaning from Cardiopulmonary Bypass in Patients Undergoing on-Pump Coronary Artery Bypass Grafting Surgery: An Observational Study

Abstract Background: Hyperlactatemia after cardiac surgery is common. However, the association and the implications of hyperlactatemia on the prognosis after cardiopulmonary bypass (CPB) remains controversial. This study investigated the associations between early-onset hyperlactatemia and the need for doses of inotropes and vasopressors during weaning from CPB, hemodynamic stability after weaning from CPB, and the duration of postoperative mechanical ventilation. Patients and Methods: This prospective cohort study included 300 patients who underwent elective on-pump coronary artery bypass grafting (CABG) surgery and had normal systolic function >55%. Serum lactate levels were measured 1 h before induction, upon initiation of CPB, after removal of aortic cannula and on admission to the intensive care unit (ICU). Patients were divided into two groups: patients with lactate levels <4 mmol/L (Group N) and those with lactate levels ≥4 mmol/L (Group H). Results: Patients with hyperlactatemia constituted 20.7% of the study population. The number of patients who required adrenaline and noradrenaline administration upon weaning from CPB, as well as the doses of these drugs, were significantly higher in Group H (P < 0.001). Arterial blood pressure levels after weaning from CPB and upon admission to the ICU were significantly lower in Group H patients (P < 0.001). The duration of post-operative mechanical ventilation was longer in Group H patients (P < 0.001). Conclusion: Early-onset hyperlactatemia was associated with worse outcomes after CABG surgery. There was difficult weaning from CPB with increased inotrope and vasopressor drug support, early post-operative hemodynamic instability, and a prolonged duration of post-operative mechanical ventilation.

PLASMA DYNAMICS OF NEUTROPHIL EXTRACELLULAR TRAPS AND CELL-FREE DNA IN SEPTIC AND NONSEPTIC VASOPLEGIC SHOCK: A PROSPECTIVE COMPARATIVE OBSERVATIONAL COHORT STUDY.

Background: The association between neutrophil extracellular traps (NETs) and the requirement for vasopressor and inotropic support in vasoplegic shock is unclear. This study aimed to investigate the dynamics of plasma levels of NETs and cell-free DNA (cfDNA) up to 48 h after the admission to the intensive care unit (ICU) for management of vasoplegic shock of infectious (SEPSIS) or noninfectious (following cardiac surgery, CARDIAC) origin. Methods: This is a prospective, observational study of NETs and cfDNA plasma levels at 0H (admission) and then at 12H, 24H, and 48H in SEPSIS and CARDIAC patients. The vasopressor inotropic score (VIS), the Sequential Organ Failure Assessment (SOFA) score, and time spent with invasive ventilation, in ICU and in hospital, were recorded. Associations between NETs/cfDNA and VIS and SOFA were analyzed by Spearman's correlation (rho), and between NETs/cfDNA and ventilation/ICU/hospitalization times by generalized linear regression. Results: Both NETs and cfDNA remained elevated over 48 h in SEPSIS (n = 46) and CARDIAC (n = 30) patients, with time-weighted average concentrations greatest in SEPSIS (NETs median difference 0.06 [0.02-0.11], P = 0.005; cfDNA median difference 0.48 [0.20-1.02], P < 0.001). The VIS correlated to NETs (rho = 0.3-0.60 in SEPSIS, P < 0.01, rho = 0.36-0.57 in CARDIAC, P ≤ 0.01) and cfDNA (rho = 0.40-0.56 in SEPSIS, P < 0.01, rho = 0.38-0.47 in CARDIAC, P < 0.05). NETs correlated with SOFA. Neither NETs nor cfDNA were independently associated with ventilator/ICU/hospitalization times. Conclusion: Plasma levels of NETs and cfDNA correlated with the dose of vasopressors and inotropes administered over 48 h in patients with vasoplegic shock from sepsis or following cardiac surgery. NETs levels also correlated with organ dysfunction. These findings suggest that similar mechanisms involving release of NETs are involved in the pathophysiology of vasoplegic shock irrespective of an infectious or noninfectious etiology.

Evaluating the Effects of Time From Brain Death and Type of Inotrope Usage on Result of Heart Transplant: Results of 1-Year Follow-Up.

Heart transplant is the most effective treatment in patients with advanced heart failure who are refractory to medical treatment. The brain death interval and type of inotrope We assessed the effects of these parameters on heart transplant outcomes. In this follow-up study, we followed heart transplant recipients for 1 year to study patient survival, ejection fraction, adverse events, and organ rejection. We evaluated follow-up results on time from brainstem death test to the cross-clamp placement, as well as the type of inotrope used. Our study enrolled 54 heart transplant candidates. The inotrope dose was 3.66 ± 0.99 μg/kg/min, and the most used inotrope, with 28 cases (51.9%), was related to dopamine. Six cases (11.1%) of death and 1 case of infection after transplant were observed in recipients. The average ejection fraction of transplanted hearts before transplant, instantly at time of transplant, and 1 month, 6 months, and 1 year after transplant was 54.9 ± 0.68, 52.9 ± 10.4, 51.9 ± 10.7, 50.1 ± 10.9, and 46.8 ± 17, respectively; this decreasing trend over time was significant (P =.001). Furthermore, ejection fraction changes following transplant did not differ significantly in transplanted hearts regarding brain death interval and type of inotrope used. Our study revealed that cardiac output of a transplanted heart may decrease over time and the time elapsed from brain death, and both dopamine and norepinephrine could have negligible effects on cardiac function.

Association between Neutrophil to Lymphocyte Ratio and Post Operative Atrial Fibrillation after Coronary Artery Bypass Graft operation.

ABSTRACT Background: Post operative atrial fibrillation (POAF) is associated with cardiovascular outcomes such as stroke, heart failure, and mortality. Neutrophil to lymphocyte ratio (NLR) is one of biomarker of inflammation. The use of cor pulmonary bypass(CPB), surgical trauma and reperfusion injury during cardiac surgery causes inflammation. NLR is suspected to be a biomarker that represents the inflammatory response as a modulator of POAF, but data are still lacking.This study analyzed the association between NLR and POAF after coronary artery bypass graft (CABG) operation.Methods: This was an Observational analytic study, involving patients after the CABG procedure in Kariadi Hospital between June 2022 to September 2023. NLR was assessed in the first three hours after operation. ECG Holter was attained for 96 hours post-CABG procedure.Results: The total subject was 62 patients, consisting of 57 men and 5 women with a mean age of 58,7 ± 6.39 years. Mean postoperative NLR 4.95 ± 2.17 with a median of 4.56 (1.52-11.00). There was a significant association between post-operative NLR with POAF after CABG (p=0.006, OR 4.64, 95%CI 1.50-14.35). High inotropic dose and β blocker initiation time less than 45 hours correlate significantly with POAF after CABG (p&lt;0.001, OR 6.94 dan p=0.001, OR 0.17).Conclusions: Postoperative NLR is associated significantly with POAF after CABG. Keywords: Neutrophil to Lymphocyte Ratio, Post Operative Atrial Fibrillation, coronary artery bypass graft, ECG Holter

Perioperative Challenges and Outcome After Surgical Correction of Post-myocardial Infarction Ventricular Septal Rupture: A Retrospective Single Center Study.

Ventricular septal rupture (VSR) is a rare but grave complication of acute myocardial infarction (AMI). It is a mechanical complication of myocardial infarction where patients may present either in a compensated state or in cardiogenic shock. The aim of the study is to determine the in-hospital mortality. The study also aims to identify the predictors of outcomes (in-hospital mortality, vasoactive inotrope score (VIS), duration of ICU stay and mechanical ventilation in the postoperative period) and compare the clinical and surgical parameters between survivors and non-survivors. This is a retrospective study. The data of 90 patients was collected from the medical records and the data comprising of 13 patients who underwent VSR closure by single patch technique, or septal occluder, and those who expired before receiving the treatment, was excluded. The data of 77 patients diagnosed with post-AMI VSR and who underwent surgical closure of VSR by double patch technique was included in this study. Clinical findings and echocardiography parameters were recorded from the perioperative period. The statistical software used was SPSS version 27. The primary outcome was determining the in-hospital mortality. The secondary outcome was identifying the clinical parameters that are significantly more in the non-survivors, and the factors predicting the in-hopsital mortality and morbidity (increased duration of ICU stay, and of mechanical ventilation, postoperative requirement of high doses of vasopressors and inotropes). Subgroup analysis was done to identify the relation of various clinical parameters with the postoperative complications. The factors predicting the in-hospital mortality were illustrated by a forest plot. The mean age of the patients was 60.35 (±9.9) years, 56 (72.7%) were males, and 21 (27.3%) were females. Requirement of mechanical ventilation preoperatively (OR 3.92 [CI 2.91-6.96]), cardiogenic shock at presentation (OR 4 [CI 2.33 - 6.85]), requirement of IABP (OR 2.05 [CI 1.38-3.94]), were predictors of mortality. The apical location of VSR had been favorable for survival. The EUROScore II at presentation correlated with the postoperative VIS (level of significance [LS] 0.0011, R 0.36. The in-hospital mortality in this study was 33.76%. The in-hospital mortality of VSR is 33.76%. Cardiogenic shock at presentation, non-apical site of VSR, preoperative requirement of mechanical ventilation, high VIS preoperatively, perioperative utilization of IABP, prolonged CPB time, postoperative duration of mechanical ventilation, and high postoperative VIS were the factors associated with increased odds of in-hospital mortality.

Mortality on extracorporeal membrane oxygenation: Evaluation of independent risk factors and causes of death during venoarterial and venovenous support.

Most patients on extracorporeal membrane oxygenation (ECMO) decease during therapy on the system. However, the actual causes of death have not been studied sufficiently. This study analyses the etiology, prevalence, and risk factors for the outcome variable death during ongoing ECMO for all patients and divided according to venoarterial (VA) or venovenous (VV) support. We retrospectively analysed all patients receiving ECMO support at our institution between March 2006 to January 2021. Only the patients deceased during ongoing support were included. 2016 patients were placed on VA (n = 1168; 58%) or VV (n = 848; 42%) ECMO; 759 patients (37.7%) deceased on support. The causes of death differed between the support types: VA ECMO patients mostly died from cerebral ischemia (34%), low-cardiac output (LCO; 24.1%) and multi-organ failure (MOF; 21.6%), whereas in VV ECMO cases, refractory respiratory failure (28.2%), and sepsis (20.4%) dominated. Multivariate regression analysis revealed cardiopulmonary resuscitation (CPR) and acidosis prior to ECMO as risk factors for dying on VA ECMO, while high inotropic doses pre-ECMO, a high fraction of inspired oxygen on day 1, elevated lactate dehydrogenase, and international normalized ratio levels lead to an unfavourable outcome in VV ECMO patients. Even in highly experienced centers, ECMO mortality remains high and occurs mainly on support or 24h after its termination. The causes of death differ between VV and VA ECMO, depending on the underlying diseases responsible for the need of extracorporeal support.

Impact of CytoSorb and CKRT on hemodynamics in pediatric patients with septic shock: the PedCyto study.

There is a lack of data to support the use of hemoadsorption in pediatric septic shock. The aim of our study was to assess the effectiveness and safety of CytoSorb therapy in this setting. Phase II interventional single arm pilot study in which 17 consecutive children admitted with septic shock who required continuous kidney replacement therapy (CKRT) and weighed ≥10 kg were included. A CytoSorb (CytoSorbents Inc, New Jersey, USA) hemoadsorption cartridge was added to the CKRT every 24 h for a maximum of 96 h. A control group of 13 children with septic shock treated with CKRT but not hemoadsorption at Children's Hospital Bambino Gesù and enrolled in the EuroAKId register was selected as an historical cohort. The primary outcome of the study was a reduction in vasopressor or inotrope dose of >50% from baseline by the end of CytoSorb therapy. Secondary outcomes included hemodynamic and biological changes, changes in severity scores, and 28-day mortality. There were significant decreases in the Vasoactive Inotropic Score (VIS) and the Pediatric Logistic Organ Dysfunction 2 (PELOD-2) score at 72 and 96 h from the start of the CytoSorb therapy compared to baseline; the reductions were larger in the hemoadsorption group than in the control group (historical cohort). 28-day mortality was lower, although not significantly, in the hemoadsorption group when compared to the control group (5/17 [29%] vs. 8/13 [61%] OR 0.26 [95% CI: 0.05-1.2]; p = 0.08). CytoSorb therapy may have some benefits in pediatric patients with septic shock. Future larger randomized trials are needed in this setting. https://clinicaltrials.gov/ct2/show/NCT05658588, identifier (Clinicaltrials.gov NCT05658588).

CARC20: Intra-operative Use of Intra-aortic Balloon Pump to Generate Pulsatile Flow During Heart Transplantation

Introduction: The physiologic impact of pulsatile flow (PF) on end-organ perfusion during cardiopulmonary bypass (CPB) is controversial. One method of generating PF during CPB is to use an intra-aortic balloon pump (IABP). Maintaining the IABP during CPB to produce a state of PF for patients undergoing heart transplantation (HT) may impact end-organ perfusion, with implications for short-term graft function and immediate post-operative outcomes. Methods: A single-center retrospective cohort study of adult patients bridged to HT with IABP was conducted between January 2018 and December 2022. Patients were excluded if they were <18 years old, not bridged to HT with IABP, or underwent simultaneous multi-organ transplant. For patients bridged to HT with IABP, beginning in May 2022 the IABP was allowed to continue inflating and deflating during CPB. Upon initiation of CPB, the IABP was set on an internal rate of 80 beats per minute. Patients who underwent HT with IABP turned off while on CPB (IABP-Off) and patients maintained on IABP during HT (IABP-On) were propensity matched according to age, organ ischemia time, and intraoperative dobutamine dose (mcg/kg/min). Results: A total of 70 patients bridged to HT with IABP were propensity matched into IABP-Off (n=12) versus IABP-On (n=12) groups. IABP-Off and IABP-On groups were similar with respect to age (p=0.93), sex (p=0.54), race (p=0.68), BMI (p=0.37), previous sternotomy (p=0.27), and waitlist time (p=0.31). IABP-Off and IABP-On groups had similar organ ischemia times (166.9±40.3 vs. 165.8±55.0 minutes, p=0.96), similar CPB times (109.3±20.6 vs. 111.3±29.7 minutes, p=0.43), and similar case lengths (449.5±108.7 vs. 449.4±115.3 minutes, p=0.50). The groups received similar amounts of intraoperative products and fluids. IABP-Off and IABP-On groups were matched on intraoperative dobutamine dose (2.85±1.73 vs. 3.09±1.76, p=0.74) and received similar doses of other intraoperative inotropes, with the IABP-Off group trending towards a higher norepinephrine dose that did not reach statistical significance. There was no difference in the first measured post-operative lactate between groups, although patients in the IABP-On group had significantly lower peak lactates in the first 24 hours post-transplant (2.39±1.17 vs. 4.31±2.95, p=0.02). There was no difference between groups with respect to post-operative creatinine or length of stay or mortality. Conclusion: Patients maintained on IABP had lower peak lactates in the first 24 hours post-transplant compared to patients in whom IABP was turned off and trended to require less norepinephrine. This limited preliminary data suggests that maintaining pulsatility during CPB may result in improved end-organ perfusion. Table 1. Characteristics of the IABP-Off and IABP-On Cohorts

Is there any difference in the therapeutic effects of Levosimendan on advanced HFrEF patients with sinus rhythm or atrial fibrillation?

Patients with advanced heart failure have a high incidence of atrial fibrillation (AF) and develop into heart failure with reduced ejection fraction (HFrEF), and require higher doses of inotropes. However, it is uncertain about the differences in the effects of levosimendan in HFrEF patients with sinus rhythm or AF. A total of 63 advanced HFrEF subjects (ejection fraction < 40%) were divided into sinus rhythm (SR, n = 34) and atrial fibrillation (AF, n = 29) cohorts. All patients received six cycles of intermittent repeated levosimendan infusion. After 3 months of treatment, B-type natriuretic peptide (BNP), estimated glomerular filtration rate, resting heart rate (rHR), creatinine, left ventricle ejection fraction (LVEF), left ventricular end diastolic diameter and blood pressure body weight, NYHA classification were measured. After completing the course of treatment, LVEF, BNP, and rHR were significantly decreased (p < 0.0.5), and no significant differences between the two groups were observed (p > 0.05). The NYHA classification improved in the SR group but not in the AF group. There was no significant difference between patients with different rHRs (≤70 bpm vs. >70 bpm) in the SR group (p > 0.05) or in the AF group (rHR ≤ 90 bpm vs. rHR >90 bpm) (p > 0.05). This study showed no difference in the therapeutic effect of intermittent repeated levosimendan infusion on advanced HFrEF with different heart rhythms (SR or AF); Advanced HFrEF patients receive levosimendan treatment without taking the inference of heart rhythm.

Analysis of systemic vascular resistance after cardiac surgery: a retrospective cohort study.

Hypotension is a dangerous vital sign frequently encountered during the postoperative management of cardiac surgery. However, factors influencing the systemic vascular resistance index (SVRI), which is strongly related to hypotension, are not well understood. This study evaluated the characteristics of the SVRI according to the type of cardiac surgery. During this retrospective cohort study, we used the clinical data of patients who underwent cardiac surgery at Asahi General Hospital from April 2014 to August 2020. We analyzed their vital signs during the first 12 hours after surgery and evaluated the differences in vital signs among four types of surgery: mitral valve (MV) surgery; aortic valve (AV) surgery; coronary artery bypass grafting (CABG); and thoracic aorta (TA) surgery. Data were compared among these four groups using one-way analysis of variance every 2 hours postoperatively. Those with significant differences were further compared using the post hoc Tukey-Kramer test. A total of 493 patients participated in this study. Overall, the SVRI decreased within 2 hours after the cardiopulmonary bypass surgery. The SVRI after MV surgery was significantly lower than that after other surgery types. The doses of inotropes used for MV surgery and TA surgery were significantly greater than those used for the other surgery types. The SVRI changes significantly after cardiac surgery and may decrease, especially after MV surgery. For better results, it is necessary to consider the differences in the SVRI that are associated with different types of cardiac surgery.

Comparison of the effect of 1:1 and 1:2 frequencies of intra-aortic balloon pump on hemodynamics of the patients undergoing coronary artery bypass graft surgery.

Some patients require intra-aortic balloon pump (IABP) after coronary artery bypass graft (CABG) surgery. IABP can be adjusted to different frequencies such as 1:1, 1:2, or 1:3. In this study, we tried to compare the effect of 1:1 and 1:2 frequencies of IABP on hemodynamic status of the patients after CABG surgery. In this experimental study, all patients using IABP after CABG surgery were entered the study as pretest and posttest groups. The study could not be blinded because of the clearness of posttest group for the same echocardiographist. The pretest group included patients using a 1:1 frequency of IABP device. The posttest group included patients in the pretest group who were exposed to a 1:2 frequency for 20 minutes. In both groups, on the moderate dose of inotropic support, hemodynamic parameters of patients including systolic blood pressure (SBP), diastolic blood pressure (DBP), mean arterial pressure (MAP), heart rate (HR), cardiac output (CO), cardiac index (CI), stroke volume (SV), and velocity time integral (VTI) in the aorta during systole were measured. Both groups were compared using Wilcoxon signed rank test. SPSS software was used for analysis and P < 0.05 was considered to be statistically significant. Twelve patients were entered into the study. Three patients were excluded because of open chest and instability of vital signs. Nine patients completed the study. 3 patients were men and 6 were women. The mean age was 58.32 ± 13.18 years. MAP in 1:1 frequency was significantly higher than 1:2 (P = 0.043); however, there was no significant difference between 1:1 and 1:2 in other hemodynamic parameters, namely CO, CI, SV, HR, and VTI. In patients on moderate dose of inotropes, IABP frequencies of 1:1 and 1:2 have the same effect on hemodynamic parameters such as CI, SBP, DBP, HR, and left ventricular outflow tract (LVOT) VTI; meanwhile, MAP remains higher in 1:1 frequency.

Safety use of high frequency oscillatory ventilation in transport of newborn infants affected by severe respiratory failure: preliminary data in central Tuscany

BackgroundNeonatal Emergency Transport Services play a fundamental role in neonatal care. Stabilization before transport of newborns suffering from severe respiratory failure is often a challenging problem and some critically ill infants may benefit from High Frequency Oscillatory Ventilation (HFOV) as rescue treatment. In these cases, transition to conventional ventilation for transport may cause a deterioration in clinical conditions. HFOV during neonatal transport has been only exceptionally used, due to technical difficulties. Since May 2018, a new neonatal transport unit is available at the Neonatal Protected Transport Service of the Meyer University Hospital in Florence, equipped with a pulmonary ventilator capable of delivering HFOV. Therefore, we conducted an analysis on patients transferred in HFOV to Neonatal Intensive Care Unit (NICU), in order to evaluate the safety and feasibility of its use during neonatal transport.MethodsA retrospective analysis was performed reviewing medical records of the neonates transported by Meyer Children Hospital’s Neonatal Transport Service between May 2018 and December 2020, and newborns treated with HFOV during ground neonatal transport were identified. Safety was assessed by the comparison of vital signs, hemogas-analysis values and pulmonary ventilator parameters, at the time of departure and upon arrival in NICU. The dose of inotropes, the main respiratory complications (air leak, dislocation or obstruction of the endotracheal tube, loss of chest vibrations) and the number of deaths and transfer failures were recorded.ResultsOut of the approximate 400 newborns transported during the analysis period, 9 were transported in HFOV. We did not find any statistically significant difference in vital parameters, hemogas-analytical values and pulmonary ventilator settings recorded before and after neonatal transport of the nine patients’ parameters (p > 0,05). No patient required additional inotropes during transport. No transport-related deaths or significant complications occurred during transport.ConclusionsThe interest of our report is in the possibility of using HFOV during inter-hospital neonatal transfer. As far as our experience has shown, HFOV appears to be safe for the transportation of newborns with severe respiratory failure. Nevertheless, further larger, prospective and multicentre studies are needed to better evaluate the safety and efficacy of HFOV during neonatal transport.

Perioperative junctional ectopic tachycardia associated with congenital heart disease: risk factors and appropriate interventions.

The risk factors and the appropriate interventions for perioperative junctional ectopic tachycardia (JET) in congenital heart disease (CHD) surgery have not been sufficiently investigated despite the severity of this complication. This study aimed to examine the risk factors and interventions for perioperative JET. From 2013 to 2020, 1062 surgeries for CHD (median patient age: 4.3years, range 0.0-53.0) with or without a cardiopulmonary bypass (CPB) were performed at Hokkaido University, Japan. We investigated the correlation between perioperative JET morbidity factors, such as age, genetic background, CPB/aortic cross-clamp (ACC) time, use of inotropes and dexmedetomidine, STAT score, and laboratory indices. The efficacy of JET therapies was also evaluated. Of the 1062 patients, 86 (8.1%) developed JET. The 30-day mortality was significantly high in JET groups (7% vs. 0.8%). The independent risk factors for JET included heterotaxy syndrome [odds ratio (OR) 4.83; 95% confidence interval (CI) 2.18-10.07], ACC time exceeding 90min (OR 1.90; CI 1.27-2.39), and the use of 3 or more inotropes (OR 4.11; CI 3.02-5.60). The combination of anti-arrhythmic drugs and a temporary pacemaker was the most effective therapy for intractable JET. Perioperative JET after CHD surgery remains a common cause of mortality. Inotrope use was a risk factor for developing JET overall surgery risk. In short ACC surgeries, heterotaxy syndrome could increase the risk of JET, which could develop even without inotrope use in long ACC surgeries. It is crucial not to delay the treatment in cases with unstable hemodynamics caused by this arrhythmia. It is recommended to reduce numbers not dose of inotropes.

Acute Pump Thrombosis Within 1 Hour Of Heartmate 3 Implantation.

<h3>Introduction</h3> HeartMate 3 (HM3) and HeartWare (HVAD) are the most commonly used centrifugal Left ventricular assist devices (LVAD) in the current era. Pump thrombosis is a serious adverse event in LVAD patients. The earliest reported case of HM3 pump thrombosis was on the 3rd-day post-implantation. We present a rare case of pump thrombosis within the first hour of implantation. <h3>Case</h3> 39-year-old male with non-ischemic cardiomyopathy (LVEF 20-25%) was referred to our center for advanced heart failure therapies. He was transferred on milrinone 0.25 mcg/kg/min and urgent right heart catheterization was performed: RA 12, PA 46/30 with mean of 30, PCWP 30 mmHg, CO 3.17 L/min and CI 1.5 L/min/m². He was noted to be in cardiogenic shock with INTERMACS 2 profile. After multidisciplinary team discussion, urgent HM3 implantation was done. A thoracotomy and hemi-sternotomy approach was utilized. Before LVAD implantation, the LV cavity was examined and noted to be free of any clot. Heparin was reversed with standard protamine at the conclusion of cardiopulmonary bypass. No blood products or pro-coagulants were administered. Approximately 60 minutes after the end of the surgery, low flow alarms started. Intraoperative transesophageal echocardiogram was still in place and revealed no pericardial effusion or tamponade. Maneuvers including ramping speed and increasing dose of inotropes had no effect; the patient's right ventricular function was adequate, but his aortic valve could not be closed. After sternal reopening, the absence of tamponade was confirmed and there was no kinking of the outflow graft. <h3>Decision Making</h3> Given the acute persistent drop in pump flow despite the above corrective measures, there was a strong suspicion of pump thrombosis. Patient's chest was re-opened. The pump was unlocked from the sewing ring and inspected. The inflow cannula had fresh, nearly occlusive thrombus present (Figure 1). Thrombus involved all centered surfaces and also the outflow side of the pump. Pump exchange without reversal of heparin was performed. The pump was sent to the manufacturer for inspection. Histological analysis confirmed the pump thrombus. The patient's subsequent hypercoagulable workup was negative. <h3>Conclusion</h3> This case represents a unique instance of a very early pump thrombosis and should be kept in mind if new, low flow alarms are encountered immediately post-implant.

Comparing the outcomes of bedside percutaneous VA-ECMO decannulation by ProGlide and Manta in a high-ECMO-volume center in Hong Kong.

The use of veno-arterial extracorporeal membrane oxygenation (VA-ECMO) decannulation with different percutaneous closure devices has been increasing. At our center, ProGlide devices have been used since November 2018, and Manta devices became an alternative since March 2020. This study aimed to compare the success and complication rates and the clinical outcomes of ProGlide and Manta devices for VA-ECMO decannulation after arteriotomy wound closure. We retrospectively reviewed the results of bedside VA-ECMO decannulation between November 2018 and June 2021. Patients with VA-ECMO who could be bridged to recovery were recruited and divided into the ProGlide or Manta group based on the closure device used. Procedure time, amount of blood loss, amount of blood products transfused, and use of vasoactive medications during the procedure were documented. Clinical examination and Doppler ultrasound were performed to detect any complications. After the closure technique, ProGlide was used in 44 patients and Manta was used in 13. There was no significant difference in the success rate between the ProGlide and Manta groups (86.4% vs. 100%). Amount of blood loss was greater in the ProGlide group than in the Manta group (290 [100-400] ml vs. 50 [50-100] ml), and more patients in the ProGlide group required an increased dose of inotropes during the procedure (59.1% vs. 15.4%), but the transfusion requirement was similar between the two groups. The success rate of hemostasis using arteriotomy wound closure during VA-ECMO decannulation was similar between the two devices.

Cerebral Oximetry-Monitored Nitroglycerin Infusion and Tissue Perfusion during Rewarming of Cardiopulmonary Bypass in Cardiac Surgery: A Prospective Randomized Trial.

Background: Nitroglycerin facilitates microcirculation and oxygen delivery through vasodilation. The purpose of this study was to clarify the effects of nitroglycerin-induced vasodilation and potential hypotension on tissue perfusion under cerebral oximetry monitoring during rewarming in cardiopulmonary bypass. Methods: Elective cardiac surgical patients were randomly assigned to either a nitroglycerin group (n = 32) with an intravenous infusion of 1–5 mcg/kg/min or a control group (n = 31) with 0–0.1 mcg/kg/min infusion, since the initiation of rewarming. Perioperative arterial blood gas data were collected in addition to hemodynamic variables, cerebral oximetry values, urine output, and postoperative outcomes. Results: Nearly one-fifth (6/32) of patients in the nitroglycerin group experienced transient (≤5 min) profound hypotension (mean arterial blood pressure ≤40 mmHg) after the initiation of infusion. There were no significant differences between groups in terms of perioperative levels of cerebral oximetry, cardiac index, plasma glucose, lactate, bicarbonate, base excess, or post-bypass activated coagulation time. In the nitroglycerin group, urine output was nonsignificantly higher during cardiopulmonary bypass (p = 0.099) and within 8 h after surgery (p = 0.157). Perioperative transfused blood products, postoperative inotropic doses, extubation time, and intensive care unit stay were comparable for the two groups. Conclusions: Initiation of intravenous nitroglycerin infusion (at 1–5 mcg/kg/min) during rewarming in hypothermic cardiopulmonary bypass resulted in transient profound hypotension in one-fifth of patients and did not improve perioperative cerebral oxygenation, tissue perfusion, and coagulation in cardiac surgery.

High-throughput, real-time monitoring of engineered skeletal muscle function using magnetic sensing

Engineered muscle tissues represent powerful tools for examining tissue level contractile properties of skeletal muscle. However, limitations in the throughput associated with standard analysis methods limit their utility for longitudinal study, high throughput drug screens, and disease modeling. Here we present a method for integrating 3D engineered skeletal muscles with a magnetic sensing system to facilitate non-invasive, longitudinal analysis of developing contraction kinetics. Using this platform, we show that engineered skeletal muscle tissues derived from both induced pluripotent stem cell and primary sources undergo improvements in contractile output over time in culture. We demonstrate how magnetic sensing of contractility can be employed for simultaneous assessment of multiple tissues subjected to different doses of known skeletal muscle inotropes as well as the stratification of healthy versus diseased functional profiles in normal and dystrophic muscle cells. Based on these data, this combined culture system and magnet-based contractility platform greatly broadens the potential for 3D engineered skeletal muscle tissues to impact the translation of novel therapies from the lab to the clinic.

Abstract 12910: Impact of Perioperative Management of Cardiogenic Shock Using Percutaneous Ventricular Assist Device for Cardiovascular Surgery

Introduction: Cardiogenic shock (CS) is still most challenging clinical conditions in cardiovascular medicine. Recently, hemodynamic support using percutaneous ventricular assist device (pVAD) demonstrated feasible and safe for CS, however the use of p-LVAD in the perioperative management presenting refractory CS eligible for cardiovascular surgery (CVS) is still unclear. Hypothesis: We hypothesize that the perioperative use of pLVAD was safe and effective and allow LV unload that can be associated with the good cardiac recovery. Methods: This was a retrospective study including 17 patients admitted at our centers who presented CS and with indication to CSV (average STS score 32.4%), in which p-LVAD was used as a bridge for hemodynamic stabilization. The primary endpoint was the clinical and hemodynamic stabilization before CVS, and the secondary endpoint was cardiac recovery and 30-day mortality. Results: The significant increasing of cardiac power output (0.41 to 0.82 W, p&lt;0.05) with titration the dose of inotropes (inotrope score 10.4 to 6.2, p&lt;0.05) was observed. Serum lactate level was also decreased (5.8 to 1.6, p&lt;0.01), which is indicator of tissue perfusion. The perioperative stabilization allowed the 15 patients (88.2 %) to be eligible for scheduled CVS after a median time of 2.0 days under pLVAD. Postoperatively, all patients could wean off p-PVAD with improvement of LVEF (38.6 to 47.4%, p&lt;0.05). 30-day mortality was 17.6 % which was superior to STS score. Conclusions: The use of the pLVAD is safe and feasible in patients eligible for CVS presenting refractory CS. It is also effective for clinical and hemodynamic stabilization preoperatively and postoperative cardiac recovery and improvement of clinical outcomes.

Effects of Levosimendan on Systemic Perfusion in Patients with Low Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) Score: Experience from a Single Center in Taiwan.

Patients with cardiogenic shock have a high risk of mortality. Intravenous levosimendan can provide pharmacologic inotrope support. We aimed to investigate the effect of levosimendan in patients with extremely severe cardiogenic shock and low Interagency Registry for Mechanically Assisted Circulatory Support (INTERMACS) score with or without mechanical circulatory support. From January 2017 to May 2019, 24 patients with INTERMACS 1-4 were enrolled in this retrospective study. All patients had systemic malperfusion and were treated with levosimendan. Biochemistry data related to systemic perfusion were recorded and compared before and at 24 and 72 hours after levosimendan administration. Echocardiography and Kansas City Cardiomyopathy Questionnaire (KCCQ) were completed 2 months later to assess left ventricular ejection fraction (LVEF) and quality of life (QoL), respectively. Arterial pressure and heart rate did not significantly differ before and after levosimendan administration. Atrial fibrillation and ventricular premature complex increased without significance. The dose of inotropes could be significantly tapered down. There were no significant differences in blood urea nitrogen, creatinine, and lactate levels. Urine output significantly increased (p = 0.018), and liver-related enzymes improved but without significance. B-type natriuretic peptide significantly decreased (p = 0.007) at 24 hours after levosimendan administration. Echocardiography showed significantly improved LVEF 2 months later (22.43 ± 8.13% to 35.87 ± 13.4%, p = 0.001). KCCQ showed significantly improved physical activity and greater relief of symptoms (p = 0.003). The survival-to-discharge rate was 75%. We observed a decrease in B-type natriuretic peptide, better urine output, and alleviated hepatic injury in the levosimendan group. Most patients who survived without transplantation had significantly improved LVEF and better QoL after levosimendan administration.

Managing patients of shock and acute kidney injury in tertiary care cardiac ICU: Experience with continuous renal replacement therapy

BackgroundClinical experience on details of CRRT initiation and outcomes in cardiac intensive care unit (CICU) patients is not available from developing countries like India. This study shares the 5-year clinical experience of managing CICU patients requiring CRRT in a tertiary care cardiac center of North India. Materials and methodsMedical records of all CICU patients with acute kidney injury (AKI) managed by CRRT from October 2011 to September 2016 at tertiary referral center in North India were retrospectively reviewed. Multiple logistic regression analysis was used to identify predictors of post-CRRT mortality. ResultsA total of 630 patients received CRRT during the study period. Most commonly AKI developed in patients with acute coronary syndrome (30.2 %) with cardiogenic shock. 55.9 % of the CRRT patients were >60 years of age, and/or on multiple supports in ICU including, mechanical ventilation, high doses of inotropes & vasopressors and other cardiovascular support. Of those on CRRT, 130 (20.6 %) patients had died, 215 (34.1 %) were discharged and 285 (45.2 %) could not complete the desired course. Multivariate regression analysis showed independent association of mortality with high vasoactive-inotropic score, single CRRT cycle and low mean arterial pressure in CRRT patients. ConclusionAbout 34.1 % of patients receiving CRRT were alive at discharge, emphasizing the feasibility and utility of CRRT as a promising modality in this population for improving outcomes.