Elective Coronary Bypass Grafting Research Articles

Differential effects of heart failure with reduced ejection fraction on locomotor and respiratory muscles

Abstract Background Muscle weakness impairs quality-of-life, exercise capacity, and survival in patients with heart failure and reduced left ventricular ejection fraction (HFrEF). However, the effects on systemic concentrations and local expression of inflammatory cytokines and myokines as well as metabolic markers might differ between locomotor and respiratory muscles. Purpose We prospectively evaluated clinical, functional, and molecular alterations of the diaphragm and the M. vastus lateralis (MVL) from HFrEF patients receiving a left ventricular assist device compared to patients without heart failure undergoing elective coronary bypass grafting (control). Methods Participants (Controls=21, HFrEF=18) underwent cardiopulmonary exercise and respiratory and leg muscle testing. Serum concentrations and local expression of inflammatory cytokines and myokines as well as key enzymes of metabolic pathways were examined in biopsies of the diaphragm and MVL. Results Exercise capacity, respiratory muscle function and endurance force of locomotor muscles were significantly reduced in HFrEF compared with controls (all p<0.05). The serum concentration of Il-6, Il-1beta and TNF-alpha were significantly higher or solely detectable in HFrEF compared with controls. Local mRNA expression of Il-6 was not different in MVL but 2.2-fold higher in the diaphragm of HFrEF compared with controls (p=0.013). In contrast, mRNA expression of Il-6 receptor was significantly reduced by 38% (p=0.004) in MVL of HFrEF compared with controls but comparable in the diaphragm. Serum concentrations of FGF-21 and Musclin were significantly higher in HFrEF compared with controls (all p<0.05). Local mRNA expression of FGF-21 was significantly lower in both MVL and diaphragm of HFrEF compared with controls. FGF-21 receptor 1 mRNA expression was reduced by 18% in the MVL of HFrEF (p=0.02), whereas co-receptor klotho was comparable to controls. In the diaphragm, FGF-21 receptor 1 mRNA expression was comparable between HFrEF and controls, but the co-receptor klotho had a 5-fold higher mRNA expression in HFrEF (p=0.002). We examined the activity of key enzymes of glucose, lipid and ketone metabolism as well as key enzymes of the Krebs cycle. The main differences were found for ß-hydroxyacyl-CoA Dehydrogenase in the diaphragm with a 1.6-fold higher activity in HFrEF compared with controls (p=0.01) and for succinyl-CoA: 3-ketoacid-coenzyme A transferase in the MVL with a 2-fold higher activity in HFrEF compared with controls (p<0.01) indicating a main utilization of lipids in the diaphragm and of ketones in the MVL for energy supply. Conclusions HFrEF induced divergent effects on inflammatory markers, myokine expression and metabolic parameters in locomotor and respiratory muscles in HFrEF patients compared with controls. This indicates that different molecular alterations contribute to locomotor/respiratory muscle dysfunction and reduced whole-body exercise capacity.

An econometric approach to aggregating multiple cardiovascular outcomes in German hospitals

ObjectiveDevelopment of an aggregate quality index to evaluate hospital performance in cardiovascular events treatment.MethodsWe applied a two-stage regression approach using an accelerated failure time model based on variance weights to estimate hospital quality over four cardiovascular interventions: elective coronary bypass graft, elective cardiac resynchronization therapy, and emergency treatment for acute myocardial infarction. Mortality and readmissions were used as outcomes. For the estimation we used data from a statutory health insurer in Germany from 2005 to 2016.ResultsThe precision-based weights calculated in the first stage were higher for mortality than for readmissions. In general, teaching hospitals performed better in our ranking of hospital quality compared to non-teaching hospitals, as did private not-for-profit hospitals compared to hospitals with public or private for-profit ownership.DiscussionThe proposed approach is a new method to aggregate single hospital quality outcomes using objective, precision-based weights. Likelihood-based accelerated failure time models make use of existing data more efficiently compared to widely used models relying on dichotomized data. The main advantage of the variance-based weights approach is that the extent to which an indicator contributes to the aggregate index depends on the amount of its variance.

Learning process and results in endoscopic saphenous vein harvesting technique

Background/Aim: Endoscopic saphenous vein graft harvesting (EVH) has been increasingly used in coronary bypass graft (CABG) surgery in recent years due to its cosmetic advantage and reduced morbidity. However, for the successful application of this technique, a learning process is required. In this study, we aimed to compare the results of the experience we obtained in the initial phase and later periods of the EVH technique. Methods: Forty patients who underwent elective CABG between July 2015 and April 2017 were included in this retrospective cohort study. The first 20 patients (Group 1) and the next 20 patients (Group 2), whose saphenous vein graft (SVG) was prepared with the EVH technique were compared. The length and preparation time of SVGs prepared with EVH, local findings such as hematoma, necrosis, wound infection, and healing, demographic data, comorbidity, intraoperative and postoperative data, postoperative intensive care and hospitalization times, cosmetic satisfaction and wearing compression stockings were recorded. Results: While the mean operation time was 201.4 (25.0) minutes in Group 1, it was 184.6 (17.1) minutes in Group 2 (P=0.018). There was no difference in the mean SVG lengths between the groups (P>0.05). While SVG preparation time was 75.3 (26.2) minutes in Group 1, it was 35.4 (6.0) minutes in Group 2 (P<0.001). The number of minor branch injuries in the SVG in Groups 1 and 2 were eight (40%), and two (10%), respectively, and all underwent primary repair (P<0.001). Mean length of hospital stay was similar between the groups (P=0.955). No hematoma, infection or necrosis requiring surgical intervention was observed in the extremity from which the SVG was taken. The use of compression stockings was longer in group 1 than in group 2 for the reduction or complete disappearance of edema (56.4 (23.3) vs 42.0 (19.4) days, P=0.040). No patient in any of the groups required rehospitalization due to infection at the saphenous vein incision site and incision healing problem. According to the satisfaction survey, cosmetic satisfaction was high in both groups (P=0.530). Conclusion: We think that after the completion of the learning process on twenty patients, the EVH technique can be used more widely, with much better results in terms of both patient cosmetic satisfaction and reducing morbidity.

Purchases of medical therapy recommended for coronary artery disease before and after elective revascularisation

AimsWe studied the purchases of medical therapy recommended for coronary artery disease patients before and after elective revascularisation (percutaneous coronary intervention (PCI) or coronary bypass grafting (CABG)).MethodsAll patients who underwent an elective PCI (N = 1557) or CABG (N = 1768) at the Heart Center, Kuopio University hospital between 2007 and 2014 were included. Data were collected from the hospital’s coronary register and national registers, and obtained for 3 years before and 1 year after the revascularisation.ResultsAltogether 85.2% of PCI patients and 88.1% of CABG patients had purchased lipid-modifying agents before the procedure, and 94.9% and 96.8% during the post-procedure follow-up year, respectively. Beta-blocking agents were purchased by 84.9% of PCI patients before and by 87.9% after the procedure and by 86.3% of CABG patients before and 97.1% after the operation. Of PCI patients, 64.3% had purchased organic long-acting nitrates before the procedure and 54.4% also after the procedure. Among CABG patients, the purchase of organic long-acting nitrates fell from 59.7% before to 10.1% after the operation. The use of ADP receptor blocking agents increased in PCI patients (26.3 to 83.9%) and the use of warfarin in CABG patients (9.4 to 21.3%). Medication purchases were more common among those who had greater use of hospital services before and after the procedures.ConclusionsIn both PCI and CABG patients, the use of medical therapy before and after revascularisation procedure complied with current guidelines. Purchases of long-acting nitrates were common in the PCI group even after the procedure.

P5983Pre-operative physical performance as an independent predictor of in-hospital outcomes in older patients undergoing elective cardiac surgery

Abstract Introduction Risk stratification of patients candidate to cardiac surgery is usually based on the Society of Thoracic Surgeons (STS) score or on the Euroscore II. However, these risk scores has limited predictive value in elderly patients. Purpose We conducted a study to determine whether the Short Physical Performance Battery (SPPB), a tool assessing physical performance, predicts hospital death and major morbidity, beyond STS risk score. The outcome was a composite end-point as defined by STS Major Morbidity or Operative Mortality (STS-MM) in STS Risk Model Outcomes: operative mortality, stroke, renal failure, prolonged mechanical ventilation, deep sternal wound infection, and reoperation. Methods In this prospective, single-center, cohort, hospital-based study, conducted at Careggi University Hospital, Florence, Italy, all patients aged 75+ years referred for an elective coronary aortic by-pass grafting, valvular surgery or combined cardiac surgery were evaluated pre-operatively. Assessment included SPPB, cognitive and functional status and evaluation of comorbidity. Patients receiving emergency/urgent cardiac surgery or a procedure not considered in the STS risk score calculator, who reported previous cardiac surgery or were clinically unstable were excluded. Participants were classified according to the STS-Predicted Risk Of Mortality (STS-PROM) as at low (&lt;4%), intermediate (4 to 8%) or high risk (&gt;8%). Results Out of 250 participants (females: 48.4%; mean age: 79.9 years), 148 (59.2%) were at low, 73 (29.2%) at intermediate and 29 (11.6%) at high risk, based on the STS-PROM. Mean±SEM SPPB score was 8.8±0.2, 7.1±0.4 and 6.0±0.7 in participants at low, intermediate, and high risk, respectively (p&lt;0.001). The outcome occurred in 67 subjects (26.8%). SPPB score predicted the outcome in the entire study sample, controlling for STS-MM score, CKD, and anaemia (adjusted OR: 0.89, 95% CI 0.81–0.98 per each point increase; p 0.017). When analyses were repeated separately in participants with STS-PROM indicative of low (&lt;4%) and in those at medium-high risk, the predictive value of SPPB was enhanced in the formers (adjusted OR 0.73, 95% CI 0.62–0.86 per each point increase; p&lt;0.001- controlling for STS score), whereas was lost in the latter. An alternative model was subsequently tested, where STS score was not included and peripheral artery disease and creatinine (variables contributing to the STS score) were individually entered: SPPB was confirmed as a significant predictor also in this model, controlling for anaemia, peripheral artery disease, and creatinine. The corresponding AUC was 0.813 (Figure 1). Figure 1 Conclusions SPPB predicts mortality and major morbidity in older patients undergoing elective cardiac surgery, in particular in those classified as low-risk with the STS risk score. Use of SPPB should therefore be recommended to improve preoperative risk stratification of older patients.

Application of strain and other echocardiographic parameters in the evaluation of early and long-term clinical outcomes after cardiac surgery revascularization

BackgroundCoronary artery bypass graft (CABG) surgery is an effective therapeutic strategy for coronary heart disease (CHD). Myocardial longitudinal strain echocardiography with 2D speckle tracking could obtain ventricular function with better accuracy and reliability than the left ventricular ejection fraction.The aim of the study was to assess changes in left ventricular function in patients before and after surgical revascularization for a 24-month period of observation, using echocardiography with speckle tracking strain imaging. We searched for echocardiographic predictors of poor early and long-term outcome after CABG.MethodsWe enrolled 69 patients scheduled for elective coronary bypass grafting. Patients were divided into groups based on pre-operative systolic and diastolic parameters, depending on the GLS value and the E’ Lat and E/E’ value. The correlation between these parameters and early and long-term outcomes was analyzed.ResultsPreoperative EF was preserved in 86, 95% (60) patients. Pre-operative reduced GLS was observed in 73.91% (51) of patients and severely reduced in 31.88% (22).In the first post-operative 6-month period, we observed a significant decrease in the GLS. The GLS was a predictor of early postoperative outcome for intubation time, the inotropes use and length of ICU stay. Diastolic dysfunction was a predictor of the greater inotrope requirements.ConclusionsGlobal longitudinal strain and diastolic dysfunction parameters are a good predictors of worse early outcome after CABG.

VAA ECMO: A Hybrid Cannulation Strategy in a Patient with Severe Peripheral Arterial Disease

Introduction Peripheral arterial disease (PAD) can restrict vascular access options for venoarterial extracorporeal membrane oxygenation (VA ECMO). In emergent situations, a comprehensive vascular assessment is impractical, and when severe PAD is encountered, cannulation approaches may be limited. We report a successful cannulation strategy in a patient with severe PAD using bilateral femoral arterial access. Case A 69-year-old White male with ischemic cardiomyopathy with baseline EF 20-25%, coronary bypass grafting (CABG), and peripheral arterial disease (PAD) was admitted to an outside hospital for an elective redo CABG. He had post-cardiotomy shock requiring inotropes and a balloon pump. In 48 hours, he progressed to refractory cardiogenic shock and multiorgan failure with oliguria, coagulopathy, and mild cognitive impairment. VA-ECMO was emergently initiated as a potential bridge to durable ventricular assist device, pending renal recovery.After cut down, heavy circumferential calcification of the left common femoral artery (CFA) was observed, with no palpable pulse. Seldinger technique with incremental dilation was performed. However, a standard 180 cm wire met resistance and could not be advanced beyond 20 cm. Hoping this was extensive plaque, rather than a complete occlusion, a 19-French arterial cannula was placed, with a 6-French antegrade perfusion cannula in the left superficial femoral artery (SFA). ECMO was initiated and only 1 L of flow at 4000 RPM was achieved, indicating the resistance encountered likely implied a complete or critical stenosis of the left iliac artery. A second 19-French arterial cannulation in the right CFA was performed with no resistance this time. The arterial cannulae were connected in a Y configuration and ECMO resumed with roughly 3.5 L at 4000 RPM. The right common femoral vein was accessed with a 21-French venous cannula.He was extubated in less than 48 hours and did well for about 5 days, with evidence of LV recovery on ramp studies. Unfortunately, he then developed hypoxic respiratory failure, hemoptysis, recurrence of multiorgan failure, and hemodynamic instability, suspicious for septic shock. At this point, his family elected to initiate comfort measures, particularly in light of worsening cognitive status. Summary Atherosclerotic vessels pose access difficulties and risk vascular complications. As such, severe PAD often limits patient selection for VA ECMO. To the best of our knowledge, this is the first reported case utilizing a bilateral femoral arterial approach to augment a low flow state in the setting of severe PAD. Various hybrid cannulation strategies may be considered with respect to individual anatomy and broaden the patient pool eligible for VA ECMO.

Effects of sodium pyruvate solution used in autologous blood recovery on function of salvaged red blood cells

Objective To assess effects of sodium pyruvate solution used in autologous blood recovery on function of salvaged red blood cells (RBCs). Methods Thirty patients whose blood was autologously recovered and processed using a Dideco Electa device were enrolled.Fifteen patients undergoing elective off-pump coronary artery bypass grafting surgery were assigned to 0.9% sodium chloride solution group (C group), and fifteen patients undergoing elective total cystectomy were assigned to sodium pyruvate solution group (P group). Hemolytic ratio, P50[the oxygen partial pressure(PO2) corresponding to 50% saturation of the hemoglobin with oxygen], 2,3-disphosphoglycerate(2,3-DPG), sodium(Na+), potassium(K+), lactic acid (Lac) and blood glucose (Glu) of venous RBCs (extracted from the patient's central vein when beginning to wash the collected blood in the reservoir, time T1), salvaged RBCs at 0 h(time T2), salvaged RBCs at 4 h(storage at 21-24 ℃, time T3) and salvaged RBCs at 24 h(storage at 1-6 ℃, time T4) of the two group were measured and compared. Results At time T1, there was no statistically significant difference between all indexes of two groups (P>0.05). At time T2, T3 and T4, there was no statistically significant difference between hemolytic ratio, Glu, 2,3-DPG and P50 value of two groups (P>0.05), but Na+, K+ and Lac value of C group were statistically significant higher than those values of P group (P<0.05). Conclusions The effect of sodium pyruvate solution as washing solution on salvaged RBCs was better than the effect of 0.9% sodium chloride solution. Key words: Sodium pyruvate; Autologous blood recovery; Red blood cell

Selenium, Vitamin C and N-Acetylcysteine do not Reduce the Risk of Acute Kidney Injury after Off-Pump CABG: a Randomized Clinical Trial.

ObjectiveThe aim of this study was to investigate the impact of perioperative administration of N-acetylcysteine, selenium and vitamin C on the incidence and outcomes of acute kidney injury after off-pump coronary bypass graft surgery.Methods291 patients requiring elective off-pump coronary bypass graft surgery were randomized to receive either N-acetylcysteine, vitamin C and selenium 600 mg, 1500 mg, 0.5 mg, and nothing orally twice a day, respectively, from the day before to 2 days after surgery. They were assessed for the development of acute kidney injury using Acute Kidney Injury Network criteria, time of onset, its severity and duration, duration of mechanical ventilation, intensive care unit and hospital length of stay, and in-hospital mortality.Results272 patients completed the study. The total incidence of acute kidney injury was 22.1% (n=60) with 14 (20.9%), 15 (22.1%), 21 (31.8%), and 10 (14.1%) patients in the vitamin C, NAC, selenium, and control groups, respectively (P=0.096). We did not register significant differences in the incidence, the time of occurrence, the severity and the duration of acute kidney injury, as well as the duration of mechanical ventilation, the intensive care unit and hospital length of stay, and the in-hospital mortality among the four groups.ConclusionWe found that perioperative administration of N-acetylcysteine, vitamin C and selenium were not effective in preventing acute kidney injury and associated morbidity and mortality after off-pump coronary bypass graft surgery.

Effect of time of discontinuing clopidogrel administration before operation on blood-saving effect of tranexamic acid

Objective To evaluate the effect of time of discontinuing clopidogrel administration before operation on blood-saving effect of tranexamic acid. Methods One hundred and eighty patients of both sexes, aged 18-70 yr, weighing 45-85 kg, scheduled for elective first coronary artery bypass grafting under cardiopulmonary bypass, were divided into A, B and C groups (n=60 each) according to clopidogrel use before operation. In group A, clopidogrel 75 mg/d was taken orally, and time of stopping clopidogrel administration before operation <7 days.In group B, clopidogrel 75 mg/d was taken orally, and time of stopping use of clopidogrel before operation ≥7 days.Patients received no clopidogrel before operation in group C. After induction of anesthesia, tranexamic acid was infused at a loading dose of 10 mg/kg over 20 min, followed by an infusion of 10 mg·kg-1·h-1 until the end of operation.Blood loss and requirement for allogeneic erythrocytes, plasma and platelet were recorded before removal of drainage tubes after operation.The dose of heparin and protamine was recorded.The development of perioperative adverse reactions was also recorded. Results There was no significant change in the amount of heparin and protamine, ratio of protamine to heparin for heparin neutralization or incidence of perioperative adverse reactions between the three groups (P>0.05). Compared with group C, the incidence of major bleeding, transfusion of and requirement for allogeneic erythrocytes, plasma and platelets were significantly increased in group A (P 0.05). There was no significant difference in postoperative blood loss or transfusion of allogeneic erythrocytes, plasma and platelets between group B and group A (P>0.05). Conclusion The time of discontinuing clopidogrel administration before operation exerts no effect on blood-saving effect of tranexamic acid. Key words: Platelet aggregation inhibitors; Tranexamic acid; Blood transfusion

Effectiveness of minimal acute normovolemic hemodilution to minimize allogenic blood transfusion and re-exploration in elective adult coronary artery bypass graft surgery using colloid as a replacement solution

Background and aim Various studies have questioned the efficacy of intraoperative acute normovolemic hemodilution (ANH) in reducing bleeding, the need for allogenic transfusion, and the incidence of re-exploration in cardiac surgery. The aim of the present study was to evaluate the effectiveness of the use of minimal ANH for blood transfusion requirements and re-opening in elective adult coronary artery bypass graft surgery using cardiopulmonary bypass. Patients and methods This prospective, randomized controlled study was conducted on 100 consecutive adult patients who underwent elective coronary artery bypass graft. Patients were randomly divided into two equal groups: the ANH group (n=50) and the control group (n=50). In the ANH group, 5–8 ml/kg of autologous blood was withdrawn after administering anesthesia and before systemic heparinization. Simultaneously, colloid solution (6% hydroxyethyl starch 130/0.4; Voluven) was infused in a ratio of 1:1, and then the blood was re-infused after bypass. Hemodilation was not carried out for the control group. Total amount of allogenic-packed red blood cell, fresh frozen plasma, platelet concentrate transfusion, and the number of patients undergoing re-opening because of excessive bleeding were calculated for the two groups. Results A significant decrease was observed in the number of red blood cell units and fresh frozen plasma transfusion per patient in the ANH group compared with the control group. Conversely, chest tube output, representing postoperative bleeding and platelet count, did not differ between the two groups. Conclusion In this study, the use of the minimal ANH technique reduced the consumption of allogenic red blood cells and fresh frozen plasma in adult cardiac surgery patients. However, this technique had no effect on postoperative bleeding, incidence of re-exploration, and platelet count.

Efficacy of preoperative infusion of glutamine for myocardial protection in patients undergoing cardiac surgery with cardiopulmonary bypass

Objective To evaluate the efficacy of preoperative infusion of glutamine for myocardial protection in patients undergoing cardiac surgery with cardiopulmonary bypass(CPB). Methods Forty patients, aged 18-80 yr, of ASA physical status Ⅰ-Ⅲ(NYHA Ⅰ-Ⅲ), scheduled for elective cardiac valve replacement and/or coronary artery bypass grafting with CPB, with their left ventricular ejection fraction ≥40%, were enrolled in the study.The patients were randomly divided into 2 groups using a random number table: glutamine group(group G, n=18)and control group(group C, n=22). In group G, the mixture of glutamine 0.4 g/kg(2 ml/kg)and 8.5% compound amino acid(10 ml/kg)was infused over 1 h starting from 24 and 1 h before surgery.Lactated Ringer's solution 12 ml/kg was infused intravenously over 1 h starting from 24 and 1 h before surgery.Before skin incision, at the end of surgery and at 20 h after surgery, venous blood samples were collected for detection of malondialdehyde(MDA)concentrations using ELISA.Before skin incision and at 6 and 20 h after restoration of spontaneous heart beat, venous blood samples were collected to determine the plasma concentration of cardiac troponin I(cTnI). The restoration of spontaneous heart beat, ventricular pacing, postoperative ventilation time, duration of ICU stay, consumption of dopamine and dobutamine during ICU stay, total postoperative length of hospital stay, adverse events such as heart failure, respiratory failure, abnormal hepatic and renal function, and the mortality rate during hospital stay were recorded. Results A total of 15 patients in group G and 18 patients in group C completed the study.Compared to group C, the plasma cTnI concentration at 20 h after restoration of spontaneous heart beat, plasma MDA concentration before operation, at the end of operation and at 20 h after operation, and consumption of dopamine during ICU stay were significantly decreased in group G. There was no significant difference between the two groups in the constituent ratio of mode of spontaneous heart beats, rate of ventricular pacing after spontaneous heart beats, postoperative duration of mechanical ventilation, consumption of dobutamine during ICU stay, duration of ICU stay, postoperative length of hospital stay, incidence of postoperative adverse effects, and mortality rate. Conclusion Although preoperative infusion of glutamine can inhibit oxidative stress response and attenuate postoperative myocardial injury, it provides no clinical significance in the patients undergoing cardiac surgery with CPB. Key words: Glutamine; Cardiac surgical procedures; Cardiopulmonary bypass; Myocardium; Prognosis

Impact of Sleep Disordered Breathing on Morbidity and Mortality after Elective Coronary Bypass Graft Surgery -A Bicentric Prospective Controlled Observational Study

Objectives: Concomitant sleep disordered breathing (SDB) is common in patients undergoing coronary artery bypass graft surgery (CABG). However, SDB is significantly underdiagnosed in these patients although its impact on postoperative recovery is considerable. Aim of this prospective study was to evaluate SDB as a risk factor for postoperative morbidity and to identify SDB related postoperative CABG complications.

The effect of lidocaine and amiodarone on prevention of ventricular fibrillation in patients undergoing coronary artery bypass grafting.

Ventricular fibrillation is common after aortic declamping in patients undergoing open heart surgery. This situation has a negative impact on morbidity and mortality. The aim of this prospective study was to compare the effect of administering lidocaine versus amiodarone before aortic declamping during elective coronary bypass grafting, paying close attention to when the initial effect of amiodarone sets in. In this double blind, prospective, randomized, controlled study, 86 patients who were candidates for elective coronary artery bypass grafting were recruited into three groups: group lidocaine (group L, n=29); group amiodarone (group A, n=27); and group placebo (group P, n=30). Group L patients received 1.5 mg/kg of lidocaine 2 minutes before aortic declamping and group A patients received 300 mg of amiodarone intravenously 15 minutes before release of the aortic cross clamp. The primary endpoints were the incidence of ventricular fibrillation and the number of shocks required to terminate ventricular fibrillation. The frequency of ventricular fibrillation occurrence was significantly higher in group P (70%) when compared with group A (37%) and group L (38%) (P=.017). There was no statistically significant difference between the amiodarone and the lidocaine groups regarding ventricular fibrillation. However, when ventricular fibrillation occurred, the percentage of patients requiring electrical defibrillation was significantly higher in both group L and group P when compared with group A (P=.023). We suggest that during coronary arterial bypass surgery, administration of an amiodarone regime before release of the aortic cross clamp, paying particular attention to the start of the initial effect of amiodarone, is no more effective than lidocaine for prevention from arrhythmia; however, amiodarone reduces the need for electrical defibrillation.

Intraoperative bispectral index monitoring and time to extubation after cardiac surgery: secondary analysis of a randomized controlled trial.

BackgroundFast track recovery is a care process goal after cardiac surgery. Intraoperative anesthetic depth may impact recovery, but the impact of brain monitoring on time to extubation and intensive care unit (ICU) length of stay after cardiac surgery has not been extensively studied. Our goal was to determine if BIS-guided anesthesia improves time to extubation compared to MAC-guided anesthesia in a cardiac surgery population.MethodsIn this secondary outcome analysis of a randomized controlled study, we analyzed 294 patients undergoing elective coronary bypass grafting, valve replacements, and bypass plus valve replacements at a single tertiary referral center between February 1, 2009 and April 30, 2010. We analyzed cardiac surgery patients that had been randomized to BIS-guided anesthesia alerts (n = 131) or MAC-guided anesthesia alerts (n = 163). The primary outcome measure was time to extubation in the BIS-guided and anesthetic concentration-guided groups. Secondary outcomes were length of stay in the ICU and total postoperative hospital length of stay.ResultsValid extubation time data were available for 247 of 294 patients. The median [IQR] time to extubation was 307 [215 to 771] minutes in the BIS group and 323 [196 to 730] minutes in the anesthetic concentration group (p = 0.61). The median [IQR] ICU length of stay was 54 [29 to 97] hours versus 70 [44 to 99] hours (p = 0.11). In terms of postoperative hospital length of stay, there was no difference between the groups with median [IQR] times of 6 [5-8] days (p = 0.69) in each group.ConclusionsThe use of intraoperative BIS monitoring during cardiac surgery did not change time to extubation, ICU length of stay or hospital length of stay. Data regarding BIS monitoring and recovery in an exclusively cardiac surgery population are consistent with recent effectiveness studies in the general surgical population.Trial registrationClinicalTrials.gov number NCT00689091.

Acute Effect of Intravenous Administration of Magnesium Sulfate on Serum Levels of Interleukin-6 and Tumor Necrosis Factor-α in Patients Undergoing Elective Coronary Bypass Graft With Cardiopulmonary Bypass.

Background:Cardiovascular problems are among the most common health issues. A considerable number of cardiac patients undergo cardiac surgery, and coronary artery disease patients constitute about two-thirds of all these surgeries. The application of cardiopulmonary bypass (CBP) usually results in some untoward effects.Objectives:Studies have suggested magnesium sulfate (MgSO4) as an anti-inflammatory agent in a coronary artery bypass graft (CABG). This study aimed to assess the effect of an IV MgSO4 infusion during elective CABG (with CBP) on the blood levels of interleukin-6 (IL-6) and tumor necrosis factor alpha (TNF-α).Materials and Methods:During a 12 month period, after review board approval and based on inclusion and exclusion criteria, 90 patients were selected and entered randomly into one of the two study groups (MgSO4 or placebo). Anesthesia, surgery and CBP were performed in exactly the same way, except for the use of MgSO4 or a placebo. Both preoperative and postoperative plasma levels of IL-6 and TNF-α were checked and compared between the two groups using an ELISA.Results:There was no difference found between the two groups with regard to; gender, basic variables, Ejection Fraction (EF), CBP time and aortic cross-clamp time. The preoperative levels of IL-6 and TNF-α were not different; however, their postoperative levels were significantly higher in the placebo group (P value = 0.01 for IL-6 and 0.005 for TNF-α).Conclusions:This study showed that MgSO4 infusion could suppress part of the inflammatory response after CABG with CBP. This was demonstrated by decreased levels of interleukin-6 and TNF-α in postoperative serum levels in elective CABG with CBP.

A comparative clinical study of dexmedetomidine versus placebo to attenuate hemodynamic response to endotracheal intubation in patients undergoing off pump coronary arterial bypass grafting

Context: Direct laryngoscopy and endotracheal intubation are the most stressful periods during induction of anesthesia. These events can lead to hypertension, tachycardia, arrhythmias and myocardial ischaemia. Aims: (1) To evaluate the haemodynamic response to laryngoscopy and endotracheal intubation with a single preinduction infusion of dexmedetomidine (DEX) 1 μg/kg over a 10 min period, (2) To assess the incidence of side effects, that is, rebound hypertension, bradycardia and hypotension etc., associated with the use of DEX. Settings and Design: This was a prospective, double-blind, parallel group randomized clinical trial of DEX (1 μg/kg) before anesthetic induction to study the attenuation of hemodynamic response to endotracheal intubation in 60 adult patients undergoing elective off pump coronary arterial bypass grafting. Materials and Methods: Patients were randomly allocated to receive either DEX (DEX group, n = 30) or 0.9% normal saline (PLA group, n = 30). Hemodynamic variables were recorded at baseline (Abbreviated as TB), after completion of drug infusion (Abbreviated as TC), 3 min after induction and immediately before intubation (T0), at the 1 st (T1), 3 rd (T3) and 5 th (T5) min after intubation. Statistical Analysis Used: The data are presented as mean ± standard deviation. Demographic data were analysed by Student's t-test between the two groups. Analysis of variance for repeated measures f-test was used to analyze changes over time. A P < 0.05 was considered as significant and P < 0.01 or 0.001 was considered as highly significant. Results: All the hemodynamic variables were comparable in both groups at baseline. Heart rate values were statistically significantly lower in the DEX group at TC and highly statistically significantly lower at T1, T3 and T5 values. Systolic blood pressure values were statistically significantly lower in the DEX group at T0 and highly statistically significantly lower at T1, T3 and T5. Diastolic blood pressure and mean blood pressure values and systolic pulmonary artery pressure values were highly statistically significantly lower in the DEX group at T1, T3 and T5. Diastolic pulmonary artery pressure were statistically significantly lower in the DEX group at TC, T0 and T1 and highly statistically significantly lower at T3. Mean pulmonary artery pressure were statistically significantly lower in the DEX group at T0 and highly statistically significantly lower at TC, T1 and T3. Arterial oxygen saturation was statistically significantly lower in the DEX group at TC. There was no case of hypotension or bradycardia in our case series. Conclusions: Dexmedetomeditine (1 μg/kg) attenuates hemodynamic response to laryngoscopy and intubation in elective surgery for off pump coronary artery bypass grafting.

Prophylaxis with erythropoietin versus placebo reduces acute kidney injury and neutrophil gelatinase-associated lipocalin in patients undergoing cardiac surgery: a randomized, double-blind controlled trial

BackgroundCardiac surgery-associated acute kidney injury (CSA-AKI) is a common complication following coronary bypass graft (CABG) surgery. Multi-factorial causes of CSA-AKI involve oxidative stress and inflammation. Erythropoietin (EPO) has been shown from many studies to have a reno-protective effect. The present study was conducted to examine the role of EPO in preventing CSA-AKI.MethodsThis prospective, randomized, double-blind, placebo-controlled trial was conducted in the Cardiovascular and Thoracic Unit. One hundred patients randomly received either 200 U/kg of rHuEPO (n = 50) or saline (n = 50) intravenously three days before operation, and rHuEPO 100 U/kg or saline at operation time. The serum creatinine (SCr), estimated glomerular filtration rate (eGFR) and urine neutrophil gelatinase-associated lipocaline (NGAL) were measured in order to evaluate renal injury following CABG.ResultsThe incidence of CSA-AKI was significantly lower in rHuEPO group (14%) when compared with the placebo group (38%; p < 0.01). The mean intensive care unit (ICU) and hospital stays of the rHuEPO group were significantly shorter than the placebo group (p < 0.01). Postoperative increases in SCr and decreases in eGFR were significantly lower in the rHuEPO group than the placebo group (p < 0.05). The mean urine NGAL in rHuEPO group was significantly lower than the placebo group at 3 hr, 6 hr, 12 hr and 18 hr after CABG (p < 0.05), respectively.ConclusionsProphylaxis administration with intravenous rHuEPO before cardiac surgery decreased the incidence of CSA-AKI and urine NGAL with reduced days in ICU and hospital in elective CABG patients.Trial registrationClinicalTrials.gov: NCT01066351

Minimal extracorporeal circulation improves outcome in diabetic patients undergoing elective coronary bypass grafting – a prospective randomized study

Minimal extracorporeal circulation improves outcome in diabetic patients undergoing elective coronary bypass grafting – a prospective randomized study

Açık Kalp Cerrahisi Sırasında Kardiyopulmoner Baypas Sonrası Oluşan Akciğer İskemisi-Reperfüzyon Hasarını Önlemede E Vitamininin Etkinliği

Objective: The purpose of the study was to investigate the effects of vitamin E in the protection of the lung from potential ischemia-reperfusion injury during elective coronary artery bypass graft surgery. Material and Methods: This controlled randomized single-center study included patients who underwent elective coronary bypass grafting (CABG) operation. Forty-nine patients were randomly divided into 2 groups. Water soluble Vitamin E (100 mg) in tepid saline (n=25) or tepid saline alone (n=24) was administered via the jugular vein before the aortic cross clamping. Serum total antioxidant capacity (TAC) levels and serum malonedialdehyde levels (MDA) were measured. Pulmonary biopsies were obtained before the aortic cross clamping and 60 minutes after removing the cross clamp. Biopsies were examined histopathologically under electron microscopy. Results: Serum MDA levels at T1 (15 minutes after removal of the cross clamp) and T2 (30 minutes after removal of the cross clamp) were higher in the control group compared to the Vitamin group. Serum TAC levels at T1, T2 and T3 (60 minutes after removal of the cross clamp) were higher in the Vitamin E group compared to the control group. Histopathologic injury grade was lower in the Vitamin E group than in the control group. Conclusion: Vitamin E was found to be protective against reperfusion induced oxidative injury in the early operative period.