Femoral Arterial Cannula Research Articles

Noninvasive Monitoring of Changes in Cerebral Hemodynamics During Prolonged Field Care for Hemorrhagic Shock and Hypoxia-Induced Injuries With Portable Diffuse Optical Sensors.

Achieving simultaneous cerebral blood flow (CBF) and oxygenation measures, specifically for point-of-care injury monitoring in prolonged field care, requires the implementation of appropriate methodologies and advanced medical device design, development, and evaluation. The near-infrared spectroscopy (NIRS) method measures the absorbance of light whose attenuation is related to cerebral blood volume and oxygenation. By contrast, diffuse correlation spectroscopy (DCS) allows continuous noninvasive monitoring of microvascular blood flow by directly measuring the degree of light scattering because of red blood cell (RBC) movement in tissue capillaries. Hence, this study utilizes these two optical approaches (DCS-NIRS) to obtain a more complete hemodynamic monitoring by providing cerebral microvascular blood flow, hemoglobin oxygenation and deoxygenation in hemorrhage, and hypoxia-induced injuries. Piglet models of hemorrhage and hypoxia-induced brain injury were used with DCS and NIRS sensors placed over the preorbital to temporal skull regions. To induce hemorrhagic shock, up to 70% of the animal's total blood volume was withdrawn through graded hemorrhage serially via a syringe from a femoral artery cannula in 10 mL/kg aliquots over 1 minute every 10 minutes. A second group of animals was subjected to hypoxia for ∼1 hour through graded hypoxia by serial titration from normoxic fraction inspired oxygen of 21% to hypoxic fraction inspired oxygen of 6%. A subset of animals served as sham-controls undergoing anesthesia, instrumentation, and ventilation as the injury groups, yet experiencing no blood loss or hypoxia. We first investigated the relationship between hemorrhagic shock and no shock by using measured biomarkers, including blood flow index from DCS associated with CBF and oxygenated (HbO) and de-oxygenated hemoglobin from NIRS. The statistical analysis revealed a significant difference between no shock and hemorrhagic shock (P < .01). The HbO decreased with each blood loss as expected, yet the de-oxygenated hemoglobin was slightly changed. During hypoxia-induced global hypoxic-ischemic injury tests, the CBF results from graded hypoxia were consistent with the response previously measured during hemorrhagic shock. Moreover, HbO decreased when the animal was hypoxic, as expected. A statistical analysis was also conducted to compare the results with those of the sham controls. There is a consistency in blood flow measures in both injury mechanisms (hemorrhagic shock and hypoxia), which is significant as the new prototype system provides similar measures and trends for each brain injury type, suggesting that the optical system can be used in response to different injury mechanisms. Notably, the results support the idea that this optical system can probe the hemodynamic status of local cerebral cortical tissue and provide insight into the underlying changes of cerebral tissue perfusion at the microvascular level. These measurement capabilities can improve shock identification and monitoring of medical management of injuries, particularly hemorrhagic shock, in prolonged field care.

Harnessing extracellular cold-inducible RNA binding protein by PS-OMe miR130: A promising shield against hemorrhage-induced lung injury.

Hemorrhagic shock (HS) poses a life-threatening condition with the lungs being one of the most susceptible organs to its deleterious effects. Extracellular cold-inducible RNA binding protein has emerged as a pivotal mediator of inflammation, and its release has been observed as a case of HS-induced tissue injury. Previous studies unveiled a promising engineered microRNA, designated PS-OMe miR130, which inhibits extracellular cold-inducible RNA binding protein, thereby safeguarding vital organs. In this study, we hypothesized that PS-OMe miR130 serves as a protective shield against HS-induced lung injury by curtailing the overzealous inflammatory immune response. Hemorrhagic shock was induced in male C57BL6 mice by withdrawing blood via a femoral artery cannula to a mean arterial pressure of 30 mm Hg for 90 minutes. The mice were resuscitated with twice the shed blood volume with Ringer's lactate solution. They were then treated intravenously with either phosphate-buffered saline (vehicle) or 62.5 nmol PS-OMe miR130. At 4 hours later, blood and lungs were harvested. Following PS-OMe miR130 treatment in HS mice, a substantial decrease was observed in serum injury markers including aspartate aminotransferase, alanine transaminase, lactate dehydrogenase, and blood urea nitrogen. Serum interleukin (IL)-6 exhibited a similar reduction. In lung tissues, PS-OMe miR130 led to a significant decrease in the messenger RNA expressions of pro-inflammatory cytokines (IL-6, IL-1β, and tumor necrosis factor α), chemokines (keratinocyte-derived chemokine and macrophage inflammatory protein 2), and an endothelial injury marker, E-selectin. PS-OMe miR130 also produced substantial inhibition of lung myeloperoxidase activity and resulted in a marked reduction in lung injury as evidenced by histological evaluation. This was further confirmed by the observation that PS-OMe miR130 significantly reduced the presence of lymphocyte antigen 6 family member G-positive neutrophils and terminal deoxynucleotidyl transferase dUTP nick end labeling-positive apoptotic cells. PS-OMe miR130 emerges as a potent safeguard against HS-induced lung injury by effectively inhibiting pro-inflammation and injuries, offering a promising therapeutic strategy in such critical clinical condition.

Lilrb4 ameliorates ileal injury in rats with hemorrhagic shock and suppresses the activation of NF-κB signaling pathway

Hemorrhagic shock (HS) leads to intestinal damage and subsequent multiple organ dysfunction syndrome. Intestinal barrier dysfunction is the main cause of multiple organ failure associated with HS. Leukocyte immunoglobulin-like receptor B4 (Lilrb4) belongs to the Ig superfamily and is a vital natural immunomodulatory receptor. The purpose of this study was to identify the role and molecular mechanism of Lilrb4 in HS-induced ileal injury. In this work, HS was established by femoral artery cannula and 90 min of HS (blood pressure, 35–40 mmHg), followed by resuscitation. RNA sequencing analysis showed that Lilrb4 was highly expressed in the ileum of HS rats. As observed, HS rats exhibited severe ileal injury, characterized by enlarged subepithelial space, edema, exfoliation and extensive loss of villi. Whereas, lentivirus system-mediated Lilrb4 overexpression considerably mitigated these alterations. HS led to increased release of markers associated with intestinal injury, which was effectively reversed by Lilrb4 overexpression. In addition, after resuscitation, Lilrb4 overexpression inhibited HS-triggered inflammatory response, as evidenced by decreased levels of proinflammatory cytokines. Lilrb4 also inhibited the activation of NF-κB signal induced by HS. Notably, Lilrb4 modulated the balance of regulatory T (Treg)-T helper 17 (Th17) cells in the mesenteric lymph node (MLN), which may also contribute to its protective role in HS progression. In aggregate, these findings confirmed that Lilrb4 overexpression protected against ileal injury caused by HS, indicating that Lilrb4 may be a potential candidate for the treatment of HS.

Practical approach to confirm femoral artery patency after percutaneous closure for veno-arterial extracorporeal membrane oxygenation decannulation.

We describe a technique to assess blood flow distal to the decannulation site after deployment of Perclose ProGlide (Abbott Vascular, Abbott Park, Ill) in patients on femoral veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. An antegrade distal perfusion catheter was placed in all patients, and decannulation was primarily performed at bedside (N = 11/12). With the VA-ECMO circuit switched off, a needle was inserted into the arterial tubing, passed through the femoral arterial cannula into the artery. The arterial cannula was removed over a wire and the previously placed Proglide Perclose sutures were secured. Back bleeding from the antegrade distal perfusion catheter, confirmed using a three-way connector, indicated blood flow to the superficial femoral artery. This was followed by confirmation of blood flow to the lower leg using a Doppler ultrasound. Hemostasis of the antegrade perfusion catheter was achieved through manual compression. We implemented this technique in 12 patients with a technical success rate of 100%. There were no ipsilateral leg ischemia, bleeding, pseudoaneurysm, or infection after decannulation. This technique allows prompt assessment of blood flow to the distal leg immediately following arterial decannulation.

P96: Using Fenestrated Stent to Increase the Flow of ECMO of Superior Vena Cava Compression Syndrome

Introduction: Superior vena cava syndrome (SVCS) is an obstruction of the venous return to the heart through SVC or any other significant branches. The obstruction may be external, like thoracic mass compressing the SVC, or internal, like thrombosis or tumor, which directly invades the SVC. Patients experiencing a medical emergency after being initially stabilized require treatment for SVCS, including endovenous recanalization and the implantation of an SVC stent to reduce the risk of abrupt respiratory arrest and death. This case report details a situation in which reduced outflow in a VA ECMO would substantially improve by using a fenestrated stent of SVC. Case Presentation: A 54-year-old female presented to our medical center with weight loss and solid food dysphagia for three months. Chest CT scan showed a new mediastinal mass of 10x9x8cm with minor pericardial and pleural effusions. A transbronchial biopsy was attempted; however, the patient arrested during the bronchoscopy procedure. CPR was initiated, and the ECMO team was contacted for VA ECMO cannulation, which was done through the right femoral artery cannula size 15 Fr due to the narrowing of the artery, and the left femoral vein cannula size 23 Fr. ROSC was achieved, and the patient was transferred to the ICU. During the night shift, the ECMO flow was hard to maintain with fluids. First, that was due to the small arterial cannula. However, the issue was realized with the ECMO outflow volume issue. The next day, In the hybrid operating room, a fenestrated SVC stent was placed in SVC, brachiocephalic, and internal jugular veins (Figure 1). All patient hemodynamics improved post stenting, including ECMO, flows, especially outflow. Discussion: Endovenous treatment of SVC syndrome includes percutaneous transluminal balloon angioplasty (PTA), stenting, and thrombolysis performed alone or in combination. Stenting is usually in the SVC rather than several locations for SVC syndrome. However, our case is unique as the primary fenestrated stent was deployed in the SVC, and additionally, brachiocephalic and IJ veins were stented through the fenestration, which relieved the SVCS. In addition, it enhanced ECMO outflow flow instantly. Conclusion: This case illustrates that stenting in SVCS is a valid therapeutic option to increase ECMO flow in this patient group.Figure 1. Image A: Fluoroscopy showing SVC stenosis. Image B: redacted view of SVC fluoroscopy Image C: Balloon angioplasty of SVC stenosis under fluoroscopy. Image D: Fenestrated stent placement in the SVC under fluoroscopy. Image E: Stent deployed Internal jugular Image F: Post stenting image showing deployed brachiocephalic Internal jugular vein through fenestrations of primary stent.

Novel cannulation strategy with a bidirectional cannula for distal limb perfusion during peripheral veno-arterial extracorporeal life support: A preliminary, single-centre study.

Limb ischemia is a severe complication of peripheral veno-arterial extracorporeal life support (V-A ECLS). Several techniques have been developed to prevent this, but it remains a major and frequent adverse event (incidence: 10-30%). In 2019, a new cannula with bidirectional flow (retrograde towards the heart and antegrade towards the distal limb) has been introduced. A single-centre experience with this cannula in patients undergoing peripheral V-A ECLS is herewith reported. This prospective observational study included adults (≥18years) undergoing V-A ECLS from January 2021 to October 2022 with the use of a bidirectional femoral artery cannula. Primary outcome was limb ischemia requiring intervention during cardio-circulatory support. Secondary outcomes were compartment syndrome, limb amputation, cannulation site bleeding, need for other surgical intervention due to cannula related complications, duplex ultrasound parameters from the femoral vessels, and in-hospital survival. Twenty-two consecutive patients were included. During extracorporeal life support (ECLS) support, limb ischemia requiring intervention occurred in one patient (4.5%) and no patients developed a compartment syndrome, or required a fasciotomy or amputation. Significant bleeding was reported in two patients (9%) due to slight cannula dislodgement, easily solved with cannula repositioning. In-hospital survival was 63.6%. The bidirectional cannula is associated with a low risk for limb ischemia-related complications compared to current literature, and apparently represents a safe alternative to dedicated distal perfusion cannula. Further studies are warranted to confirm these preliminary findings.

Save the Leg: Utilization of Distal Perfusion Catheter With Impella CP® May Prevent Morbidity of Limb.

Leg ischemia is a potential complication of percutaneous left ventricular assist device (Impella CP®) placement. To avoid leg ischemia in at-risk patients, a distal perfusion catheter (DPC) should be placed. In utilizing a passive distal perfusion system from the contralateral femoral artery, we optimized blood flow to the distal limb mitigating leg ischemia. A 65-year-old female with dilated cardiomyopathy complicated by hemodynamic instability was placed on an Impella CP via the right femoral artery. A DPC was placed to the right distal femoral artery and connected to the wire re-access port of the Impella CP. Despite this, the leg became ischemic shortly after admission to the ICU. A contralateral femoral arterial line was placed in standard fashion, and it was connected to the DPC while the wire re-access port was capped. Shortly after placement of the new DPC system, the right lower extremity distal pulses returned, and distal leg ischemia was resolved. Another patient, a 67-year-old male with acute myocardial infarction, was placed on an Impella CP via the left femoral artery for cardiogenic shock. His hemodynamics continued to deteriorate, requiring initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) via the right femoral artery and vein with associated DPC placement. Shortly after the initiation of VA ECMO, the Impella CP-related extremity (left leg) became ischemic. A left femoral DPC was placed and connected to the side port of the right femoral arterial cannula. After initiation of the additional DPC system, the left leg ischemia resolved. Distal leg ischemia with Impella CP is not a rare event. Utilization of a DPC to Impella CP may decrease the morbidity of limb malperfusion.

Intermediate-Term Outcomes of Totally Endoscopic Atrial Septal Defect Repair on Beating Heart in Small Children.

Objective: Manipulation in a narrow surgical field and risks of femoral arterial (FA) complications are difficulties when applying totally endoscopic surgery (TES) for congenital heart disease in small children. This study was conducted to investigate the feasibility of TES for atrial septal defect (ASD) repair in children weighing 13 to 20 kg. Methods: From July 2016 to July 2021, 14 patients with a mean age of 5.4 ± 2.2 years and mean weight of 15.57 ± 2.39 kg (range, 13 to 20 kg), underwent TES for ASD repair on the beating heart. FA cannulation was established through a Dacron graft. An additional FA cannula (2 to 4 Fr smaller than the expected size) was placed into the left FA in case of increasing arterial pressure. Three 5 or 5.5 mm trocars and one 12 mm port were used. The surgical field was filled with CO2. No aortic clamp, no aortic root needle, and no snaring of the inferior vena cava were used. The mean follow-up time was 37.9 ± 12.5 months. Results: Cardiopulmonary bypass (CPB) installation time, CPB time, and operation time were 42.6 ± 16.5 min, 113.1 ± 33.1 min, and 209.6 ± 50.6 min, respectively. Total drainage volume was 125.4 ± 89.2 mL. Patients did not need analgesics on day 4 or 5 after surgery. No severe complications, including arterial complications, were recorded during follow-up. Conclusions: By optimizing the surgical field and setting the FA cannula correctly, TES for ASD closure is feasible in small children weighing between 13 and 20 kg.

Bifurcated Arterial Circulation for Hybrid Aortic Reconstruction: A Novel Technique.

Hybrid aortic procedures present many new challenges to the management of cardiopulmonary bypass (CPB). Reoperation or previous thoracic endovascular aortic repair (TEVAR) can further complicate these procedures, increasing the need for flexibility within the CPB system to execute multiple perfusion strategies as cases dictate. This technique describes the use of a bifurcated arterial circulation to provide both cerebral and lower body perfusion during a redo hybrid aortic arch reconstruction. The arterial line was divided into upper and lower body limbs, and connected to an 8-mm Dacron graft to the axillary artery, as well as a percutaneous 16-Fr. OptiSite femoral arterial cannula respectively. A 25-Fr. multi-stage femoral venous cannula was placed percutaneously as well. CPB was initiated utilizing both arterial cannulas with near-infrared spectroscopy and electroencephalogram to monitor the adequacy of cerebral perfusion. Moderate hypothermia of 26°C was induced and a CODA balloon (Cook Medical, Bloomington, IN) was deployed to occlude the proximal limb of a thoracic endovascular repair (TEVAR) graft; the common trunk of the debranched arch vessels was clamped proximally, allowing for simultaneous upper and lower body perfusion. Upon completion of the distal arch, the CODA balloon was removed and total body perfusion was reinitiated via central cannulation utilizing a sidearm on the arch graft.

Cardiac output monitoring using transthoracic echocardiography in children after cardiac surgery-an observational study of feasibility and concordance with transpulmonary thermodilution

Abstract Background Transthoracic echocardiography (TTE) is commonly used after pediatric cardiac surgery to monitor cardiac function and adequacy of surgery; however it depends on the availability of good echo window and operator skill [1]. Transpulmonary thermodilution (TPTD) is feasible along with calibrated continuous cardiac output measurement in children but seldom used due to cost and the need for a specialized catheter [2]. We hypothesized that TTE would be as good as TPTD, but limited in feasibility following pediatric cardiac surgery. Hence, the concordance, agreement as well as feasibility and trending of cardiac output monitoring by TTE was compared against a reference TPTD method in real-world usage in children after congenital heart surgery. Methods This was a secondary analysis of data from a previously registered and conducted study in our unit. TPTD monitoring was instituted in children undergoing congenital heart disease repair on cardiopulmonary bypass with a 3F femoral arterial cannula and a central venous injectate temperature sensor. Cardiac output was also measured by transthoracic echocardiography by measurement of the left ventricular outflow tract (LVOT) diameter, LVOT velocity time integral (VTI) and the heart rate as previously described [3,4]. Measurements were taken after arrival in the ICU, and every 12 hours till after extubation. Correlation, Bland-Altman analysis and polar analysis was done for cardiac output measured by TPTD and TTE. Results TTE and TPTD measurements of cardiac output correlated well (Pearson's correlation coefficient 0.94; 95% CI 0.90–0.96) (Fig. 1A). Bland Altman analysis showed a mean bias of 0.15 l/min and upper and lower limits of agreement of 0.81 and −0.51 l/min respectively (Fig. 1B). Cardiac output measurement by TTE was possible in 72 instances while TPTD allowed measurement in all 113 instances. Hence, TTE was not feasible in 41 instances across 14 patients, including 19 instances in acyanotic and 22 instances in cyanotic patients. Polar analysis revealed acceptable trending. Conclusions TTE derived cardiac output demonstrated good correlation, minimal bias and narrow limits of agreement versus TPTD, and was feasible in most cases. This suggests TTE is an acceptable cardiac output measurement modality post pediatric cardiac surgery, as in adults [5]. TPTD-based continuous cardiac output monitoring might have a complementary role in pediatric cardiac critical care, particularly in high risk cases. Funding Acknowledgement Type of funding sources: Public Institution(s). Main funding source(s): Institutional Special Research Grant from Postgraduate Institute of Medical Education and Research, Chandigarh, India. Figure 1

WHOLE BODY PERFUSION STRATEGY FOR AORTIC ARCH REPAIR UNDER NORMOTERMIA AND BEATING HEART TECHNIQUE IN PEDIATRIC PATIENTS. THREE CLINICAL CASES

Introduction The incidence of aortic arch pathology in older children is rare. Most often this occurs as a result of a previous aortic arch operation and less often it could be detected primarily. Previously, we successfully used normothermic perfusion during neonatal aortic arch repair. In this paper we evaluate the effectiveness of the method of selective whole body perfusion with coronary perfusion on the beating heart during aortic arch reconstruction in older children. Methods Between October 2019 and February 2021, 3 children underwent aortic arch surgery at our institution using the defined protocol. During the cardiopulmonary bypass (CPB), antegrade cerebral perfusion (ACP), antegrade coronary perfusion on beating heart and distal retrograde femoral aortic perfusion at a constant blood temperature 36 C were used. During the surgery, cerebral and visceral perfusion were monitored using near-infrared spectroscopy (NIRS) and transcranial dopplerography, electrocardiography and arterial blood gases. The data was collected prospectively. Results Patient one. Male, 6 years old, 27 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 78 min, ACP – 44 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 10 fr. Ultrafiltration during CPB. Mechanical ventilation - 18 hours post/op. Blood lactate 6 hours post/op – 1,8 mmol/l. ICU admission – 24 hours. Hospital discharge 12 days. Patient two, 17 y.o., 38 kg. Elective admission. Diagnosis: Aortic arch hypoplasia. The history of coarctation of the aorta surgery. Surgery: Aortic arch reconstruction. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 2,5 l/min. CPB time – 136 min, ACP time – 54 min. BCA cannula – 14 fr, coronary cannula – 4fr, femoral artery cannula – 15 fr. Ultrafiltration during CPB. Mechanical ventilation – 4 hours post/op. Blood lactate 6 hours post/op – 2,6 mmol/l. ICU admission – 16 hours. Hospital discharge 17 days. Patient three. Female, 4 years old, 15 kg. Admitted urgently. Diagnosis: Critical aortic arch stenosis. Brachiocephalic artery (BCA) and left common carotid artery (LCCA) stenosis. The history of coarctation of the aorta surgery. Low ejection fraction. Surgery: Aortic arch, BCA and LCCA repair. CPB: Normothermic. Selective ACP, antegrade coronary perfusion on beating heart and distal retrograde femorall aortic perfusion. Flow 3 l/min. CPB time – 107 min, ACP – 68 min. BCA cannula – 12 fr, coronary cannula – 4fr, femoral artery cannula – 12 fr. Ultrafiltration during CPB. Mechanical ventilation - 44 hours post/op. Blood lactate 6 hours post/op – 1,6 mmol/l. ICU admission – 5 days. Hospital discharge 26 days. During surgery, laboratory and instrumental parameters were within reference values. Patients had no neurological deficiency during hospital stage. Discussion These clinical cases show that the whole-body perfusion with coronary perfusion on beating heart provide safe conditions during aortic arch surgery in children using normothermia. Using this protocol, we were able to eliminate risk factors: circulatory arrest, hypothermia, cardioplegia, extended

Evaluation of the agreement of two oscillometric blood pressure devices with invasive blood pressure in anaesthetized chimpanzees (Pan troglodytes)

ObjectiveTo evaluate the agreement of two noninvasive blood pressure devices: a human device with the cuff placed on the wrist (Omron R1) and a veterinary device with the cuff placed on the upper brachium (Surgivet Advisor Vital Signs Monitor) with invasive blood pressure (IBP) measurement in anaesthetized chimpanzees. Study designProspective clinical study. AnimalsA convenience sample of 11 adult chimpanzees undergoing anaesthesia for translocation and routine health checks. MethodsSystolic (SAP) and diastolic arterial pressures (DAP) were continuously recorded via a transducer connected to a femoral artery cannula, and at 5 minute intervals from the two oscillometric devices. Agreement was explored using Bland-Altman analysis and bias defined as the mean difference between the two measurement methods. Spearman correlation coefficients were calculated. Significance was set at p < 0.05. ResultsBias and standard deviation for the Surgivet compared with IBP were 8.6 ± 18 for SAP and 8.4 ± 9.9 for DAP, showing a significant underestimation of both variables. Limits of agreement (LOA) were from –27 to 44 for SAP and from –11 to 28 for DAP. Correlation coefficients between the Surgivet and IBP values were 0.86 for SAP and 0.85 for DAP (p < 0.0001). Bias and standard deviation for the Omron compared with the IBP were –21 ± 25 for SAP and –18 ± 15 for DAP, showing a significant overestimation of both variables. LOA were from –70 to –28 for SAP and from –47 to 11 for DAP. Spearman correlation coefficients between the Omron and IBP values were 0.64 for SAP and 0.72 for DAP (p < 0.0001). Conclusions and clinical relevanceAlthough neither device met all the criteria for device validation, the Surgivet presented better agreement with IBP values than the Omron in adult anaesthetized chimpanzees.

Peripheral vascular complications following totally endoscopic cardiac surgery

BackgroundClinical application of minimally invasive cardiac surgery has increased annually. Cardiopulmonary bypass is established by peripheral cannulation during minimally invasive cardiac surgery. The methodology of peripheral cannulation has unique characteristics, which have associated risks and complications. Few studies have been conducted on this topic. In this study, we focused on complications of peripheral cannulation in totally endoscopic cardiac surgery.MethodsPatients who underwent totally endoscopic cardiac surgery with cardiopulmonary bypass established by peripheral cannulation at our institution between January 2019 and June 2020 were reviewed. Specific cannulation strategies and related cannulation complications were noted.ResultsOne hundred forty-eight patients underwent totally endoscopic cardiac surgery. One hundred forty-eight cannulations were performed in the femoral artery and vein, and eleven were performed in the internal jugular vein (combined with the femoral vein). The median size of the femoral artery cannula was 22Fr, and that of the venous canula was 24Fr. One patient died of retroperitoneal haematoma due to femoral artery injury. Three patients had postoperative lower limb oedema. One patient had a postoperative diagnosis of femoral vein thrombosis.ConclusionsDifferent from cannulation in patients with aortic dissection and aneurysms, femoral artery cannulation is safe in totally endoscopic cardiac surgery. Venous cannulation is characterized by a large-bore venous cannula and a short period of use. There are few reports about complications of venous cannulation. The main complication in this study was mechanical injury, and the key to preventing this injury is meticulous manipulation during surgery.

Hybrid and parallel extracorporeal membrane oxygenation circuits

Hybrid and parallel extracorporeal membrane oxygenation circuits

Pediatric arterial femoral cannulations for extracorporeal membrane oxygenation: Does size really matter?

Background: No studies exist comparing various femoral artery cannula sizes in children on ECMO. We hypothesize that smaller arterial cannulas provide adequate flow in children while decreasing vascular complications. Methods: We performed a retrospective review of the ELSO database from 2012–2017. We included children undergoing femoral venoarterial ECMO between ages 12 and 18 years and weighing more than 30 kg. Arterial cannula sizes were grouped as: 15-16Fr, 17–18Fr, 19–20Fr and ≥21Fr. Arterial pump flow, bleeding complications, limb ischemia, and mechanical complications were compared by cannula size. Distal perfusion catheter and percutaneous placement were also compared for complications. Results: A total of 429 patients were included with 28.2% 15–16Fr, 32.2% 17–18Fr, 22.8% 19–20Fr, and 16.8% ≥ 21Fr arterial femoral cannulas. Median age was lower in the 15–16Fr group compared to the largest cannula group (14.7 years vs 15.5 years, p < 0.01). The overall mean arterial flow was 57.4 +/- 17.0 mL/kg/min with no difference in mean arterial flow rates among the cannula size groups (p = 0.85). There were no significant differences in all complications, bleeding or mechanical complications by arterial cannula size group. However, there was an increased risk of limb ischemia in the ≥21Fr group compared to the 15–16Fr group (OR 4.38, 95% CI 1.24–15.43; p = 0.02). Distal perfusion catheter was shown to increase the risk of mechanical complications (OR 1.78; 95% CI 1.03–3.07; p = 0.04) but did not make a statistically significant difference in limb ischemia (OR 0.37; 95% CI 0.12–1.11; p = 0.07). Conclusion: Review of the ELSO database demonstrates that the use of larger arterial cannulas compared to 15-16Fr cannulas are not needed to achieve similar pump flows for hemodynamic support but the largest cannula sizes may increase the risk of ischemic complications.

Cardiac Output Measurement With Echocardiography and Pressure Recording Analytical Method in Pediatric Patients Admitted to the Cardiac Intensive Care Unit: A Retrospective Assessment of Bias Between the Two Methods

This study aimed to compare, in a cohort of critically ill children with biventricular anatomy and no cardiovascular shunt, cardiac output (CO) and cardiac index (CI) assessed by echocardiography and a continuous pulse-contour method, MostCareUP, to measure the differences between these techniques (biasCO and biasCI), and their association with clinical variables. Retrospective study. Tertiary pediatric cardiac intensive care unit. Children admitted to the pediatric cardiac intensive care unit who underwent echocardiography with CO measurement. None. Thirty-five patients were included. BiasCO was -0.02 (0.26) L/min (percentage error 36%). BiasCI was 0.07 (0.34) L/min/m2 (percentage error 18%). Biases and percentage errors were higher in 24 nonsupervised echocardiographies. A negative biasCO (overestimation by MostCareUP) was associated with post-surgical status (v cardiomyopathy), higher systolic arterial pressure, and spontaneous breathing (v intubation). When only absolute values were considered, biasCONONEG correlated with age, weight, arterial pressure, and heart rate, whereas biasCINONEG was associated with a femoral arterial cannula, no use of inotropes, and the absence of mechanical ventilation. After adjustment, biasCONONEG remained independently associated with patients' body weight(p = 0.0001). BiasCINONEG showed a nonlinear relationship with weight below 20 kg and above 40 kg. Children with extreme low or high weights, those who are extubated, and those with a femoral cannula carry the highest bias. When younger patients are considered, CI should be evaluated instead of CO, because biases are better highlighted by indexing data on body surface area. In children, both echocardiography and MostCareUP may be responsible of inaccurate CO/CI assessment.

Result of minimally invasive cardiac surgery in Thong Nhat Hospital

Abstract Introduction: Minimally invasive surgery has been a trend in modern medicine and there are no exceptions in the cardiothoracic surgery, which has been widely applied in Vietnam recently. Thong Nhat Hospital has deployed the minimally invasive cardiac surgery (MICS) for a trial septal defect (ASD) and left atrial myxoma since July 2018. Therefore we conducted this research to evaluate the result of this novel method in our hospital thus improving techniques and refining the procedures. Subjects and methods: We retrospectively reviewed all the patients underwent video assisted MICS in Thong Nhat Hospital from July 2018 to February 2020. Results: There had a total of 12 patients, in which 10 had an Atrial Septal Defect(ASD) and 2 had left atrial myxomal. Male/Female ratio was 1:1, mean age was 44,2 ± 4,5. All patients were intubated with double lumen endotracheal tube. Patients were put on cardiopulmonary bypass(CPB) with femoral artery cannula and bicaval cannulas achieved with right femoral vein and right internal jugular vein cannulation. Mean CPB duration was 98,6 ± 13,6 minutes (70 - 155), aortic cross-clamping duration was 44,2 ± 6,8 minutes (0 - 88), there were 5 cases underwent off - pump ASD closure. 1 case had post-op hemorrhage that required reoperation, cause of hemorrhage was due to injury to the internal thoracic artery, there was no death. Conclusions: The application of MICS in treating ASD and left atrial myxoma showed positive short and medium term results, there was no severe complications or death.

The evaluation of prevalence of poor distal leg perfusion in totally endoscopic cardiac surgeries: a cohort study

Introduction To ensure patient safety during Totally Endoscopic Cardiac Surgeries (TECS), patients are peripherally cannulated for coupling to the Cardiopulmonary Bypass (CPB) (1). Despite its necessity, the cannulated leg might experience clinically relevant ischemia (CRI), defined as a minimum of 15% Tissue Oxygenation Index (TOI) drop, lasting at least 4 minutes, possibly leading to poor peri- and postoperative clinical outcomes (2). TOI-values were assessed using non-invasive, Near-Infrared Spectroscopy (NIRS; 200NX-NIRO, Hamamatsu®, Japan) measurements of the skin covering the ipsilateral calf muscles. NIRS enables the quantification of the TOI, based on the difference in light absorption between oxygenated en deoxygenated haemoglobin molecules. The 200NX-NIRO has shown great sensitivity and specificity in the clinical setting (3-5). The objective was to evaluate the prevalence of poor distal leg perfusion related to short-term, peri-operative, CPB-time, since these data remain largerly unknown. Methods All consecutive patients 18 years or older, and scheduled for a TECS-based valve surgery (YIL AVR and/or MVATS), coronary surgery (ENDO ACAB or ENDO CABG), or a combination were included. Perioperative TOI-values were assessed at: baseline (B) = 5 minutes before insertion of the femoral arterial cannula (FAC); Event 1 (E1) = insertion of the FAC; Event 2 (E2) = onset of CPB; Event 3 (E3) = offset of CPB; Event 4 (E4) = removal of the FAC. Results 116 patients were included for statistical analysis. Differences between TOI-values were analysed using Wilcoxon signed rank tests. CRI in the cannulated leg was demonstrated in 18,80% (n = 22) of all cases, and showed significantly lower TOI-values for all events (E1, E2, E3 and E4) compared to the baseline TOI-value (Figure 1): p Discussion Although not all patients showed CRI in the cannulated leg, some degree of hypoperfusion was demonstrated over all cannulated legs. However, these are interim results and thus, further research regarding postoperative follow-up is necessary and might offer insights on how to prevent or prematurely treat ischemia and/or ischemia-related complications in the subclinical stage.

Evidence-based translational research approach may help to select the best femoral arterial cannula for adolescent/adult extracorporeal life support population

Evidence-based translational research approach may help to select the best femoral arterial cannula for adolescent/adult extracorporeal life support population

Aggressive placement of distal limb perfusion catheter in venoarterial extracorporeal membrane oxygenation.

The aim of this study is to review the impacts of aggressive placement of a distal perfusion catheter on the outcomes in patients supported with venoarterial extracorporeal membrane oxygenation via femoral cannulation. Analysis was performed with 143 consecutive femoral venoarterial extracorporeal membrane oxygenation cannulation. Patients were divided into two groups: the early period (October 2010 to December 2012, N = 47) where placement of a distal perfusion catheter was attempted percutaneously but not surgically and the late period (January 2013 to November 2018, N = 96) in which placement of distal perfusion catheter was aggressively utilized both percutaneously and surgically. The modification of venoarterial extracorporeal membrane oxygenation cannulation protocol for the late period involved (1) an immediate insertion of a distal perfusion catheter regardless of the size of femoral arterial cannula, (2) an open insertion of a distal perfusion catheter if percutaneous approach failed, and (3) when venoarterial extracorporeal membrane oxygenation cannulation was completed at a non-extracorporeal membrane oxygenation cannulation center, it was encouraged that they attempt insertion of a distal perfusion catheter at the time of cannulation. In the late period, a distal perfusion catheter was placed in 96% (92/96) which was significantly increased from 66% (31/47) in the early period. Of these 92 patients in late period, nine patients (9.8%) required open direct insertion of a distal perfusion catheter. The incidence of lower limb ischemia (early vs. late period 26% vs 12%, P = 0.031) was significantly decreased in the late period. Logistic regression analyses showed that distal perfusion catheter placement was the only factor for preventing lower limb ischemia. Aggressive insertion of a distal perfusion catheter even utilizing surgical cut-down technique was shown to decrease the incidence of distal limb complications.