Inotropic Requirement Research Articles

Large Animal Investigation of Cardiopulmonary Support for Acute-on-Chronic Right Ventricular Failure: Physiologic and Hemodynamic Consequences of Circuit Configuration

<h3>Purpose</h3> Right ventricular failure (RVF) is a major cause of mortality in pulmonary hypertension (PH) patients. Mechanical circulatory support holds promise for this population, but there are currently no clinical devices for long-term right ventricular (RV) support. Investigations into optimal device parameters and cannulation configurations for PH-induced RVF (PH-RVF) are needed. <h3>Methods</h3> We developed and evaluated a low-profile, ventricular assist device (VAD)-quality pump combined with a low-resistance membrane oxygenator, the Pulmonary Assist Device (PAD), for RV support in 11 sheep with chronic PH and RV hypertrophy. Four central cannulation configurations were evaluated: (1) right atrium-to-left atrium (RA-LA, N=3), (2) RA-to-pulmonary artery (RA-PA, N=3), (3) pumpless PA-to-LA (PA-LA, N=2), and (4) RA-ascending aorta (RA-Ao, N=3). Acute RVF was induced, and mechanical support was provided for up to 6 hours with blood flow rates of 1-3 L/min. Circuit, hemodynamic and echocardiographic data were collected. <h3>Results</h3> RA-LA achieved blood flow of 3 L/min within pump's operable speed, while RA-PA and RA-Ao were flow-limited due to higher circuit afterload. PA-LA could not achieve flow above 1 L/min. The oxygenator maintained a low resistance of <4 mmHg/L/min and provided oxygen delivery of 114 mL/min. RA-LA demonstrated serial RV unloading and lower inotropic dependence with increasing circuit flow. RA-Ao exhibited some RV unloading, but to a lesser extent compared to RA-LA. Meanwhile, the hemodynamic response was highly variable in RA-PA. In one trial of RA-PA, the circuit elicited severe pulmonary hemorrhage. Based on echocardiograms, only RA-LA preserved physiologic ventricular geometry. <h3>Conclusion</h3> RA-LA successfully unloads the RV at a lower pump speed, lower inotrope requirement, and improved LV filling compared to RA-Ao. RA-PA and pumpless PA-LA configurations were less viable as RV support in this study.

Impella 5.0 is associated with a reduction in vasoactive support and improves hemodynamics in cardiogenic shock: A single-center experience

Treatment of cardiogenic shock (CS) often requires the use of vasopressors and inotropic agents, which are associated with an increase in mortality. Data on change in vasopressor and inotrope requirements post Impella 5.0 placement is scarce. Thus, we aimed to study the ability of Impella 5.0 to reduce these requirements. Retrospective analysis of consecutive patients with CS receiving Impella 5.0 was performed. Vasopressor-Inotrope Score (VIS) and a Modified Catecholamine Equivalent score (MCES) was calculated prior to and up to 72 h post-Impella implantation. Primary outcome was change in MCES from baseline to 48-h post implantation and secondary outcomes included change in VIS, changes in MCES according to SCAI Stage and to underlying etiology, and freedom from mortality at 30-days. Twenty-eight patients with median age of 61 (48, 67) years were included. Impella 5.0 was associated with significant reduction in MCES from baseline [9.7 (5.3, 17)] to 48 h [5.7 (3.8, 7.5), p = 0.001]. VIS was also significantly reduced from baseline [8.3 (3.8, 19.9)] to 48 h [5.0 (2.5, 8), p = 0.003]. MCES at 48 h was significantly reduced in patients with SCAI Stage E versus Stage C (p = 0.026) and with acute myocardial infarction versus acute decompensated heart (p = 0.003). Thirty-day survival was 0% in patients that had a baseline MCES ⩾ 10 without a reduction in MCES of at least 5 at 24 h. Impella 5.0 is associated with a significant reduction in MCES and VIS scores in patients presenting with CS with 30-day survival being dependent on MCES.

Impact of Processed Electroencephalography in Cardiac Surgery: A Retrospective Analysis

The use of brain function monitoring with processed electroencephalography (pEEG) during cardiac surgery is gaining interest for the optimization of hypnotic agent delivery during the maintenance of anesthesia. The authors sought to determine whether the routine use of pEEG-guided anesthesia is associated with a reduction of hemodynamic instability during cardiopulmonary bypass (CPB) separation and subsequently reduces vasoactive and inotropic requirements in the intensive care unit. This is a retrospective cohort study based on an existing database. A single cardiac surgical center. Three hundred patients undergoing cardiac surgery, under CPB, between December 2013 and March 2020. None. One hundred and fifty patients had pEEG-guided anesthesia, and 150 patients did not have a pEEG-guided anesthesia. Multiple logistic regression demonstrated that pEEG-guided anesthesia was not associated with a successful CPB separation (p=0.12). However, the use of pEEG-guided anesthesia reduced by 57% the odds of being in a higher category for vasoactive inotropic score compared to patients without pEEG (odds ratio=0.43; 95% confidence interval: 0.26-0.73; p=0.002). Duration of mechanical ventilation, fluid balance, and blood losses were also reduced in the pEEG anesthesia-guided group (p < 0.003), but there were no differences in organ dysfunction duration and mortality. During cardiac surgery, pEEG-guided anesthesia allowed a reduction in the use of inotropic or vasoactive agents at arrival in the intensive care unit. However, it did not facilitate weaning from CPB compared to a group where pEEG was unavailable. A pEEG-guided anesthetic management could promote early vasopressor weaning after cardiac surgery.

Effect of Levosimendan and Milrinone Combination in Chronic Kidney Disease Patients Who Underwent Cardiac Surgery

Background: The effect of levosimendan use in chronic kidney disease (CKD) patients who underwent cardiac surgery has been investigated in a small number of subjects. Our purpose of this study was to investigate the hemodynamic effects of perioperative levosimendan in combination with milrinone administration in CKD patients underwent cardiac surgery and with poor left ventricle. Methods: 164 CKD patients (the mean age = 56 yrs) with poor left ventricle and a high pulmonary artery hypertension were included in this study. Mean creatinine clearance was lower than 30-59 mL/min/1,73 m² (moderate to severe renal impairment). Levosimendan and milrinone were administered to 84 patients (study group; SG). The remaining 80 patients treated with placebo (placebo group; PG). We compared cardiac output (CO), cardiac index (CI), systemic vascular resistance (SVRI), pulmonary vascular resistance (PVR), myocardial enzymes, and tumor necrosis factor alpha (TNF-alpha) immediately after surgery and at 2 h, 6 h, 12 h, and 24 h after operation. Results: No significant difference in operative mortality between groups was observed (6.3% vs. 7.7%, P=0.76). The SG showed lower rates of postoperative low-cardiac output syndrome (LCOS) (29.3% vs. 41.6%, P=0.001), and arrhytmia (26.8% vs. 44.6%) (P=0.01). CO and CI values were significantly higher in SG after the end of 6 h. PVR values were significantly low in SG (P=0.034). The amount of inotropic requirement was low in SG (P= 0.002). The laboratory analyses showed that c-TnI and TNF-alpha levels were low in SG (P= 0.0001). Compared to preoperative period, higher mean LVEF was found in both groups in the postoperative period, but the mean increase in LVEF in SG was higher than in the PG (11.70±2.39 vs. 6.2±1.30) (P<0.001). Conclusion: The use of levosimendan plus milrinone significantly improved hemodynamics in CKD patients with poor left ventricle who underwent cardiac surgery. Duration of ICU and hospitalization were decreased significantly with inodilators treatment. Therefore, we suggest the use of levosimendan and milrinone combination in per- and postoperative period in cardiac surgery patients with CKD and poor left ventricle.

Presentation and Outcomes of Patients With End-Stage Kidney Disease Hospitalized With COVID-19 at a Tertiary Center in Riyadh, Kingdom of Saudi Arabia.

BackgroundPatients with end-stage kidney disease (ESKD) are disproportionately vulnerable to COVID-19 and its complications due to the older age and significant burden of comorbid conditions. Data about the impact of COVID-19 on the ESKD population in the Kingdom of Saudi Arabia is scarce, and this study aims to bridge this gap.MethodThis is a retrospective cohort study that included ESKD patients who were receiving either in-center hemodialysis (HD) or peritoneal dialysis (PD) for at least three months and were hospitalized due to COVID-19 at King Abdulaziz Medical City in Riyadh (KAMC) between March 2020 and March 2021. Of note, the in-center hemodialysis means that the patients come to the dialysis center three times per week to receive their dialysis sessions, as home hemodialysis is not available at our center. Multivariate logistic regression was performed to explore the association of clinical characteristics and laboratory parameters with ICU admission and mortality.ResultsA total of 104 patients were included in the analysis. The mean age was 62.6 (SD=17.4) years, 101 (97%) were on HD, predominantly through a central venous catheter (72%), and 53 patients (51%) were male. Patients with COVID-19 were either asymptomatic (42%) or had mild symptoms (37%), mainly cough and fever. At the time of admission, 37 patients (36%) had extrapulmonary symptoms, and 13 patients (12%) had altered mental status. Normal chest X-ray (48%), followed by bilateral lung infiltrates (24%), and unilateral lung infiltrate (11%) were the most common radiological findings. We did not observe any thromboembolic events. Twenty patients (19%) required ICU admission and 19 patients (18%) died during hospitalization. Predictors for in-hospital mortality were: 1) the need for inotropes (adjusted OR: 53.01, p=0.006), 2) age (adjusted OR: 1.07, p=0.019), and 3) C-reactive protein (CRP) level on admission (adjusted OR: 1.02, p=0.04). We did not find any strong predictor for ICU admission.ConclusionOur study demonstrated that COVID-19 carries significant mortality and morbidity in the ESKD population. Age, inotropic support requirement and elevated CRP on admission predicted mortality in our population. The high rate of adverse outcomes of COVID-19 among ESRD patients calls for strict implementation of preventive measures, including vaccination, social distancing, and universal masking at the level of both the healthcare providers and patients. Further studies are needed to assess the association of COVID-19 and hypercoagulability ESKD population.

New dermatological findings of MIS-C: Can mucocutaneous involvement be associated with Severe Disease Course?

Little is known about mucocutaneous involvement in critically ill patients with the multisystem inflammatory syndrome in children (MIS-C). The aim of our study was to describe the localisation and variety of rash and to investigate whether presenting with rash at admission alters the clinical course of MIS-C. This prospective, observational cohort study was conducted amongst children under 18 years of age who were admitted to our paediatric intensive care unit (PICU) between May 2020 and May 2021 with a possible diagnosis of MIS-C. A total of 33 children with MIS-C, 21 boys (64%), with a median age of 9.4 years (3.4-11.5) were enrolled. Twenty-four children presented with mucocutaneous symptoms (72%). Age, male gender, PICU length of stay, presenting symptoms, inotrope requirement, the existence of myocarditis or respiratory failure were higher but not significantly different in patients with rash compared to those without rash (P > 0.05). The median duration of symptoms before admission and presence of cervical lymphadenopathy were significantly higher in patients than those without rash (P < 0.05). Children with a rash had a significantly higher neutrophil count, CRP, procalcitonin, troponin levels and lower lymphocyte counts and albumin levels than those without rash (P < 0.05). Twelve children with rash (50%) had symmetrical intertriginous distribution. Two children had erythematous lesions on the areola and the surroundings. In conclusion, intertriginous involvement, periareolar erythema and other mucocutaneous manifestations might be the first alarming symptoms of moderate to severe MIS-C. Therefore, close monitoring with a multidisciplinary approach should be considered for these patients to assess potential disease progression.

Clinical impact of del Nido cardioplegia in adult cardiac surgery: A prospective randomized trial

ObjectiveThe study objective was to assess the benefits of del Nido cardioplegia compared with cold blood cardioplegia solution in terms of myocardial protection during adult cardiac surgery. MethodsA total of 474 adult patients undergoing coronary artery bypass grafting, heart valve surgery, thoracic aortic surgery, or combined procedures were randomized to the del Nido cardioplegia group (n = 234) or the cold blood cardioplegia solution group (n = 240) after provided informed consent. The primary end points assessed inotropic support requirements, severe cardiovascular events, and troponin trend within the first 48 hours of intensive care unit stay. Reperfusion arrhythmias, aortic crossclamp and cardiopulmonary bypass times, and other clinical perioperative variables were considered as secondary end points. ResultsNo statistically significant differences were found regarding postoperative inotropic support requirements or the incidence of severe cardiovascular events. The del Nido cardioplegia group showed a higher return to spontaneous sinus rhythm (P< .001), a lower number of defibrillation attempts (P< .001), and an earlier peak troponin value in the postoperative period. Peak blood glucose levels and intravenous insulin requirements were significantly lower in the del Nido cardioplegia group. We found no significant differences regarding aortic crossclamp or cardiopulmonary bypass time. We did observe a lower incidence of postoperative stroke in the del Nido cardioplegia group (2.6% vs 6.7%; P= .035). Conclusionsdel Nido cardioplegia can be used safely and with comparable outcomes compared with traditional cardioplegia solutions. Additional advantages over glycemic control, reperfusion arrhythmias, and its comfortable redosing interval make del Nido an interesting alternative for myocardial protection in adult cardiac surgery. A significant decrease in postoperative stroke will require further research to shed light on the results of this study. Video Abstract [Display omitted]

Prenatal therapy with magnesium sulphate and intestinal obstruction due to meconium in preterm newborns

IntroductionMagnesium sulphate (MgSO4) therapy has shown to be useful as a neurological protector in the preterm newborn below 32 weeks of gestation. The most documented adverse effect is cardiorespiratory failure, whereas its relationship with meconium obstruction is controversial. The main objective of this study was to analyse the possible association between prenatal MgSO4 therapy and meconium obstruction. Patients and methodsAn analytical retrospective study was conducted on <32 weeks preterm babies admitted to a tertiary-level hospital (January 2016–December 2017). Epidemiological, prenatal and postnatal data on the outcomes were obtained, analysed and compared in both groups (exposed to MgSO4 and not exposed). ResultsThe study included 201 patients (146 exposed and 55 non-exposed). There were no significant differences in the mean gestational age (28.4 ± 2.2 vs. 28.7 ± 2.8 weeks, respectively), or in the rest of epidemiological and perinatal variables. Prenatal corticosteroid therapy was more frequent in the MgSO4 group (75.9 vs. 53.7%; p = .002), and in the non-exposed group there were more multiple pregnancies (52.7 vs. 36.6%; p = .027), and female gender (56.4 vs. 37%; p = .013). There were no statistically significant differences in the presence of meconium obstruction (75.9% in exposed vs. 67.3% in non-exposed; p = .23), although repeated rectal stimulation was more frequent in the exposed group (43.2 vs. 27.9%; p = .08). Furthermore, there were no significant differences in the main cardiorespiratory variables: 1-min Apgar score (6.2 in MgSO4− exposed vs. 5.6 in non-exposed; p = .75), 5-min Apgar score (7.9 vs. 7.6; p = .31), advanced newborn resuscitation (26 vs. 31.5%; p = .44), maximum FiO2 (45.5 vs. 48; p = .58), and initial inotropic requirements (10.3 vs. 20.8%; p = .55). ConclusionsThis study found no correlations between MgSO4 therapy and meconium obstruction or cardiorespiratory failure.

Risk Factors for Mortality From Late-Onset Sepsis Among Preterm Very-Low-Birthweight Infants: A Single-Center Cohort Study From Singapore.

ObjectiveTo determine the risk factors for mortality associated with late onset sepsis (LOS) among preterm very-low-birthweight (VLBW) infants.Study DesignWe performed a retrospective cohort study of infants born <32 weeks gestation and <1,500 gm admitted to a Singaporean tertiary-level neonatal intensive care unit. We determined the clinical, microbial, and laboratory risk factors associated with mortality due to culture-positive LOS in this cohort.ResultsA total of 1,740 infants were admitted, of which 169 (9.7%) developed LOS and 27 (16%) died. Compared to survivors, those who died had lower birth gestational age (median 24 vs. 25 weeks, p = 0.02) and earlier LOS occurrence (median 10 vs. 17 days, p = 0.007). There was no difference in the incidence of meningitis (11.1 vs. 16.9%, p = 0.3), NEC (18.5 vs. 14.8%, p = 0.6), or intestinal surgery (18.5 vs. 23.3%, p = 0.6) among infants who died compared to survivors. Gram-negative bacteria accounted for 21/27 (77.8%) LOS-associated deaths and almost all (13/14, 93%) fulminant episodes. The presence of multiorgan failure, as evidenced by the need for mechanical ventilation (100 vs. 79.0%, p = 0.008), elevated lactate (12.4 vs. 2.1 mmol/L, p < 0.001), and inotropic support (92.6 vs. 37.5%, p < 0.001), was significantly associated with mortality. Infants who died had significantly lower white blood cell (WBC) counts (median 4.2 × 109/L vs. 9.9 × 109/L, p = 0.001), lower platelet count (median 40 × 109/L vs. 62 × 109/L, p = 0.01), and higher immature to total neutrophil (I: T) ratio (0.2 vs. 0.1, p = 0.002). Inotrope requirement [AOR 22.4 (95%CI 2.9, 103.7)], WBC <4 × 109/L [AOR 4.7 (1.7, 13.2)], and I: T ratio >0.3 [AOR 3.6 (1.3, 9.7)] were independently associated with LOS mortality.ConclusionsIn a setting with predominantly Gram-negative bacterial infections, the need for inotropic support, leukopenia, and elevated I: T ratio were significantly associated with LOS mortality among preterm VLBW infants.

Study of Disease Severity and Outcomes in COVID-19 Patients With Chronic Kidney Disease at a Tertiary Care Hospital in South India.

Background: Coronavirus disease 2019 (COVID-19) disproportionately affects individuals with various comorbidities. Among these, chronic kidney disease (CKD) has been shown to be strongly associated with the progression to severe disease. This study aimed to assess the severity and disease outcomes in patients with COVID-19 infection and CKD.Methods: This is a retrospective study conducted at a tertiary care hospital from July 2021 to September 2021. The case records of patients with CKD and COVID-19 were studied. They were compared with age and gender-matched controls equally. The presenting symptoms, clinical course, severity of illness, laboratory markers, need for ventilator support, and mortality outcomes were studied.Results: In total, 40 CKD and 40 non-CKD patients with COVID-19 were included in the study. It was also observed that among the patients with CKD, more patients had fever, breathlessness, and diarrhea. The requirement for noninvasive ventilation, ventilator, and inotropes was on the higher average for patients with CKD. Overall mortality was 27.5% in the CKD group and 2.5% in the non-CKD group, which was statistically significant (p = 0.002).Conclusions: COVID-19 patients with CKD had more severe illnesses with a requirement of ventilator support and had higher mortality than the patients without CKD. Patients with CKD are a key subset of patients with COVID-19 for whom more aggressive early treatment and stricter preventive measures may be beneficial.

Correlation of cardiac troponin T levels with inotrope requirement, hypoxic-ischemic encephalopathy, and survival in asphyxiated neonates.

BACKGROUNDCardiac involvement in neonates with perinatal asphyxia not only complicates perinatal management but also contributes to increased mortality. AIMTo assess cardiac troponin T (cTnT) levels in asphyxiated neonates and their correlation with echocardiography findings, inotrope requirement, hypoxic-ischemic encephalopathy (HIE) stages, and mortality.METHODScTnT levels, echocardiographic findings, the requirement of inotropes, HIE stages, and outcome were studied in neonates of gestational age ≥ 34 wk with perinatal asphyxia.RESULTSAmong 57 neonates with perinatal asphyxia, male gender, cesarean section, forceps/vacuum-assisted vaginal delivery and late preterm included 33 (57.9%), 23 (40.4%), 3 (5.3%), and 12 (21.1%) respectively. The mean gestational age was 38.4 wk (1.6 wk). HIE stages I, II, and III were observed in 7 (12.3%), 37 (64.9%), and 9 (15.8%) neonates respectively. 26 (45.6%) neonates had echocardiographic changes and 19 (33.3%) required inotropes. cTnT levels were elevated in 41 (71.9%) neonates [median (IQR); 0.285 (0.211-0.422) ng/mL]. The Median cTnT level showed an increasing trend with increasing changes in echocardiography (P = 0.002). Two neonates with mitral regurgitation and global hypokinesia had the highest cTnT levels (1.99 and 0.651 ng/mL). Of 31 neonates with normal echocardiography, 18 (58.06%) showed elevated cTnT. cTnT levels were significantly higher in those who required inotropic support than those who did not (P = 0.007). Neonates with HIE stage III had significantly higher cTnT levels compared to those with HIE stage I/II (P = 0.013). Survivors had lower median cTnT levels [0.210 (0.122-0.316) ng/mL] than who succumbed [0.597 (0.356-1.146) ng/mL].CONCLUSIONcTnT levels suggestive of cardiac involvement were observed in 71.9% of asphyxiated neonates. cTnT levels correlated with echocardiography findings, inotrope requirement, HIE stages, and mortality.

Sequential left internal mammary artery grafting in combination with the aortic no-touch technique.

AimThis study aimed to investigate the short-term outcomes achieved with off-pump bypass combined with the aortic no-touch technique where sequential anastomoses between the left internal mammary artery (LIMA), left anterior descending (LAD) and diagonal artery were employed.Material and methodsA total of 583 patients (mean age 63, 80% male) who underwent off-pump bypass (LIMA-diagonal-LAD sequential) were enrolled in this retrospective analysis. Data regarding the frequency of in-hospital postoperative complications, intra-aortic balloon pump (IABP) and inotropic agent requirement, re-exploration for bleeding, and length of hospital stay were collected. Anastomosis patency was evaluated in 49 patients who underwent angiography.Results2.6% of the participants received inotropic agents and 0.5% required IABP. Frequency of acute renal failure, sternal wound infection, cerebrovascular event, respiratory failure, and hemodialysis was less than 1% in total. Among the 49 patients undergoing angiography at an average 41 ±17 months after bypass, the LIMA-LAD was patent in 98% and the LIMA-diagonal was patent in 84% of the subjects. Preoperative left ventricle ejection fraction (LVEF) and recent myocardial infarction (MI) prior to bypass were significantly correlated with postoperative IABP and inotropic agent requirement (r = 0.165, p < 0.01 for LVEF, p = 0.021 for recent MI).ConclusionsOff-pump bypass in combination with the aortic no-touch technique is associated with favorable postoperative outcomes including reduced postoperative stroke, renal dysfunction, IABP, and inotropic agent requirement compared to the results of previous randomized prospective studies published in the literature.

Impact of Prenatal Diagnosis on the Management and Prognosis of Infants with Congenital Heart Disease- A Retrospective Study

Introduction: Prenatal diagnosis is important in outcome of various congenital anomalies in recent times especially in congenital heart diseases. This study would help in recognising the importance of prenatal diagnosis and in understanding the management of newborns with congenital heart diseases. Aim: To evaluate the impact of prenatal diagnosis on the management and prognosis of infants with congenital heart disease. Materials and Methods: This retrospective study was conducted in Department of Paediatrics at Dr. Vasantrao Pawar Medical College, Nashik, Maharshtra, India, from January 2018 to January 2021. The study was performed on newborns who were diagnosed with Congenital Heart Diseases (CHD) during hospitalisation, in an inborn and outborn unit of Neonatal Intensive Care Unit (NICU). The data recorded for requirement of inotropes, ventilation, arterial blood gas analysis and outcome in the form of survival. The babies were classified into Prenatal ECHO (PNE) group and No Prenatal ECHO Available (NPEA) group, based on availability of prenatal Echocardiogram (ECHO) diagnostic report. CHDs were categorised into critical/major and minor. For the comparison of quantitative variables, Unpaired t-test/Mann- Whitney test was used. For the comparison of qualitative variable, Fisher’s-exact test/Chi-square test was used, as necessary. Results: There were 5000 admissions in the inborn and outborn neonatal unit during the study period, of which 159 cases had a diagnosis of CHDs. The PNE group consisted of 61 neonates who had been diagnosed with CHD and the NPEA group consisted of 67 neonates who were not antenatally diagnosed to have CHD. Ionotropic support needed for PNE group (4.5%) was comparatively lesser than NPEA group (14.3%). Need for ventilation was reduced in PNE group (4.5%) as compared to NPEA group (14.3%). Mean for serum lactate and serum bicarbonate was 3.49±2.58 and 16.24±4.31 in PNE group, whereas, it was 5.08±2.79 and 15.12±4.13 in NPEA group on admission in NICU. In management of critical CHDs, 2/31 (6.5%) babies died in PNE group compared to 11/37 (29.7%) in NPEA group (p-value=0.09). Conclusion: Antenatal diagnosis helps in meticulous management of neonates with congenital heart diseases in terms of fewer requirement of inotropes, need of ventilation and improved management. There was no significant difference in outcome in the form of survival.

Prospective randomized study comparing outcome of myocardial protection with Del-Nido Cardioplegia versus Saint Thomas Cardioplegia in adult cardiac surgical patients.

Objectives:To compare the effectiveness of Del-Nido cardioplegia as myocardial protective agent with Saint Thomas cardioplegia in adult cardiac surgical patients.Methods:This prospective randomized study was conducted in cardiac surgery department of Bahawal Victoria hospital Bahawalpur, from October 2020 to March 2021. Eighty adult patients who underwent primary Isolated coronary artery bypass grafting (CABG) or isolated Valve surgery requiring cardiopulmonary bypass were randomly divided into Del Nido (DN, n=40) and Saint Thomas (ST, n=40) groups. Data regarding operative and post-operative variables such as cardiopulmonary bypass (CPB) and aortic cross clamp (AXC) times, inotropic requirements, resumption of sinus rhythm, need for electrical defibrillation, post-operative CKMB, blood requirement and ICU stay were noted.Results:CPB and AXC times were statistically insignificantly different. Resumption of Sinus rhythm was seen significantly in more patients of DN group (95%) than in ST group (72.5%) [p-value 0.05]. Less patients of DN group (5%) were candidates of electrical defibrillation than ST group (17.5%) [p-value <0.001). Post- operative CKMB values were significantly lower in DN group as compared to ST group (30.5±22.6 IU vs 50.5±50.28 IU, p value.008). Blood transfusion was significantly lower in DN group; 50% versus 80% in ST group (p-value 0.005). Ventilation time was significantly less in DN group than ST group (165.95±48.09 minutes versus 165.95±48.09 minutes respectively, p-value 0.03). While ICU stay was also less in DN group; 5.2±0.8 days versus 6.05±1.6 days in ST group (p-value 0.003).Conclusion:Del-Nido cardioplegia is a reliable and better myocardial protective agent than Saint Thomas cardioplegia in adult cardiac surgical procedures.

Euvolemic off pump coronary surgery further improves early postoperative outcomes.

Background:Fluid resuscitation during Off-Pump Coronary Surgery (OPCABG) is still not protocolized and depends on multiple variables. We are exploring in this study whether a restrictive or euvolemic approach has any impact on short term surgical outcomes following OPCABG.Methods:It is a retrospective study of 300 patients analyzed based on the intraoperative fluid requirement with 150 patients in each group (Group I: Fluid <2 Litres, Group II: Fluid >2 Litres).Results:Multivariable analysis showed echocardiography variables such as E/e ratio, LA volume index, and atrial fibrillation (AF). LA volume index is related to the higher fluid requirement. Group II had significantly higher ventilation time (P < 0.05), drain output (P = 0.05), drain removal time (<0.05), inotropic requirement, and diuretic use.Conclusion:The requirement of the intraoperative fluid was associated with various factors including diastolic dysfunction (left atrial volume index, left ventricle mass index, E/e ratio) and preoperative dual antiplatelet use. Group II patients had longer ventilation time, diuretics use, high drain output, and required drains for a longer period of time. Although there was no statistical difference among two groups as far as postoperative AF concerned, a reversal of AF to sinus rhythm was delayed in group II patients.

Transesophageal echo-derived left ventricular ejection fraction versus myocardial performance index in predicting outcome following coronary artery bypass grafting surgery

BACKGROUND AND AIMS: Although left ventricular ejection fraction (LVEF) is the most commonly studied echocardiographic parameter for predicting postoperative outcome, its utility is limited by its preload dependency and ability to measure the only systolic function of the left ventricle. The myocardial performance index (MPI), a ratio obtained by summing up the time required for isovolumetric contraction and relaxation against the systolic ejection phase of the cardiac cycle, is the least studied parameter of left ventricular performance in perioperative settings. So, being a composite measure of systolic and diastolic function of the heart, we hypothesized that MPI can be a better predictor of postoperative outcome following coronary artery bypass grafting (CABG). The present study aimed at finding a correlation of LVEF and MPI with postoperative outcome indicators such as vasoactive inotropic score (VIS), the requirement of intra-aortic balloon pump (IABP) to maintain cardiac output, duration of mechanical ventilation, stay in the intensive care unit (ICU), postoperative morbidity and mortality.METHODS: A prospective, observational study was conducted on 110 subjects, scheduled for elective CABG. Transesophageal echocardiography (TEE) was performed after induction of anesthesia and before coronary grafting. Patients with no or grade I mitral regurgitation (vena contracta-VC <0.3 cm, effective regurgitant orifice area <0.2 cm2) and those in normal sinus rhythm were included. Patients with arrhythmia and MR of more than grade I (VC >0.3 cm, EROA >0.2 cm2) were excluded. Pre-CABG LVEF was measured using Simpson's biplane method. MPI was measured using Pulsed-wave Doppler across mitral inflow and left ventricular outflow tract. Subjects were labeled as “good” and “poor” outcomes based on standard criteria for defining the immediate postoperative outcome. Pre-CABG MPI and LVEF were correlated with these postoperative outcome variables following CABG.RESULTS: Of 110 subjects, 14 were excluded due to the presence of more than grade I MR (n = 8) and arrhythmias (n = 6) before CABG. Out of 96 subjects, 66% (n = 63) had “good” outcome and 34% (n = 33) had a “poor” outcome. Pre-CABG MPI and LVEF were (0.51 ± 0.12 and 47.2% ± 8.8%) in subjects with “good” compared to (0.57 ± 0.13 and 42.00% ± 8.70%) (P = 0.032 and 0.007 respectively) “poor” outcome following CABG. A higher pre-CABG MPI (0.57 ± 0.13) alone significantly correlated with increased VIS (r = 0.325, P = 0.001) in contrast to lower LVEF (42% ± 8.7%) (r = −0.181, P = 0.077). Both, lower precardiopulmonary bypass LVEF (40.46% ± 8.81%) and higher MPI (0.6 ± 0.11) were significantly correlated with increased ICU stay in days (r = −0.218 and r = 0.287, respectively). The mean MPI was 0.57 ± 0.08 and LVEF was 39.55% ± 4.05% in those subjects who succumbed in the postoperative period following CABG.CONCLUSION: MPI was a relatively better predictor of postoperative outcome following CABG. Increased Pre-CABG MPI was more consistent with the postoperative inotropic and vasopressor requirement. The requirement of an IABP to maintain cardiac output following CABG and mortality was correlated well with both low preoperative LVEF and higher MPI values.

Umbilical Cord Milking in Late Preterm Neonates and its Effects on Haematological and Haemodynamical ParametersA Randomised Controlled Study

Introduction: Delayed Cord Clamping (DCC) is a procedure, in which the cord is clamped after a short delay (30s to 180s) after birth. This improves iron status, reduce chances of anaemia and need for blood transfusion. However, DCC method compromised the success of resuscitation and induced various consequences, especially in neonates in need of emergency resuscitation. Umbilical Cord Milking (UCM), which is likewise a procedure of transporting additional blood from the umbilical cord to the newborn by milking or stripping the umbilical cord toward the baby, is an alternative to this approach. This study was conducted due to a lack of data on the use of umbilical cord milking in late preterm newborns. Aim: To study the effect of UCM on haematological and haemodynamical parameters in late preterm neonates. Materials and Methods: This single centre randomised controlled study was conducted, from November 2017 to August 2019 in the Department of Paediatrics, Kempegowda Institute of Medical Sciences, Bengaluru, Karnataka, India. Total 200 late preterm neonates fulfilling the inclusion criteria were randomised into cases (UCM group) and controls (Immediate cord clamping group). In UCM group, just after delivery, umbilical cord was milked towards the baby. In ICC group, cord was clamped and cut immediately. Primary outcomes included Haemoglobin (Hb), Haematocrit (Hct) and haemodynamic parameters (heart rate, respiratory rate and mean blood pressure), were noted at 48 hours of age. Clinical parameters (respiratory distress, need for oxygen, polycythemia and jaundice requiring phototherapy) were also noted. Student's t-test, Chi-square/fisher-exact test were used to find out the significance of study parameters. Results: There was a significant higher Hb in UCM group (19.27±2.64 gm/dL) than Immediate Cord Clamping (ICC) group (16.32±2.09 gm/dL) with p-value=0.012 and higher Hct in UCM group (55.41±5.07%) than the ICC group (48.99±5.57%) with a p-value &lt;0.001. Hence, there was higher placental transfusion in UCM group as shown by higher Hb and Hct in UCM group. There was also higher systolic, diastolic and mean blood pressure in the UCM group as compared to ICC group. Difference for mean arterial blood pressure was about 3 mmHg and was statistically significant (p-value &lt;0.001). Hence, UCM leads to a higher mean arterial pressure at 48 hours of life. Conclusion: Umbilical cord milking provides a greater placental transfusion, as demonstrated by higher Hb, higher Hct, higher blood pressure, and lesser requirement for inotropes and blood transfusions.

Can 18-years of data from a tertiary referral center help to identify risk factors in esophageal atresia?

Esophageal atresia is a complex esophageal malformation with an incidence of 1 in 3,500-4,000 live births, and it usually occurs together with anomalies in other systems or chromosomes. This study aimed to investigate the short-term and long-term results of cases of esophageal atresia retrospectively in our institution and to analyze the factors affecting the outcome. Charts of the patients managed for esophageal atresia in our tertiary pediatric surgery department were investigated retrospectively. Statistical analysis was performed to determine the risk factors for morbidity and mortality. One hundred and thirteen (95.8%) of 118 cases underwent a single-stage or staged esophagoesophagostomy procedure. In only five of the 40 patients with a long gap between the two atretic ends was an esophageal replacement procedure required. The most common early and late complications were anastomotic stenosis (41.6%) and gastroesophageal reflux (44.9%). In logistic regression analysis, the birthweight (OR [95% CI] = 0.998 [0.997, 0.999], P = 0.001) and preoperative inotrope requirement (OR [95% CI] = 13.8 [3.6-53.3], P < 0.001) were the two risk factors in the mortality prediction model obtained by multivariate analysis. The gap length between the two atretic ends (OR [95% CI] = 1.436 [1.010, 2.041], P = 0.044) and the number of sutures for anastomosis (OR [95% CI] = 1.313 [1.042, 1.656], P = 0.021) were the two risk factors in the gastroesophageal reflux prediction model obtained by multivariate analysis. Our study's early and late complication rates were like those found in other studies. Identifying risk factors would be beneficial and might help reduce the severity of potential complications in esophageal atresia patients. Prospective studies on large patient series would help develop registry-based, standardized management protocols.

P-P18 Thoracic epidural VS intrapleural analgesia for pancreaticoduodenectomy – a study on analgesic and non-analgesic outcomes

Abstract Background Thoracic epidural analgesia (TEA) has been the traditional option for post-operative pain management for Kausch-Whipple pancreaticoduodenectomy (KWPD) via a ‘reverse L’ incision. An alternative option with inter-pleural analgesia (IPA) has become popular. However, the superior form of analgesia for KWPD regarding analgesic and non-analgesic outcomes is unclear. This study aims to establish if IPA is equivalent to TEA. Methods Retrospective study of all patients who underwent KWPD with ‘reverse L’ incision by a single surgeon between February 2014 to June 2016. All received either IPA or TEA post-operatively; patients who had rectus sheath catheter and spinal anaesthesia were excluded. To reduce bias, the Anaesthetist, rather than Surgeon, decided the choice of analgesia based on personal skill. Efficacy regarding analgesia were collected by nursing staff as patient-reported pain severity (mild, moderate or severe). Data were collected from patient case notes and electronic records. This study analysed analgesia efficacy, complications, inotrope use, and intensive treatment unit (ITU) stay. Results A total of 40 included in the study. Twenty-two patients had TEA (45% female, median age 68 years) and 18 had IPA (44% female, median age 67 years). Median Charleson Comorbidity Index (CCI) was 5 for both. Patient-reported pain was not statistically different (p = 0.15). We noted more analgesia complications with TEA (not working=4, leakage=2, haemodynamic instability=1, lower limb anaesthesia=1) than IPA (leakage=1; p = 0.027). Eleven (50%) TEA and eight (44%) IPA patients required inotropes. TEA patients required significantly longer duration (median duration 35 VS 18 hours, p = 0.047). Median ITU stay was 3 and 2 days for TEA and IPA patients, respectively. Conclusions Both TEA and IPA provide adequate pain relief for KWPD performed via a ‘reversed L’ incision. However, evidence suggests TEA was associated with significantly more analgesia-related complications and longer inotropic requirements. Furthermore, there was also a trend towards ITU stays with TEA. Therefore, we would recommend the use of inter-pleural analgesia over thoracic epidural.

Cardiac outcomes in severe acute respiratory syndrome coronavirus-2-associated multisystem inflammatory syndrome at a tertiary paediatric hospital.

We describe a cohort of children referred with multisystem inflammatory syndrome in children associated with severe acute respiratory syndrome coronavirus 2 and compare this cohort with a 2019 cohort of children with Kawasaki disease. We conducted a retrospective cohort study of 2019 and 2020 referrals to the inflammatory cardiology service at Great Ormond Street Hospital for Children. We compared cardiac and inflammatory parameters of a sub-section of the 2020 cohort who presented with reduced left ventricular ejection fraction with the remainder of the cohort. Referrals significantly increased between February and June 2020 compared to 2019 (19.8/30 days versus 3.9/30 days). Frequency of coronary artery aneurysms (11/79 (13.9%) versus 7/47 (14.9%)) or severe coronary artery aneurysms (6/79 (7.6%) versus 3/47 (6.4%)) was similar between 2020 and 2019, respectively. The 2020 cohort was older (median age 9.07 years versus 2.38 years), more likely to be of Black, Asian, or other minority ethnic group (60/76 (78.9%) versus 25/42 (59.5%)), and more likely to require inotropic support (22 (27.5%) versus 0 (0%)). Even children with significantly reduced left ventricular ejection fraction demonstrated complete recovery of cardiac function within 10 days (mean 5.25 days ± 2.7). We observed complete recovery of myocardial dysfunction and an overall low rate of permanent coronary sequelae, indicating that the majority of children with multisystem inflammatory syndrome in children are unlikely to encounter long-term cardiac morbidity. Although the frequency of myocardial dysfunction and inotropic support requirement is not consistent with a diagnosis of Kawasaki disease, the frequency of coronary artery abnormalities and severe coronary artery abnormalities suggests a degree of phenotypic overlap.