Need For Postoperative Inotropic Support Research Articles

Exploring the impact of left ventricular diastolic dysfunction on postoperative cardiac surgery outcomes, with a focus on sex disparities: a comprehensive literature review

IntroductionLeft ventricular diastolic dysfunction (LVDD) is known to cause worse outcomes after cardiac surgery. Females have twice the risk of developing LVDD compared with males. The aim of this literature review was to evaluate the association between LVDD and early (≤30 days) outcomes after cardiac surgery, including sex disparities.MethodsWe identified 454 studies in Medline and Embase, of which 19 were included. Articles were assessed for inclusion of female patients with LVDD, ≥50 years of age undergoing cardiac surgery (on or off-pump) or transcatheter aortic valve replacement. The primary outcome was early postoperative mortality. Secondary outcomes were early postoperative complications, ICU length of stay (ICULOS), hospital length of stay (HLOS), and other sex-related postoperative outcomes.ResultsIn patients with LVDD, the majority of studies showed that higher LVDD grades correlate with higher early postoperative mortality. In patients with LVDD, who underwent on-pump cardiac surgery, female sex was significantly associated with higher LVDD grades and baseline E/e' ratios. Females with LVDD, were associated with prolonged HLOS after off-pump coronary artery bypass grafting (CABG). In combined cardiac surgery, a twofold increased risk of prolonged HLOS and increased ICULOS was reported. Furthermore, increased left ventricular end-diastolic filling pressure, an increased need for postoperative inotropic support, and difficult separation from cardiopulmonary bypass were observed.DiscussionDespite the limited number of studies focusing on sex differences, females with LVDD appear to have worse early outcomes after cardiac surgery compared to men with LVDD. Future research will need to identify sex-specific risk factors and target treatment optimization.

The role of Del Nido Cardioplegia in reducing postoperative atrial fibrillation after cardiac surgery in patients with impaired cardiac function

BackgroundPostoperative atrial fibrillation (POAF) occurs in 20% to 40% of patients who underwent cardiac surgery and can compromise the postoperative course, especially in those with reduced left ventricular ejection fraction. The most common causes are related to surgical trauma and the high variations in volemic and electrolyte balance in the postoperative period. ObjectivesAs cardioplegic solutions can significantly impact both these factors, the study aimed to assess the role of Del Nido (DN) cardioplegia on the onset of POAF. MethodsA retrospective single-center analysis was carried out on 93 patients undergoing coronary artery bypass graft surgery where cardioplegia was used. The patients were divided into two groups according to the cardioplegic solution (Cold Blood vs Del Nido), and perioperative outcomes were compared. ResultsPOAF occurred in 21.5% of patients; the patients treated with cold blood cardioplegia (CBC) showed a 3-times higher rate of POAF compared to the DN group (OR: 3.44; 95% CI: 1.1 to 10.5; p = 0.029). The CBC group showed higher serum potassium levels both after the cross-clamp removal (p<0.001), at the ICU admission (p = 0.007), and during the first 3 postoperative days (p = 0.009). The defibrillation rate at cross-clamp removal (p = 0.003), the dose of postoperative epinephrine (p<0.001), and the peak of serum troponin (p = 0.01), were lower in the DN Group. ConclusionDN cardioplegia showed significantly reduced POAF rates after cardiac surgery by acting on the electrolyte balance, myocardial protection and on the need for postoperative inotropic support.

Triiodothyronine improves contractile recovery of human atrial trabeculae after hypoxia/reoxygenation

BackgroundIn patients undergoing interventional or surgical coronary revascularization, subclinical hypothyroidism is common and associated with worse outcome, including the need for postoperative inotropic support. In isolated rat hearts with global ischemia/reperfusion, exogenous triiodothyronine (T3) reduces infarct size. Aim of this study was, to investigate whether or not exogenous T3 protects human myocardium from ischemia/reperfusion injury. MethodsRight atrial trabeculae from patients undergoing routine coronary artery bypass grafting were isolated and transferred to Tyrode's buffer. Electrically initiated (1 Hz) contractile stress (mN/mm2) was recorded for 10 min at baseline (95% O2/ 5% CO2, glucose). Sixty min hypoxia were induced by changing buffer gas and increasing stimulation rate (95% N2/ 5% CO2, choline chloride, 3 Hz) before return to reoxygenation for 30 min. T3 (500 μg/l) vs. NaOH (solvent control) was administered A) throughout (n = 11 vs. n = 9) or B) only 15 min before and during reoxygenation (n = 12 vs. n = 13). Western blot analyses of established cardioprotective signaling proteins were performed. ResultsAt baseline, contractile stress was comparable. T3 improved the cumulative recovery of contractile stress during reoxygenation from 41 ± 16 with NaOH to 55 ± 11% of baseline with T3, when given continuously in A or from 52 ± 13 with NaOH to 63 ± 11% of baseline with T3 when given just before and during reoxygenation in B. The ratio of mitochondrial complex I matrix arm to membrane NADH:ubiquinone oxidoreductase subunits (NDUF)V2 to NDUFA9 was reduced, reflecting increased complex I activity. ConclusionT3 increases contractile recovery of human right atrial trabeculae from hypoxia/reoxygenation.

Analogy of Del Nido and conventional cardioplegia in patients undergoing isolated mitral valve replacement surgery: A single-center retrospective study

ObjectiveThe objective of this study was to assess the postoperative outcomes after utilizing the Del Nido cardioplegia as compared to conventional cardioplegia, in patients undergoing isolated mitral valve replacement surgery. MethodsThis was a single-center retrospective study conducted with the data from 80 patients with mitral valve disease, who underwent cardiopulmonary bypass. The outcome assessments of the Del Nido group (n = 40) was compared with that of the non-Del Nido group (n = 40). Various time factors were analyzed as end points that included cardiopulmonary bypass time aortic cross clamp time, duration of mechanical ventilation, need for postoperative inotropic support, volume of packed red blood cells (RBCs) transfusion, length of ICU and hospital stay, among others. ResultsThe current study showed that the mean cardiopulmonary bypass time and aortic cross-clamp time were significantly shorter in the Del Nido group when compared to the non-Del Nido group (P < 0.05). The mean number of packed red blood cell pints administered in the Del Nido group was fewer than the non-Del Nido group (P < 0.05). No significant differences found in other outcome measures. ConclusionThe use of the Del Nido cardioplegia technique did significantly reduce the aortic cross-clamping time and cardio-pulmonary bypass time. The present study did also show a marked reduction in the amount of packed RBCs transfusion in the Del Nido group as compared to non-Del Nido conventional cardioplegia. Rigorous, adequately scrutinized randomized control trials are required to reiterate these findings in-order to enable us to extrapolate their benefits to a larger population.

Clinical Assessment of Perfusion Techniques During Surgical Repair of Coarctation of Aorta With Aortic Arch Hypoplasia in Neonates: A Pilot Prospective Randomized Study

We aimed to compare the safety and efficacy of 3 perfusion methods primarily used in aortic arch reconstruction in infants, namely, deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation. Forty-five infants with aortic arch obstruction and biventricular anatomy were enrolled in this pilot prospective study (ClinicalTrials.gov registration number: NCT02835703). Patients were randomly assigned into 3 groups according to the perfusion strategy (deep hypothermic circulatory arrest, n = 15; selective antegrade cerebral perfusion, n = 15; double arterial cannulation, n = 15). The primary composite endpoint was the incidence of adverse events in the early postoperative period (acute kidney injury [KDIGO criteria], new brain magnetic resonance imaging (MRI) findings, and in-hospital mortality). The secondary endpoints were intensive care unit length of stay, vasoactive-inotropic score index, and cardiopulmonary bypass duration. All patients underwent aortic arch reconstruction under cardiopulmonary bypass and were monitored with near-infrared spectroscopy during surgery. No significant differences in the baseline characteristics and cardiopulmonary bypass duration were observed among the groups. The incidence of unfavorable events was lower in the double arterial cannulation group (P = 0.041). Acute kidney injury was observed in 8, 6, and 5 patients from the deep hypothermic circulatory arrest, selective antegrade cerebral perfusion, and double arterial cannulation groups, respectively (P = 0.64). Twelve patients from the deep hypothermic circulatory arrest group had new brain MRI findings (P = 0.019). There were 5 in-hospital deaths with no significant difference among the groups (P = 0.70). The "head" and "lumbar" values on near-infrared spectroscopy during aortic arch reconstruction were significantly higher in the selective antegrade cerebral perfusion and double arterial cannulation groups than in the deep hypothermic circulatory arrest group. Patients in the double arterial cannulation group had a significantly lower vasoactive-inotropic score index 24 hours postoperatively than the deep hypothermic circulatory arrest group (P = 0.03). Vasoactive-inotropic score index >12 was found to be a risk factor for acute kidney injury and early mortality. Continuous regional perfusion during aortic arch reconstruction decreases the risk of new brain MRI findings in infants and the need for postoperative inotropic support. Although values of near-infrared spectroscopy during the procedure were significantly higher with continuous perfusion strategies, these methods do not reduce the acute kidney injury incidence compared to that with deep hypothermic circulatory arrest. Double arterial cannulation significantly reduces the need for inotropic support.

Atrial fibrillation in adults with congenital heart disease following cardiac surgery in a single center: Analysis of incidence and risk factors.

The primary aim of our work is to determine the incidence of atrial fibrillation following cardiac surgery in adults with congenital heart disease. Secondary aims include identifying risk factors predictive of developing earlypostoperative atrial fibrillation and morbidities associated with earlypostoperative atrial fibrillation. Retrospective analysis. Single center, quaternary care children's hospital. This review included patients at least 18years of age with known congenital heart disease who underwent cardiac surgery requiring a median sternotomy at our congenital heart center from January 1, 2012 to December 31, 2016. None. The primary outcome was earlypostoperative atrial fibrillation. Secondary outcomes included preoperative comorbidities, preoperative echocardiographic findings, operative details, and postoperative morbidities, such length of stay, reintubation,stroke, and death. The incidence of early postoperative atrial fibrillation was 21%. Those who developed early postoperative atrial fibrillation were older (50years vs 38years, P=<.001), had a history of atrial fibrillation prior to surgery, had preoperative pulmonary hypertension,and had longer cardiopulmonary bypass times (103minutes vs 84minutes, P=.025) when compared to those who did not develop postoperative atrial fibrillation. Multivariate analysis identified age greater than 60, preoperative pulmonary hypertension, mitral valve intervention,and the need for postoperative inotropic support as being independent predictors of postoperative atrial fibrillation. Those who developed postoperative atrial fibrillationremained in the hospital longer (9days vs 7days, P=<.001). Atrial fibrillation is a common complication following cardiac surgery in adults with congenital heart disease. Age, preoperative comorbidities, type of surgical intervention,and the need for perioperative inotropic infusions may predict the risk of atrial fibrillation in this unique patient population.

Impaired Spirometry, but Not DLCO, is Associated with Risk of Death or Right Heart Failure Following LVAD Implantation

Purpose Severe medical comorbidities are associated with poor outcomes after LVAD implantation. The association between preoperative pulmonary function and postoperative outcomes after LVAD implantation are unknown. Methods We analyzed LVAD recipients from our institution from 1/1/2015 to 2/28/2018 who had preoperative pulmonary function testing (PFT). We excluded patients bridged to LVAD with ECMO support. The primary outcome was the composite of death within 30 days, need for RVAD support within 30 days, or need for postoperative inotropic support beyond 14 days. We evaluated the association between the percent predicted values of forced expiratory volume in 1 second (FEV1pred), forced vital capacity (FVCpred) and diffusion capacity for carbon monoxide adjusted for hemoglobin (DLCO-Adjpred) and the primary outcome using univariable logistic regression. Results There were 102 patients with preoperative PFT data available. At baseline, 70 (69%) of patients had moderate or severe right ventricular (RV) dysfunction by echocardiography and 56 (55%) had moderate or severe tricuspid regurgitation (TR). Mean ± standard deviation of baseline PFT parameters were as follows: FEV1pred, 66.6% ± 14.7; FVCpred 67.4% ± 13.9; DLCO-Adjpred 56.7% ± 16.3. The primary outcome occurred in 43 (42%) patients. A 10 percentage point increase in baseline FEV1pred (OR 0.66, 95% CI 0.49-0.9, p Conclusion Reduced FEV1 and FVC were closely associated with risk of death or right heart failure. Whether preoperative spirometry adds incremental value to existing risk models requires further investigation. Specific thresholds should be investigated in larger multicenter cohorts.

719 Can peri-operative parameters predict the need for post-operative inotropic support following surgical resection of pheochromocytomas?

719 Can peri-operative parameters predict the need for post-operative inotropic support following surgical resection of pheochromocytomas?

Cardiac myxomas: a 27-year surgical experience

Amac: Bu calismada merkezimizde yapilan cerrahi kardiyak miksoma rezeksiyonunun sonuclari bildirildi. Ca­lis­ma­pla­ni:­Ocak 1985 Aralik 2012 tarihleri arasinda miksoma tanisiyla ameliyat edilen 99 hasta (67 kadin, 32 erkek, ort. yas 49.8±16 yil; dagilim 5-76 yil) retrospektif olarak incelendi. Ameliyat oncesi tani transtorasik ekokardiyografi ile konuldu. Son takip vizitine kadar gecen ortalama sure 123.4±85.7 ay idi. Bul gu lar: Tum hastalar median sternotomi ile ameliyat edildi. Tumorun kokeni 92 hastada sol atriyum olup, en sik yerlesim yeri 85 hastada interatriyal septumdu. Bir hasta haric tum hastalarda total rezeksiyon yapildi. Kirk bes hastaya (%45.5) papiller miksoma, 54 hastaya (%54.5) solid miksoma tanisi konuldu. Embolik olay riski papiller tip miksomalarda, solid tipe kiyasla, anlamli oranda yuksek bulundu (%44.4’e kiyasla %9.3, p<0.01). Erken mortalite %5 idi. Tek degiskenli analiz sonuclarina gore ileri yas (p=0.04), ameliyat oncesi atriyal fibrilasyon varligi (p=0.02), periferik emboli (p=0.03) ve ameliyat sonrasi inotropik destek ihtiyaci (p=0.008) erken mortalite icin risk faktorleri olarak belirlendi. Bes, 10 ve 20 yillik aktueryal sagkalim oranlari sirasi ile %98, %94 ve %89 idi. Sagkalanlarda nuks orani %1.2 olarak tespit edildi. So­nuc:­Kardiyak miksoma cerrahisi, dusuk ameliyat riski tasimakla birlikte, mukemmel kisa ve uzun donem sonuclar ile iliskilendirilir. Ancak, uzun donemde dusuk nuks riskine ragmen, hastalar yillik ekokardiyografi ile takip edilmelidir. Anah tar soz cuk ler: Kardiyak tumor; miksoma; cerrahi; sagkalim. Background:­ In this study, we reported the outcomes of surgical resection of cardiac myxomas performed in our center. Methods: A retrospective review of 99 patients (67 females, 32 males, mean age 49.8±16 years; range 5 to 76 years) who were operated for myxoma between January 1985 and December 2012 was conducted. Preoperative diagnosis was established by transthoracic echocardiography. The mean time to the last follow-up visit was 123.4±85.7 months. Results:­ All patients were operated through median sternotomy. The site of origin of the tumor was left atrium in 92 patients and the most common implantion site was interatrial septum in 85 patients. A complete resection of the tumor was performed in all patients except one. Forty five patients (45.5%) were diagnosed with a papillary myxoma, while 54 patients (54.5%) were diagnosed with a solid myxoma. The risk of embolic events in papillary type of myxoma was significantly higher than the solid type (44.4% vs. 9.3%, p<0.01). Early mortality was 5%. Univariant analysis showed advanced age (p=0.04), preoperative presence of atrial fibrillation (p=0.02), peripheral embolism (p=0.03), and need for postoperative inotropic support (p=0.008) as the risk factors for early mortality. Actuarial survival rate was 98%, 94% and 89% at five, 10 and 20 years, respectively. The rate of recurrence was 1.2% in survivors. Conclusion:­Surgical treatment of cardiac myxoma carries a low operative risk and is associated with excellent short and long-term results. However, despite low risk of recurrence in the long-term, the patients should be followed with annual echocardiography.

Myocardial Redox State Predicts In-Hospital Clinical Outcome After Cardiac Surgery: Effects of Short-Term Pre-Operative Statin Treatment

The purpose of this study was to evaluate the role of the myocardial redox state in the development of in-hospital complications after cardiac surgery and the effect of statins on the myocardial redox state. Statins improve clinical outcome after cardiac surgery, but it is unclear whether they exert their effects by modifying the myocardial redox state. We quantified myocardial superoxide anion (O(2)(-)) and peroxynitrite (ONOO(-)) and their enzymatic sources in samples of the right atrial appendage (RAA) from 303 patients undergoing cardiac surgery who were followed up until discharge, and in 42 patients who were randomized to receive 3-day treatment with atorvastatin 40 mg/d or placebo before surgery. The mechanisms by which atorvastatin modifies myocardial redox state were investigated in 26 RAA samples that were exposed to atorvastatin ex vivo. Atrial O(2)(-) (derived mainly from nicotinamide adenine dinucleotide phosphate [NADPH] oxidases) and ONOO(-) were independently associated with increased risk of atrial fibrillation, the need for post-operative inotropic support, and the length of hospital stay. Pre-operative atorvastatin treatment suppressed atrial NADPH oxidase activity and myocardial O(2)(-) and ONOO(-) production. Ex vivo incubation of RAA samples with atorvastatin induced a mevalonate-reversible and Rac1-mediated inhibition of NADPH oxidase. There is a strong independent association between myocardial O(2)(-)/ONOO(-) and in-hospital complications after cardiac surgery. Both myocardial O(2)(-) and ONOO(-) are reduced by pre-operative statin treatment, through a Rac1-mediated suppression of NADPH oxidase activity. These findings suggest that inhibition of myocardial NADPH oxidases may contribute to the beneficial effect of statins in patients undergoing cardiac surgery. (Effects of Atorvastatin on Endothelial Function, Vascular and Myocardial Redox State in High Cardiovascular Risk Patients; NCT01013103).

Tissue Doppler imaging is useful for predicting the need for inotropic support after cardiac surgery

Low preoperative left ventricular ejection fraction (EF) is a predictor of the need for inotropic support after cardiac surgery. However, EF can be misinterpreted and difficult to measure in some cases. The purpose of this study was to compare the value of preoperative EF and intraoperative tissue Doppler imaging variables in predicting the need for postoperative inotropic support. Forty-eight consecutive adult patients undergoing cardiac surgery were enrolled in this study. Systolic mitral annular velocity (S(m)), early diastolic mitral annular velocity (E(m)), the ratio of E(m) to late diastolic mitral annular velocity (E(m)/A(m)), and the ratio of early diastolic transmitral velocity to E(m) (E/E(m)) were measured using transesophageal echocardiography before median sternotomy. The primary outcome was the need for inotropic support for 12 or more hours after surgery. Preoperative, intraoperative, and echocardiographic characteristics were analyzed to determine the independent predictors of the need for postoperative inotropic support. Postoperative inotropic support was required for ≥12 h in 26.7% of patients. Multivariate logistic regression identified only cardiopulmonary bypass (CPB) time as an independent predictor of inotropic support (odds ratio, 1.015; 95% CI, 1.004-1.025; P = 0.004). Additional analysis was performed in the 25 patients with a CPB time of ≥200 min. In this analysis, only S(m) was significantly associated with the need for inotropic support for ≥12 h. This study suggests that those patients who have decreased S(m) and extended CPB times are more likely to require inotropic support after surgery, independent of a preserved left ventricular EF.

Cardiac protection by volatile anaesthetics

To evaluate the effects of total intravenous anaesthesia vs. volatile anaesthesia on cardiac troponin release in coronary artery bypass grafting with cardiopulmonary bypass, we performed a multicentre randomized controlled study to compare postoperative cardiac troponin release in patients receiving two different anaesthesia plans. We randomly assigned 75 patients to propofol (intravenous anaesthetic) and 75 patients to desflurane (volatile anaesthetic) in addition to an opiate-based anaesthesia for coronary artery bypass grafting. Peak postoperative troponin I release was measured as a marker of myocardial necrosis. There was a significant (P < 0.001) difference in the postoperative median (25th-75th percentiles) peak of troponin I in patients receiving propofol 5,5 (2,3-9,5) ng dL(-1) when compared to patients receiving desflurane 2,5 (1,1-5,3) ng dL(-1). The median (interquartile) troponin I area under the curve analysis confirmed the results: 68 (30.5-104.8) vs. 36.3 (17.9-86.6) h ng dL(-1) (P = 0.002). Patients receiving volatile anaesthetics had reduced need for postoperative inotropic support (24/75, 32.0% vs. 31/75, 41.3%, P = 0.04), and tends toward a reduction in number of Q-wave myocardial infarction, time on mechanical ventilation, intensive care unit and overall hospital stay. Myocardial damage measured by cardiac troponin release could be reduced by volatile anaesthetics in coronary artery bypass surgery.

A combined approach for improving cardiopulmonary bypass in coronary artery surgery: a pilot study.

This is a pilot study carried out to assess the feasibility and the clinical impact of a combined approach of cardiopulmonary bypass (CPB) with reduced anti-coagulation. We used a retrospective, non-randomized analysis of 45 consecutive patients undergoing coronary artery bypass using standard CPB with full anticoagulation (activated clotting time, ACT, > 450 s) (Group 1; n = 23) or closed, heparin-coated CPB with low anticoagulation (ACT>250 s), precise heparin and protamine titration, controlled suction, and retrograde autologous prime (Group 2; n = 22). Patients were similar except for a higher incidence of three-vessel disease in Group 2 (77.3% versus 47.8%; p < 0.03). Heparin was reduced by 41% in Group 2 and protamine by 56% (p < 0.0001). Total postoperative blood loss was similar between Groups 1 and 2 (429 +/- 149 versus 435+/-168 ml, respectively). However, the operative hematocrit decrease was lower in Group 2 (-1.6 +/- 7.5% versus -6.9 +/- 4.8%; p = 0.007), although hemodilution was similar, as reflected by the blood protein level. The need for postoperative inotropic support was less frequent in Group 2 (36.4% versus 65.2%; p = 0.05). Within the subgroup of patients weaned from CPB without requiring inotropic support (n = 35), the cardiac index dropped significantly in Group 1 (p = 0.003) 6 h after the start of CPB, whereas it remained stable in Group 2 (p = 0.92). Using multivariate analyses, Group 2 was found to be more protected than Group 1 against myocardial cellular injury (p = 0.046) and need for postoperative inotropic support (p = 0.014). The pejorative postoperative outcome in coronary artery surgery was attenuated through a combined approach aimed at improving CPB.

Cardiac troponin I after heart surgery corrective operation in infancy and childhood

Perioperative myocardial damage is an important determinant for postoperative cardiac function and recovery. Cardiac troponin I (cTNI) is a specific marker for myocardial damage. The aim of our study was to evaluate pre- and postoperative cTNI levels, the pattern of elevation in the first four postoperative days and the prognostic value after pediatric cardiac operation. Cardiac troponin I levels were measured in 115 children mean age 36 +/- 45 months (range 4 days to 189 months) undergoing elective operation of a congenital heart defect. Routine measurements were made preoperatively, immediately after cardiopulmonary bypass and serially 8, 18, 42, 90, 138 hours thereafter. Data from 13 patients undergoing surgery without cardiopulmonary bypass served as controls. Postoperative cTNI levels were correlated with intra- and postoperative parameters (such as duration of aortic crossclamping, cardiopulmonary bypass time and need for postoperative inotropic support). All preoperative cTNI levels were in the normal range. Postoperatively, the highest median cTNI levels were found in patients after repair of tetralogy of Fallot (TOF), atrioventricular septal defect (AVSD) and implantation of a homo- or xenograft. Postoperative cTNI levels correlated significantly with duration of cardiopulmonary bypass and aortic crossclamping, operative approach (ventriculotomy versus atriotomy) and inotropic support (p < 0.0001). Peak cTNI levels were found immediately after surgery in 77.4% of our patients, 8 hours postoperative in 13.9% and at 18 hours after the surgery in 5.2% of the patients. In three children cTNI continued to increase; a secondary increase was found in one patient. Two of these children died, two had a prolonged postoperative recovery. The postoperative level of cardiac troponin I could be used as a marker of perioperative myocardial injury caused by ischemia and operative trauma. Peak levels usually could be obtained immediately after surgery, but a further increase of cTNI during the following 18 hours may occur and is not necessarily related to impaired recovery. However still increasing cTNI levels after 18 hours postoperatively and a secondary increase as well may be used as indicators of poor outcome.

Partial versus full sternotomy for aortic valve replacement

Background. Recent trends suggest that smaller incisions reduce postoperative morbidity. This study tests the hypothesis that a partial upper sternotomy improves patient outcome for aortic valve replacement.Methods. A group of 50 patients who underwent aortic valve surgery through a partial upper sternotomy (group I) were compared to 50 patients who underwent aortic valve replacement through a median sternotomy during the same time period (group II). The mean age (60 ± 2 versus 63 ± 2 years; mean ± SEM) and preoperative ejection fractions (53 ± 2 versus 54 ± 2) were similar. Operations were performed with central cannulation, and antegrade/retrograde blood cardioplegia.Results. There was one death in each group. No differences were found in aortic occlusion time, mediastinal drainage, transfusion incidence, narcotic requirement, length of stay, or cost. The incidence of pleural and pericardial effusions was increased (18.4% versus 3.9%, p < 0.03), and the need for postoperative inotropic support was higher (38.7% versus 19.6%, p < 0.03) in the partial sternotomy group.Conclusions. Aortic valve replacement can be performed through a partial sternotomy with results comparable to full sternotomy. The partial sternotomy offers a cosmetic benefit, but does not significantly reduce postoperative pain, length of stay, or cost.

Intermittent Antegrade Tepid Versus Cold Blood Cardioplegia in Elective Myocardial Revascularization

Background. The ideal temperature for blood cardioplegia administration remains controversial. Methods. Fifty-two patients who required elective myocardial revascularization were prospectively randomized to receive intermittent antegrade tepid (29°C; group T, 25 patients) or cold (4°C; group C, 27 patients) blood cardioplegia. Results. The two cohorts were similar with respect to all preoperative and intraoperative variables. The mean septal temperature was higher in group T (T, 29.6° ± 1.1°C versus 17.5° ± 3.0°C; p < 0.0001). After reperfusion, group T exhibited significantly greater lactate and acid release despite similar levels of oxygen extraction ( p < 0.05). The creatine kinase-MB isoenzyme release was significantly lower in group T (764 ± 89 versus 1,120 ± 141 U · h/L; p < 0.04). Hearts protected with tepid cardioplegia demonstrated significantly increased ejection fraction with volume loading, improvement in left ventricular function at 12 hours, and decreased need for postoperative inotropic support ( p < 0.05). The frequency of ventricular defibrillation after cross-clamp removal was lower in this cohort ( p < 0.05). There were no hospital deaths, and both groups had similar postoperative courses. Conclusions. Intermittent antegrade tepid blood cardioplegia is a safe and efficacious method of myocardial protection and demonstrates advantages when compared with cold blood cardioplegia in elective myocardial revascularization.

Preoperative and Intraoperative Predictors of Inotropic Support and Long-Term Outcome in Patients Having Coronary Artery Bypass Grafting

The prognostic value of preoperative symptoms, preoperative left ventricular function, and intraoperative factors as related to postoperative outcome in coronary artery bypass grafting is unclear. This study was performed to identify risk factors that could be used as markers to predict immediate and long-term outcome, knowledge of which might allow physicians to modify these factors to decrease the likelihood of an adverse outcome. We retrospectively evaluated preoperative factors (including age, sex, New York Heart Association [NYHA] classification of symptoms, ejection fraction [EF], wall motion abnormalities, baseline left ventricular end-diastolic pressure [LVEDP], postradiographic contrast injection LVEDP, change in LVEDP with contrast injection, cardiac enlargement, and collateral vessels) and intraoperative factors (duration of bypass and aortic cross-clamp time) in 128 patients. The need for inotropic drug support was used as a marker of immediate outcome. A 36-mo follow-up used death and the postoperative NYHA classification of symptoms as markers of long-term outcome. The various factors associated with the use of inotropes and immediate outcome were analyzed by logistic regression. The factors related to inotrope use (and presumed adverse short-term outcome) in order of decreasing significance were lower EF, older age, cardiac enlargement, female sex, and higher baseline and postcontrast LVEDP. Patients with EF greater than or equal to 55%, but also having wall motion abnormalities and LVEDP change greater than or equal to 10 mm Hg, and all patients with EF less than 55% were more likely to require inotropic drug stimulation after cardiopulmonary bypass. Neither the change in LVEDP nor the presence of wall motion abnormalities independently predicted the need for postoperative inotropic support.(ABSTRACT TRUNCATED AT 250 WORDS)

Combined antegrade/retrograde cardioplegia for myocardial protection: A clinical trial

The role of retrograde coronary sinus perfusion in the preservation of ischemic myocardium is controversial. We evaluated the use of combined antegrade and retrograde cardioplegia in 59 patients undergoing coronary artery bypass surgery. Nineteen patients were administered antegrade cardioplegia, whereas 40 patients were administered antegrade plus retrograde cardioplegia. Hemodynamic data were obtained before the onset of cardiopulmonary bypass and at 1, 2, 4, 8, 16, and 24 hours after cessation of cardiopulmonary bypass. Myocardial function was assessed by measuring systemic blood pressure, heart rate, cardiac index, pulmonary artery pressure, and capillary wedge pressure. Both cohorts were similar in age, incidence of hypertension, diabetes, and previous myocardial infarction. No significant differences were noted in the need for postoperative inotropic support, the incidence of postoperative arrhythmias, myocardial infarction, heart block, or death. The two groups were similar with respect to cardiac index and systemic and pulmonary vascular resistance. However, the left ventricular stroke work index, when expressed as a function of its prebypass control value, was significantly improved (p less than 0.01) in the cohort administered combined cardioplegia. In the combined group recovery of left ventricular stroke work index occurred earlier and was more complete. These results suggest that the use of combined antegrade/retrograde cardioplegia is safe and may provide superior protection.