Postoperative Low Cardiac Output Syndrome Research Articles

Early postoperative beta-blockers are associated with improved cardiac output after late complete repair of tetralogy of Fallot: a retrospective cohort study

AbstractTetralogy of Fallot is the most common cyanotic congenital heart disease. For decades, our institution has cared for humanitarian patients with late presentation of tetralogy of Fallot. They are characterized by severe right ventricular hypertrophy with consecutive diastolic dysfunction, increasing the risk of postoperative low cardiac output syndrome (LCOS). By right ventricular restrictive physiology, we hypothesized that patients receiving early postoperative beta-blockers (within 48 h after cardiopulmonary bypass) may have better diastolic function and cardiac output. This is a retrospective cohort study in a single-center tertiary pediatric intensive care unit. We included > 1-year-old humanitarian patients with a confirmed diagnosis of tetralogy of Fallot undergoing a complete surgical repair between 2005 and 2019. We measured demographic data, preoperative echocardiographic and cardiac catheterization measures, postoperative mean heart rate, vasoactive-inotropic scores, LCOS scores, length of stay, and mechanical ventilation duration. One hundred sixty-five patients met the inclusion criteria. Fifty-nine patients (36%) received early postoperative beta-blockers, associated with a lower mean heart rate, higher vasoactive-inotropic scores, and lower LCOS scores during the first 48 h following cardiopulmonary bypass. There was no significant difference in lengths of stay and ventilation. Conclusion: Early postoperative beta-blockers lower the prevalence of postoperative LCOS at the expense of a higher need for vasoactive drugs without any consequence on length of stay and ventilation duration. This approach may benefit the specific population of children undergoing a late complete repair of tetralogy of Fallot. What is Known:• Prevalence of low cardiac output syndrome is high following a late complete surgical repair of tetralogy of Fallot. What is New:• Early postoperative beta-blockade is associated with lower heart rate, prolonged relaxation time, and lower prevalence of low cardiac output syndrome.• Negative chronotropic agents like beta-blockers may benefit selected patients undergoing a late complete repair of tetralogy of Fallot, who are numerous in low-income countries.

Correlation between Post-operative Serum Lactate Levels and Low Cardiac Output Syndrome in Patients Undergoing Coronary Artery Bypass Grafting Surgery: A Prospective Study in a Tertiary Care Hospital

Objectives: This study aimed to assess the correlation between the development of low cardiac output syndrome (LCOS) and post-operative serum lactate levels in patients undergoing coronary artery bypass grafting (CABG) surgery at a tertiary care hospital. Methodology: A prospective cross-sectional study was conducted from January to June 2021, involving 50 patients undergoing CABG surgery with cardiopulmonary bypass. Arterial samples were obtained immediately post-surgery and at six, twelve, and twenty-four-hour intervals post-operatively. The association between lactate levels and the occurrence of LCOS, need for inotropic support, and intra-aortic balloon pump (IABP) utilization was evaluated. Results: The study comprised predominantly male patients (84%). Patients were categorized into two groups based on lactate levels: Group 1 (> 4 mmol/L) and Group 2 (< 4 mmol/L). In Group 1, 32% of patients developed LCOS, 10% required IABP, and 20% needed inotropic and vasopressor support. Immediately post-CABG, the mean lactate level was 7.5 mmol/L, with 3% requiring IABP and 20% needing double inotropic support. Lactate levels decreased over time, with mean levels at six, twelve, and twenty-four hours post-surgery being 6.3 mmol/L, 3.8 mmol/L, and 3.3 mmol/L, respectively. Correspondingly, the need for IABP and inotropic support decreased. LCOS occurrence within 24 hours post-surgery correlated significantly with elevated lactate levels (p < 0.05). Conclusion: Elevated lactate levels were associated with the development of LCOS within 24 hours post-CABG surgery. Monitoring lactate levels postoperatively may serve as a valuable tool in predicting and managing LCOS in CABG patients.

Comparison of On-Pump Beating Heart Surgery Versus Conventional Bypass Surgery in Patients with Acute Myocardial Infarction Requiring Urgent Revascularization

Background: The objective of our study was to provide the initial outcomes of the traditional coronary artery surgery approach and the on-pump beating heart surgery in terms of survival and morbidity in patients who needed emergency surgery for acute myocardial infarction. Methods: A single-center retrospective study was performed from November 2013 to September 2023 on a total of 212 patients requiring emergency coronary artery surgery. Group I patients (n = 108) received traditional coronary artery bypass grafting with cross-clamping, while Group II patients (n = 104) underwent on-pump coronary surgery on the beating heart. Results: There were no disparities observed in the preoperative left ventricular function, percutaneous coronary intervention, intra-aortic balloon usage, or clinical-hemodynamic characteristics. Group I patients had significantly higher rates of postoperative mortality and low cardiac output syndrome, as well as a greater utilization of intra-aortic balloons and a higher requirement for extracorporeal membrane oxygenation (p < 0.001). Conclusions: Ultimately, the on-pump beating heart approach could serve as a viable alternative to enhance the preservation of cardiac function and decrease postoperative complications and mortality rates in patients with acute myocardial infarction who require emergency surgery.

Long-term survival after surgical treatment for post-infarction mechanical complications: results from the Caution study.

Mechanical complications (MCs) are rare but potentially fatal sequelae of acute myocardial infarction (AMI). Surgery, though challenging, is considered the treatment of choice. The authors sought to study early and long-term results of patients undergoing surgical treatment for post-AMI MCs. Patients undergone surgical treatment for post-infarction MCs between 2001 through 2019 in 27 centers worldwide were retrieved from the database of CAUTION study. In-hospital and long-term mortality were the primary outcomes. Cox proportional hazards regression models were used to determine independent factors associated with overall mortality. The study included 720 patients. The median age was 70.0 [62.0-77.0] years, with a male predominance (64.6%). The most common MC encountered was ventricular septal rupture (VSR) (59.4%). Cardiogenic shock was seen on presentation in 56.1% of patients. In-hospital mortality rate was 37.4%; in more than 50% of cases, the cause of death was low cardiac output syndrome (LCOS). Late mortality occurred in 133 patients, with a median follow-up of 4.4 [1.0-8.6] years. Overall survival at 1, 5 and 10 years was 54.0%, 48.1% and 41.0%, respectively. Older age (p<0.001) and postoperative LCOS (p<0.001) were independent predictors of overall mortality. For hospital survivors, 10-year survival was 65.7% and was significant higher for patients with VSR than those with papillary muscle rupture (long-rank P=0.022). Contemporary data from a multicenter cohort study show that surgical treatment for post-AMI MCs continues to be associated with high in-hospital mortality rates. However, long-term survival in patients surviving the immediate postoperative period is encouraging.Trial registration number: NCT03848429.

The effect of histidine-tryptophan-ketoglutarate cardioplegia alone or combined with preoperative infusion of levosimendan on vasoactive inotropic score in patients with poor cardiac function undergoing coronary artery bypass grafting

ABSTRACT Background: Patients with poor left ventricular function undergoing cardiac surgery frequently require inotropic drug support immediately after cardiopulmonary bypass. Levosimendan is an effective agent that acts via two complementary mechanisms. It enhances cardiac contractility and reduces cardiac workload. Aim: to assess the effect of histidine-tryptophan-ketoglutarate cardioplegia (HTK cardioplegia) alone or combined with preoperative infusion of levosimendan on the vasoactive inotropic score in patients with poor left ventricular function undergoing coronary artery bypass grafting. Material and method: this double-blinded randomized controlled trial was carried on 100 patients, divided into two groups; Levosimendan group (n = 49): patients received 0.1ug/kg/min levosimendan without loading, 12 hours preoperatively and continued for a total of 24 hours. Control group (n = 51): patients received a placebo 12 hours before surgery and continued for a total 24 hours. Both groups received HTK cardioplegia after cross-clamping of the aorta approximately 20 ml/kg into the ascending aorta over 6–8 minutes at a temperature of 4−10°C. Results: Levosimendan group was superior to control group with statistical significance regarding the need of intraaortic balloon pump (IABP), vasoactive inotropic score over the first 24 hours, troponin levels over the first 72 hours, ICU stays, hospital stay, and cumulative hospital costs. Although the incidence of postoperative low Cardiac output syndrome (LCOS), atrial fibrillation (AF), acute kidney injury (AKI), and overall mortality was lower in levosimendan group, but all were not statistically significant. Conclusion: Preoperative infusion of levosimendan combined with HTK cardioplegia in patients with poor cardiac function decreased vasoactive inotropic score and lowered the costs of hospital stay.

Early improvement of ejection fraction in patients with reduced ejection fraction after coronary artery bypass grafting

BackgroundDespite advancements in surgical technique, myocardial shield, and postoperative care, Coronary artery bypass grafting (CABG) among patients with reduced ejection fraction (EF) remains a surgical challenge due to their greater postoperative morbidity and mortality. This study aims to determine the early outcome of patients with reduced LVEF undergoing CABG and the improvement in the ejection fraction after revascularization. MethodsA total of 62 patients with impaired Left Ventricular (LV) systolic function (LVEF = 35–40 %) who underwent isolated On-pump CABG at the Department of Cardiothoracic Surgery in Assiut University Hospitals and who had met the listed inclusion and exclusion criteria were eligible for the study. Different variables (preoperative, intraoperative, and postoperative) were collected, studied, and compared. ResultsThe mean age of the patients was 57.81 ± 7.57 years, 66.1 % were male and 33.9 % were female. 44 (71.0%) patients were administered antegrade cardioplegia, whereas 18 (29.0%) patients were administered antegrade plus retrograde cardioplegia. Mean LVEF increased significantly from 37.97 ± 1.38% before surgery to 51.87 ± 3.54% after surgery (P ˂ 0.05). Post-operative low cardiac output syndrome occurred in 37 (59.7 %) of patients, pulmonary complications in 15 (24.2%), neurological complications in 10 (16.1%), sternal wound infection in 9 (14.5%), atrial fibrillation in 5 (8.1%) and acute kidney injury in 5 (8.1 %) of patients. In-hospital mortality was 16.1% (10 patients). ConclusionBased on the findings, CABG in patients with reduced preoperative LVEF improves the postoperative LVEF and NYHA functional class.

Surgical treatment strategy of pulmonary artery sling: a series of 110 cases

Objective: To examine the effect of surgical treatment in children with pulmonary artery sling and the surgical treatment strategy. Methods: Relevant data of 110 children with pulmonary artery sling admitted to the Department of Cardiac Surgery, Children's Hospital Affiliated to Shandong University from February 2017 to July 2022 were retrospectively analyzed. There were 55 males and 55 females, aging (M(IQR)) 9.0 (10.6) months (range: 1 to 96 months). The weight was 7.8 (3.5) kg (range: 2.5 to 25.0 kg). Of the 110 patients, 108 had different degrees of tracheal stenosis and 2 had normal trachea. Left pulmonary artery transplantation and tracheoplasty were performed in 78 patients. Left pulmonary artery transplantation was performed in 30 patients (11 in our hospital and 19 in other hospitals) due to the lack of an early tracheoplasty technique, in which 24 patients needed stage Ⅱ tracheoplasty due to obvious respiratory symptoms and limited activity endurance, and 6 cases did not intervene. Two children with normal trachea only underwent left pulmonary artery transplantation. Results: Among the 78 children who underwent surgery in the same period, 70 cases recovered smoothly after surgery, of whom respiratory symptoms were significantly reduced or disappeared during the 1 to 65 months follow-up, with similar activity endurance to normal children of the same age. Eight cases died, including 4 cases of postoperative multi-drug resistant bacteria infection, died from tracheal anastomotic opening or septic shock, 1 cases with severe congenital heart disease died from postoperative low cardiac output syndrome difficult to correct, 1 case died from blood pressure could not be maintained due to the compressed left pulmonary artery after transplantation, 2 cases of postoperative digestive system diseases (adhesive intestinal obstruction, gastrointestinal bleeding, etc.). The 24 patients in the staging group were followed for 1 to 84 months. All patients needed stage Ⅱ tracheoplasty due to respiratory symptoms and decreased endurance to activity. Eight cases of the non-intervention tracheal group were successfully separated from the ventilator, cured and discharged in a short period of time. Conclusions: Most children with pulmonary artery sling have tracheal stenosis. Children with low degree of tracheal stenosis and inconspicuous respiratory symptoms can only undergo left pulmonary artery transplantation by lateral thoracotomy. For patients combined with severe tracheal stenosis or obvious respiratory symptoms, a simultaneous left pulmonary artery transplantat and tracheoplasty is recommended.

Influence of timing of Levosimendan administration on outcomes in cardiac surgery.

Though a subgroup analysis has shown improved survival for patients suffering severely reduced ventricular function undergoing coronary artery bypass grafting, RCTs were not able to demonstrate overall beneficial effects of perioperative Levosimendan in cardiac surgery. This might be due to Levosimendan's pharmacokinetics reaching a steady-state concentration only 4-8 h after administration. Thus, this study now analysed the influence of timing of Levosimendan administration on perioperative outcome in cardiac surgery patients preoperatively presenting with severely reduced ventricular function and therefore considered at high-risk for intra- or postoperative low cardiac output syndrome. We hypothesized that prolonged preoperative Levosimendan administration ("preconditioning") would reduce mortality. All adult patients undergoing cardiac surgery between 2006 and 2018 perioperatively receiving Levosimendan were included in this retrospective, observational cohort study (n = 498). Patients were stratified into 3 groups: Levosimendan started on the day prior to surgery ("preop"), Levosimendan started on the day of surgery ("intraop") or post ICU admission ("postop"). After propensity score matching (PSM) was performed, outcomes defined according to proposed standard definitions for perioperative outcome research were compared between groups. After PSM, there were no significant differences in patients' characteristics, comorbidities and type/priority of surgery between groups. Compared to intraop or postop Levosimendan treatment, preop treated patients had significantly lower in-hospital-mortality (preop vs. intraop. vs. postop = 16,7% vs. 33,3% vs. 42,3%), duration of mechanical ventilation and rate of continuous renal replacement therapy. Prolonged preoperative treatment with Levosimendan of cardiac surgery patients preoperatively presenting with severely reduced left ventricular function might be beneficial in terms of postoperative outcome. Our results are in line with recent experts' recommendations concerning the prolonged perioperative use of Levosimendan. We strongly recommend that future randomized trials include this "preconditioning" treatment as an experimental arm.

Sutureless technique combined with vertical vein incision and pulmonary veins unroofed for correction of infracardiac total anomalous pulmonary venous connection.

We report a surgical method (sutureless technique), combined with vertical vein incision and pulmonary veins unroofed (semisutureless technique), to correct infracardiac total anomalous pulmonary venous connection (TAPVC). The clinical characteristics of 21 patients, who were diagnosed with infracardiac TAPVS between February 2017 and March 2022, were retrospectively analyzed. These patients were divided into three groups according to different surgical methods: conventional surgery group, sutureless technique group, and semisutureless technique group. The conventional surgery group enrolled five patients with a median age of 16 days (interquartile range, 9-27 days) and a median weight of 3.25 kg (interquartile range, 3.1-3.42 kg). In this group, no preoperative pulmonary vein obstruction (PVO), preoperative ventilator support, or emergency surgery were reported. The sutureless technique group enrolled seven patients with a median age of 12 days (interquartile range, 5-16 days) and a median weight of 3.04 kg (interquartile range, 2.76-3.20 kg). In this group, two patients with preoperative PVO, four patients with preoperative ventilator support, and seven patients requiring emergency operation were found. The semisutureless technique group enrolled nine patients with a median age of 14 days (interquartile range, 7-24 days) and a median weight of 3.22 kg (interquartile range, 3.15-3.50 kg). In this group, four patients with preoperative PVO, two patients with preoperative ventilator support, and seven patients requiring emergency operation were noted. In the conventional surgery group, two patients with postoperative supraventricular tachycardia, one patient with postoperative low cardiac output syndrome, one patient with PVO, and no case of postoperative death were reported. In the sutureless technique group, two patients with postoperative low cardiac output syndrome, one patient with postoperative supraventricular tachycardia, one patient with postoperative PVO, and no postoperative deaths were determined. In the semisutureless technique group, three patients had low cardiac output syndrome, two patients had supraventricular tachycardia after the operation, and one patient, who had been admitted to the hospital after cardiopulmonary resuscitation in the emergency room, died early after the operation. No case of death or PVO was noted after the operation. The semisutureless technique has positive effects. This surgery method can enlarge the anastomotic stoma, increase the volume of the left atrium, reduce the tension of the anastomotic stoma, fix the pulmonary vein to avoid distortion, and prevent postoperative hemorrhage.

Development and validation of a predictive model for low cardiac output syndrome after surgical repair of tetralogy of Fallot.

Low cardiac output syndrome (LCOS) remains a serious postoperative complication for children with tetralogy of Fallot (TOF), which often leads to increased morbidity and mortality. Early identification of LCOS and timely management are critical for better outcomes. This study aimed to develop a prediction model incorporating pre- and intraoperative characteristics for LCOS within 24 hours after surgical repair of TOF in children. The training dataset consisted of patients with TOF who underwent surgical repair in 2021, while the validation dataset consisted of patients in 2022. The univariable and multivariable logistic regression analyses were performed to recognize the risk factors of postoperative LCOS and a predictive model was established based on multivariable logistic regression analysis in the training dataset. Model predictive power was assessed using the area under the receiver operating characteristic curve (AUC). The calibration of the nomogram was evaluated and the Hosmer-Lemeshow test was used to assess the good fit. Decision curve analysis (DCA) was used to estimate the net benefits of the prediction model at different threshold probabilities. In the multivariable logistic analysis, peripheral oxygen saturation, mean blood pressure, and central venous pressure were independent risk factors for postoperative LCOS. The AUC of the predictive model for postoperative LCOS was 0.84 (95% CI: 0.77-0.91) and 0.80 (95% CI: 0.70-0.90) in the training and validation datasets, respectively. The calibration curve for the probability of LCOS showed good agreement between the prediction by nomogram and actual observation both in the training and validation datasets. The Hosmer-Lemeshow test yielded nonsignificant statistics both in the training and validation datasets (P=0.69 and 0.54, respectively), indicating a good fit. The DCA revealed that more net benefits would be obtained by using the nomogram to predict LCOS than that achieved in either the treat-all-patient scheme or the treat-none scheme both in the training and validation datasets. This study is the first to incorporate pre- and intraoperative characteristics to develop a predictive model for LCOS after surgical repair of TOF in children. This model showed good discrimination, good fit and clinical benefits.

Clinical trends of children with primary cardiac tumors: 15-year experience from a single center.

e22008 Background: Clinical presentation of pediatric primary cardiac tumors is exceptionally rare throughout the world. The purpose of our study is to evaluate clinical intervention by following up on children with primary cardiac tumors. Methods: Our study retrospectively enrolled 97 children diagnosed with primary cardiac tumors from Jan 2005 to Dec 2020 in a single center, Children’s Hospital of Nanjing Medical University by confirming with clinicoradiological and non-invasive diagnostic procedures. Primary outcome was to measure clinical trends and interventions while secondary was to analyze survival of 26 (26.80%) operative and 71 (73.19%) non-operative patients. Surgical intervention patients were followed for 6 Mo in the first postoperative year, then every year. Meanwhile, non-serious, asymptomatic, and no hemodynamic changes patients were treated non-operatively and followed up every year regularly. Results: In primary outcome, median age of children was 4.72±4.10 years (1d~16y), and median follow-up was 5.60±4.97 years (1m~15y). Most enrolled children were younger than 1 year old at the time of diagnosis. Primary cardiac tumors patients consisting of 60 rhabdomyoma (61.85%), 11 myxomas (11.34%), 7 fibromas (7.21%), 3 lymphangiomas (3.09%), 2 lipomas (2.06%), 9 unclassified tumors (9.27%) and 5 malignant tumors (5.15%) were retrospectively analyzed. Major 75 patients (77.31%) were diagnosed during various treatments of clinical symptoms, whereas 18 (18.55%) were diagnosed with routine investigation and 14 (14.43%) were diagnosed by prenatal fetal echocardiography. Herein, 26 children with critical symptoms and serious hemodynamic alteration had undergone surgical intervention in our hospital. Among them, 6 (23.07%) patients had postoperative complications; 2 (7.7%) patients were unable to survive due to post-operative arrhythmia and low cardiac output syndrome; While 2 (7.7%) patients with myxomas had a reoccurrence, and 2 (7.7%) patients had been diagnosed with another rhabdomyoma after intervention, others recovered well. Meanwhile, 71 children had non-surgical management, where 8 (11.26%) were lost to follow-up; 3 (4.22%) patients with malignant tumors were unable to survive after discharge due to unknown causes, and other patients had no serious symptoms or growth of tumors during follow-up. In secondary outcome, survival between operative and non-operative patients had no significant difference ( P &gt; 0.05). Conclusions: Clinical intervention of pediatric primary cardiac tumors may be performed one-on-one by accounting presentations, symptoms, and emergence even though majority of primary cardiac tumors in children are benign in nature, and postoperative reoccurrence is feasible, particularly for rhabdomyoma. Meanwhile, the primary goal of surgical intervention is to reinstate normal hemodynamics, and preserve significant structures and cardiac tissues.

Impact of prophylactic intra-aortic balloon pump on early outcomes in patients with severe left ventricular dysfunction undergoing elective coronary artery bypass grafting with cardiopulmonary bypass

ObjectiveOur aim was to analyse whether prophylactic preoperative intraaortic balloon pump (IABP) improves outcomes in hemodynamically stable patients with low left ventricular ejection fraction (LVEF ≤30%) undergoing elective myocardial revascularization (CABG) using cardiopulmonary bypass (CPB). Secondary aim was to identify the predictors for low cardiac output syndrome (LCOS). MethodsProspectively collected data of 207 consecutive patients with LVEF ≤30% undergoing elective isolated CABG with CPB from 01/2009 to 12/2019, 136 with and 71 patients without IABP, were retrieved retrospectively. Patients with prophylactic IABP were matched 1:1 with patients without IABP by a propensity score matching. Stepwise logistic regression was conducted to identify predictors of postoperative LCOS in the propensity-matched cohort. P value ≤0.05 was considered significant. ResultsReduced postoperative LCOS (9.9% vs. 26.8%, P = 0.017) was observed in patients receiving prophylactic IABP. Stepwise logistic regression identified preoperative IABP as preventive factor for postoperative LCOS [Odds Ratio (OR) 0.19,95% Confidence Interval (CI), 0.06–0.55, P = 0.004]. The need of vasoactive and inotropic support was lower in patients with prophylactic IABP at 24, 48 and 72 h after surgery (12.3 [8.2–18.6] vs. 22.2 [14.4–28.8], P < 0.001, 7.7 [3.3–12.3] vs.16.3 [8.9–27.8], P < 0.001 and 2.4 [0–7] vs. 11.5 [3.1–26], P < 0.001, respectively). The patients in both groups did not differ in terms of in-hospital mortality (7.0% vs. 9.9%, P = 0.763). There were no major IABP-related complications. ConclusionsElective patients with left ventricular ejection fraction ≤30% undergoing CABG with CPB and prophylactic IABP insertion had less low cardiac output syndrome and similar in-hospital mortality.

Comparison between levosimendan versus beta agonists in preservation of renal function in cardiac surgery patients with low cardiac output syndrome

ABSTRACT Background Post cardiac surgery acute kidney injury (AKI) secondary to postoperative low cardiac output syndrome (LCOS), is a serious complication. Positive inotropic agents are the main line of treatment for LCOS with different degrees of improvement of cardiac function & nephroprotective efficacy Levosimendan is a calcium sensitizer in cardiac muscles, which has a comparable positive inotropic and nephroprotective effects to that of classic beta2 agonists. Objective To evaluate the possible nephroprotective effect of levosimendan as compared to beta agonists in cardiac surgery patients with LCOS. Patients and Methods It is a prospective, randomized and comparative study conducted at Ain Shams University Hospitals over the period from December 2020 to May 2021. A total of 60 patients with post cardiac surgery low cardiac output syndrome were divided into two groups of 30 patients each. Group A (control) received beta-agonists (dobutamine or adrenaline) and Group B (study) received levosimendan. The incidence of AKI at the diagnosis of LCOS & its progression to renal failure in both groups were assessed. Results The incidence of AKI at diagnosis of LCOS postoperative was 30% (n = 9) in each group; 44% of them in the control group (n = 4) developed renal failure at discharge from ICU and none of the study group patients developed renal failure at discharge. At the time of discharge from ICU, the incidence of renal failure in beta-agonist group was 13.3%, while the incidence in the levosimendan group was 0% with statistically significant P value of 0.038. Conclusion In comparison to beta-agonists, Levosimendan may have a better nephroprotective effect that plays a role in decreasing the incidence of kidney failure in patients with post cardiac surgery LCOS. A larger randomized, controlled trials are recommended to prove such a beneficial nephroprotective effect and its exact mechanism.

Comparison between Intra-Aortic Balloon Pump and Levosimendan as Treatment Modalities for Cardiogenic Shock Post Cardiac Surgery

Purpose: Post cardiac surgery cardiogenic shock is one of the major life threatening complications of open heart surgeries. Two modalities are widely used to improve the cardiac output and overcome the acute postoperative complication beside other conventional treatment including mechanical ventilator, inotropes and vasopressors. Those modalities are levosimendan and Intra-aortic balloon pump. The purpose of this study is to investigate the prognosis of levosimendan vs IABP in patients who developed cardiogenic shock post cardiac surgery.&#x0D; Methodology: This was a prospective observational study conducted as national heart institute, Egypt on 50 patients who developed cardiogenic shock post cardiac surgery and managed by either levosimendan or Intra-aortic balloon Pump (IABP) beside other conventional therapies. Patients were then divided into two groups according to the modality used. Group I: patients who were managed by levosimendan and group II: patients who were managed by IABP. Two groups were then compared according to baseline preoperative characteristics and in-hospital course and one month follow up post discharge echocardiography.&#x0D; Findings: No significant difference regarding between in-hospital mortality between levosimendan, 44% and IABP, 52% P value 0.5. Levosimendan was associated with significantly shorter ICU stay, 5.56±2.85 compared to IABP, 8±3.34 days (P value 0.02). Levosimendan seems to be a better option than IABP or at least equivalent to it in postoperative cardiogenic shock.&#x0D; Recommendations: Levosimendan is an alternative cost effective modality for patients with post-operative low cardiac output syndrome especially when IABP isn’t available.&#x0D;

Risk factors of postoperative low cardiac output syndrome in children with congenital heart disease: A systematic review and meta-analysis.

Low cardiac output syndrome (LCOS) is the most common complication after cardiac surgery, which is associated with the extension of postoperative hospital stay and postoperative death in children with congenital heart disease (CHD). Although there are some studies on the risk factors of LCOS in children with CHD, an unified conclusion is lack at present. To synthesize the risk factors of LCOS after CHD in children, and to provide evidence-based insights into the early identification and early intervention of LCOS. The databases of the China National Knowledge Infrastructure (CNKI), Wanfang Database, China Science and Technology Journal Database (VIP), PubMed, Cochrane Library, Embase and Web of Science were searched for relevant articles that were published between the establishing time of each database and January 2022. Based on retrospective records or cohort studies, the influencing factors of postoperative low cardiac output in children with congenital heart disease were included in Meta analysis.This study followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. The risk of bias was evaluated according to the Newcastle-Ottawa Scale (NOS). RevMan 5.4 software was used to conduct the meta-analysis. A total of 1,886 records were screened, of which 18 were included in the final review. In total, 37 risk factors were identified in the systematic review. Meta- analysis showed that age, type of CHD, cardiac reoperation, biventricular shunt before operation, CPB duration, ACC duration, postoperative residual shunt, cTn-1 level 2 h after CPB > 14 ng/ml and postoperative 24 h MR-ProADM level > 1.5 nmol/l were independent risk factors of LCOS. Additionally, the level of blood oxygen saturation before the operation was found to have no statistically significant relationship with LOCS. The risk factors of postoperative LCOS in children with CHD are related to disease condition, intraoperative time and postoperative related indexes, so early prevention should be aimed at high-risk children. https://www.crd.york.ac.uk/prospero/, identifier: CRD42022323043.

Efficacy and safety of remimazolam for non-obese patients during anesthetic induction in cardiac surgery: study protocol for a multicenter randomized trial

BackgroundValvular heart disease remains common in both developed and developing countries, and it requires timely surgical treatment when necessary. However, the stability of hemodynamics during anesthesia induction in patients undergoing valve replacement surgery is difficult to maintain due to their impaired cardiac function. Remimazolam, a novel and ultrashort-acting intravenous sedative-hypnotic, may be beneficial to stable hemodynamics, but the evidence is limited. Therefore, this study aims to evaluate the effect of remimazolam induction on hemodynamics compared with midazolam and etomidate in patients undergoing valve replacement surgery.MethodsThis is a prospective, multicenter randomized controlled trial (RCT). Three hundred and sixty-three non-obese adult patients aged 45 to 80 years old undergoing valve surgery with cardiopulmonary bypass will be randomly allocated to receive remimazolam tosilate, midazolam, or etomidate during anesthetic induction. The primary outcome is the incidence of hypotension within 20 min after the administration of investigated drugs. The hypotension is defined as systolic blood pressure (SBP) < 90 mmHg or a 30% reduction in SBP from baseline or the application of vasoactive drugs. Secondary outcomes include incidence of successful sedation, time to successful sedation, incidence of delirium and postoperative low cardiac output syndrome within 7 days after surgery, hospital mortality, mechanical ventilation time, ICU length of stay, and hospital length of stay.DiscussionTo our knowledge, this is the first prospective RCT to investigate the efficacy and safety of remimazolam induction in adult cardiac surgery compared with midazolam and etomidate. This study will provide important information on the application of remimazolam in cardiac surgery in the future.Trial registrationChinese Clinical Trial Registry chictr.org.cn ChiCTR2100050122. Registered on August 16, 2021.

Comparative study between levosimendan and intra-aortic balloon pump in high risk patients undergoing beating heart coronary artery bypass surgery

Background: Preoperative left ventricular dysfunction is an independent risk factor for perioperative mortality and morbidity and is also associated with postoperative low cardiac output syndrome. IABP improved outcomes in high-risk cardiac patients. However, installation of the balloon has many disadvantages. Recently, a new drug named levosimendan is commonly used as an inotropic support with no increase oxygen demand of myocardium. Objective: The purpose of our study was to compare the efficiency of levosimendan versus intra-aortic balloon pump in patients with poor left ventricular function undergoing coronary artery bypass grafting (CABG) with ejection fraction less than 35%. Patients and Methods: Forty patients with elective multi-vessel off-pump CABG at Al-Azhar University, Air force Specialized and Al-Assema Hospitals were randomized into 2 groups, according to the treatment they received – either levosimendan (Levo group) or intra-aortic balloon counter pulsation (IABP group), and compared with respect to The use of inotropic drugs, Hemodynamics, ICU stay, hospital stay and in-hospital mortality. Results: There were no differences in preoperative characteristics including patients’ age, sex, BMI, and comorbidities. The Levosemindan group had shorter ICU and hospital stays as compared to IABP group with comparable hemodynamic functions, time of mechanical ventilation and mortality rate.

Sutureless and rapid deployment versus sutured aortic valve replacement: a propensity-matched comparison from the Sutureless and Rapid Deployment International Registry.

To compare procedural and in-hospital outcomes of patients undergoing sutureless (Perceval, Livanova PLC, London, UK) and rapid deployment (Intuity Elite, Edwards Lifesciences, Irvine, CA, USA) aortic valve replacement (group 1) versus sutured aortic valve replacement (group 2). Patients receiving isolated aortic valve replacement between 2014 and 2020 were analysed using data from the Sutureless and Rapid Deployment International Registry. Patients in group 1 and group 2 were propensity-score matched in a 1:1 ratio. A total of 7708 patients were included in the study. After matching, 2 groups of 2643 each were created. Patients in group 1 were more likely to undergo minimally invasive approaches and were associated with shorter operative times when compared with group 2. Overall in-hospital mortality was similar between groups. While an increased risk of stroke was observed in group 1 in the first study period (2014-2016; relative risk 3.76, P < 0.001), no difference was found in more recent year period (relative risk 1.66, P = 0.08; P for heterogeneity 0.003). Group 1 was associated with reduced rates of postoperative low cardiac output syndrome, atrial fibrillation and mild aortic regurgitation. New pacemaker implant was three-fold higher in group 1. Our findings showed significant differences in procedural and clinical outcomes between the study groups. These results suggest that sutureless and rapid deployment aortic valve replacement should be considered as part of a comprehensive valve programme. The knowledge of the respective post-aortic valve replacement benefits for different valve technologies may result in patient-tailored valve selection with improved clinical outcomes.

Effect of Nitric Oxide via Cardiopulmonary Bypass on Ventilator-Free Days in Young Children Undergoing Congenital Heart Disease Surgery

In children undergoing heart surgery, nitric oxide administered into the gas flow of the cardiopulmonary bypass oxygenator may reduce postoperative low cardiac output syndrome, leading to improved recovery and shorter duration of respiratory support. It remains uncertain whether nitric oxide administered into the cardiopulmonary bypass oxygenator improves ventilator-free days (days alive and free from mechanical ventilation). To determine the effect of nitric oxide applied into the cardiopulmonary bypass oxygenator vs standard care on ventilator-free days in children undergoing surgery for congenital heart disease. Double-blind, multicenter, randomized clinical trial in 6 pediatric cardiac surgical centers in Australia, New Zealand, and the Netherlands. A total of 1371 children younger than 2 years undergoing congenital heart surgery were randomized between July 2017 and April 2021, with 28-day follow-up of the last participant completed on May 24, 2021. Patients were assigned to receive nitric oxide at 20 ppm delivered into the cardiopulmonary bypass oxygenator (n = 679) or standard care cardiopulmonary bypass without nitric oxide (n = 685). The primary end point was the number of ventilator-free days from commencement of bypass until day 28. There were 4 secondary end points including a composite of low cardiac output syndrome, extracorporeal life support, or death; length of stay in the intensive care unit; length of stay in the hospital; and postoperative troponin levels. Among 1371 patients who were randomized (mean [SD] age, 21.2 [23.5] weeks; 587 girls [42.8%]), 1364 (99.5%) completed the trial. The number of ventilator-free days did not differ significantly between the nitric oxide and standard care groups, with a median of 26.6 days (IQR, 24.4 to 27.4) vs 26.4 days (IQR, 24.0 to 27.2), respectively, for an absolute difference of -0.01 days (95% CI, -0.25 to 0.22; P = .92). A total of 22.5% of the nitric oxide group and 20.9% of the standard care group developed low cardiac output syndrome within 48 hours, needed extracorporeal support within 48 hours, or died by day 28, for an adjusted odds ratio of 1.12 (95% CI, 0.85 to 1.47). Other secondary outcomes were not significantly different between the groups. In children younger than 2 years undergoing cardiopulmonary bypass surgery for congenital heart disease, the use of nitric oxide via cardiopulmonary bypass did not significantly affect the number of ventilator-free days. These findings do not support the use of nitric oxide delivered into the cardiopulmonary bypass oxygenator during heart surgery. anzctr.org.au Identifier: ACTRN12617000821392.

Cryopreserved aortic homografts for complex aortic valve or root endocarditis: a 28-year experience.

The aim of this study was to evaluate early- and long-term outcomes of cryopreserved aortic homograft (CAH) implantation for aortic valve replacement (AVR) or aortic root replacement (ARR) in patients with or without complex infective endocarditis. All adult patients undergoing AVR or ARR with CAH at our institution between January 1993 and July 2021 were included in the study. One hundred four patients, 75 males and 29 females, aged 59 ± 17 years, underwent AVR or ARR with CAH for infective endocarditis (n = 94, 90%) or aortic valve disease (n = 10, 10%). There were 33 (35%) native valve endocarditis and 61 (65%) prosthetic valve endocarditis, which were complicated by annular abscess in 77 (82%) patients, mitral valve endocarditis in 13 (14%) and tricuspid valve endocarditis in 13 (14%). The mean cardiopulmonary bypass time was 214 ± 80 min and the mean aortic cross-clamping time was 164 ± 56 min. There were 12 (12%) hospital deaths and 7 (7%) postoperative low cardiac output syndrome requiring extracorporeal membrane oxygenation in 4 patients and intra-aortic balloon pump in 3. Thirty-nine (42%) patients died during the follow-up (94% complete). The mean survival time was 13.9 ± 1.2 years. Twenty-five patients (26%) underwent late reoperation for aortic homograft degeneration (n = 17, 18%), homograft endocarditis (n = 6, 7%), homograft dehiscence (n = 1, 1%) and mitral valve regurgitation (n = 1, 1%). The mean survival free from reintervention was 15.7 ± 1.2 years. AVR or ARR with a CAH for complex endocarditis is associated with satisfactory hospital survival, considering the critical patient presentation at surgery, and excellent survival free from recurrent infection. Need for reoperation late after surgery is similar to other biological prostheses.