Pump Cardiac Surgery Research Articles

Off Pump CABG Improves Postoperative Incidence of Coagulopathy Compared with CABG on Pump

Abstract Background Coronary artery bypass grafting remains the standard treatment for patients with extensive coronary artery disease. Coronary surgery without use of cardiopulmonary bypass avoids the deleterious systemic inflammatory effects of the extracorporeal circuit. However there is an ongoing debate surrounding the clinical outcomes after on-pump versus off-pump coronary artery bypass (ONCAB versus OPCAB) grafting surgery. Aim of the Work To compare the incidence of postoperative coagulopathy transfusion of blood product therapy, (Packed RBCs, FFP and platelet concentrate) bleeding (amount of blood in chest tube drains) and reexploration, that occur in adults off pump CABG surgery in comparison to on pump CABG. Patients and Methods We enrolled sixty consecutive adult patients scheduled for isolated CABG surgery (with a median sternotomy) with or without cardiopulmonary bypass pump. The patients are allocated in two groups where thirty patients in each group (group A – On pump – ONCAB- conventional surgery) and (group B – Off pump – OPCAB – beating heart) after obtaining their written informed consent. Results The clinical outcome measure was the incidence of bleeding in group B less than group A. In our study there was highly significant increase in the amount of blood in drains, transfusion requirements and need for re-exploration within twenty four hours after surgery in group A than group B. Conclusion We concluded that off pump cardiac surgery is better than on pump procedure in decreasing risk of bleeding, post-operative transfusion requirements and risk of re-exploration.

Potential Benefit of Combined Topical and Intravenous Administration of Tranexamic Acid in Congenital Heart Surgery

Abstract Objective Pediatric patients who undergo repair of congenital heart diseases on cardiopulmonary bypass are at great risk of postoperative bleeding. The major causes of bleeding are thrombocytopenia, platelets dysfunction, hemodilution and increased fibrinolysis during cardiopulmonary bypass (CPB). Non-surgical postoperative bleeding occurs due to micro-vascular bleeding from pericardial and mediastinal tissues when blood comes in contact with non-endothelial surfaces of the Cardio-Pulmonary Bypass (CPB) machine, compounded by liberal use of heparin and a complex interaction of humoral and cellular pathways. Aim of the Work The aim of the study is to asses if there is potential benefit of intrapericardial topical application of tranexamic acid when it is combined with the intravenous administration in reduction of postoperative bleeding after pediatric cardiac surgery on cardiopulmonary bypass (CPB). Patients and Methods Type of the study: Interventional, randomized and double blinded clinical trial. Study Setting: The operating theaters of Ain Shams University Hospitals. Study period: Over one year (from March 2020 to March 2021). Standard management: Intravenous Tranexamic acid (TxA) injection. Results The estimated blood loss postoperatively in first 24 hrs. Were less in the combined group than the IV group. Requirements of blood transfusion also were statically significant in combined group than IV group from aspects of volume of PRBCs transfusion, Total number of patients exposed to transfusion and transfusion rate. There is no difference regarding ICU stay and need of surgical re exploration. Conclusion The combined use of low dose IV and topical intrapericardial tranexamic acid in children with congenital heart disease undergoing on pump cardiac surgery reduced the risk of post-operative bleeding and need for blood products transfusion when compared to the administration of IV tranexamic acid only suggesting a potential benefit of topical tranexamic acid in hemostasis.

Ferroptosis Mechanisms Involved in on Pump Cardiac Surgery Related Acute Kidney Injury

Ferroptosis Mechanisms Involved in on Pump Cardiac Surgery Related Acute Kidney Injury

The association between intraoperative cardiopulmonary bypass power and complications after cardiac surgery.

Low cardiac power (product of flow and pressure) has been shown to be associated with mortality in patients with cardiogenic shock after acute myocardial infarction, but has not been studied in cardiac surgical patients. This study's hypothesis was that cardiac power during cardiopulmonary bypass for cardiac surgery would have a greater association with adverse events than either flow or MAP (mean arterial pressure) alone. We undertook a retrospective observational study using patient data from February 2015 to March 2022 undergoing cardiac surgery at Fiona Stanley Hospital in Perth Australia. Excluded were patient age less than 18years old, patients undergoing thoracic transplantation, ventricular assist devices, off pump cardiac surgery and aortic surgery. The primary outcome was a composite outcome of 30-days mortality, stroke or new-onset renal insufficiency. Overall, 1984 cardiac surgeries were included in the analysis. Neither duration nor area below thresholds tested for power, MAP or flow was associated with the primary composite outcome. However, we found that an area below MAP thresholds 35-50mmHg was associated with new renal insufficiency (adjusted odds ratio 1.17 [95% CI 1.02 to 1.35] for patients spending 10min at 10mmHg below 50mmHg MAP compared to those who did not). This study suggests that MAP during cardiopulmonary bypass, but not power or flow, was an independent risk factor for adverse renal outcomes for cardiac surgical patients.

Postoperative Fluid Therapy in Adult Cardiac Surgical Patients and Acute Kidney Injury: A Prospective Observational Study

Abstract Background Normal saline (0.9% NS) is a common intravenous fluid used worldwide. Recent studies have shown that NS use is associated with increased incidence of acute kidney injury (AKI) and a need for renal replacement therapy (RRT). The practice is changing toward using balanced solutions to prevent AKI. Postcardiac surgery patients are more prone to develop AKI after cardiopulmonary bypass (CPB). We aim to study the type of fluid administrated, incidence of AKI, need for RRT, and overall outcome of these patients. Methods This prospective observational study was conducted in the cardiothoracic intensive care unit (cardiothoracic and vascular surgery intensive care unit) in a cohort of 197 adult patients who underwent on pump cardiac surgery in our hospital from July 2021 to October 2021 as a pilot study. Data was analyzed using SPSS 20.0 (IBM, Chicago, Illinois, United States). A p-value < 0.05 was considered significant. Results In our study, 58 (29.34%) patients developed AKI in the first three postoperative days and 16 (8.12%) patients required RRT. Incidence of AKI was found to be higher in patients who received NS only, as fluid of choice was 34.48% compared with other intravenous fluids. Patients with AKI had higher positive fluid balance (p < 0.001), longer CPB (p < 0.001), and aortic cross clamp (p = 0.006) times. Intensive care unit and hospital stay and mortality rates were higher in AKI patients than those without AKI (p < 0.001). Conclusion Our study demonstrated that NS was the commonly used crystalloid in our patients and was associated with increased incidence of AKI and RRT when compared with other balanced salts solutions.

Effect of different perioperative glycemic protocols in nondiabetic patients undergoing open heart surgery: a comparative study

Introduction: Hyperglycemia during cardiac surgery is common due to stress response and cardiopulmonary bypass. Increased blood glucose is associated with poor outcomes, more complications and increased mortality in diabetic as well as nondiabetic patients due to negative effect on endothelial function, myocardium and inflammatory response. Perioperative blood glucose control and correct target value in cardiac surgery patients remain an ongoing controversy. This study was conducted to observe the effect of two different glycemic protocols in non-diabetic patients undergoing on pump cardiac surgery. Materials and methods: A total of 102 non diabetic patients were randomly distributed into two groups: Group A, Group B. After induction a continuous insulin infusion at the rate of 0.1 unit/kg/hr was started in both groups when blood glucose level (BGL) was >140mg/dl in Group A and >180mg/dl in Group B. The infusion rate was adjusted to maintain BGL at 120-140mg/dl in Group A and 160-180mg/dl in Group B. BGL was measured at different points of time. Perioperative effects, requirement of cardiac drugs, insulin used and infection related complications were assessed. Results: Finally data of 100 patients were analyzed. Rate of deep sternal wound infection [Group A:B= 3(6.12%):4(7.84%)] and other infection related complications were similar in both the groups (p>0.05). Length of ICU stay was significantly longer in Group B than Group A (p=0.013). Conclusion: Perioperative infection rate in nondiabetic cardiac patients is not higher when Target blood glucose level is 160-180mg/dl as compared to120-140mg/dl. Though length of ICU stay is less in lower blood glucose group; perioperative morbidities and 30 day mortality is similar in both blood glucose range.

The cardioprotective effect of intralipid in decreasing the ischemic insults during off-pump coronary artery revascularization

BackgroundOff pump coronary artery revascularization (OPCAB) surgeries have benefits over the conventional on pump cardiac surgery, because it avoids the trauma caused by cardiopulmonary bypass (CPB) and minimize aortic manipulation. However, some disadvantages of OPCAB include the concern of ineffective coronary revascularization. Some drugs have shown the ability to protect the myocardium in different studies, by different methods. The usage of intralipid has been shown to make a better functional recovery of the cardiac muscles and help to decrease the myocardial infarct size, it shortens the action potential time, which show polyunsaturated fatty acids diets mechanism as an antiarrhythmic drug, and are associated with low incidence of coronary artery disease.MethodsWe divided patients into two groups according to the randomization envelopes: intralipid group (group A) received 1.5 ml/kg intralipid 20% through central venous line after sternotomy over 1 h and during infusion, blood pressure, heart rate, and temperature were monitored all through the infusion time. Control group (group B) received normal saline 0.9% in the same volume over the same duration.ResultsThis study showed that infusion of 1.5 ml/kg intralipid after sternotomy in off pump coronary artery revascularization given as preconditioning agent improve the myocardial ischemia reperfusion injury, decrease the need for high doses of nor adrenaline infusion after revascularization, earlier normalization in troponin levels starting 24 h after surgery and higher values of cardiac index were measured in ICU using PICCO.ConclusionsThis study showed the benefits of infusion of 1.5 ml/kg of intralipid after sternotomy, in preconditioning during OPCABG. Preconditioning with intralipid proved to decrease reperfusion injury in myocardium expressed by improvement in cardiac functions (EF and cardiac index) and normalization of specific cardiac marker (cardiac troponin I).

Is a fixed low-dose protamine better at reducing postoperative bleeding in off pump coronary artery bypass grafting?

Protamine is used ubiquitously in all cardiac surgeries for reversal of heparin. Risk of postoperative bleeding is increased with inadequate heparin reversal or due to anticoagulant side effects of protamine; hence, it is important to dose protamine properly. This study compares 80% protamine dose with full dose on postoperative bleeding and transfusion needs in OPCAB. The aim of our study was to find whether lower dose of protamine could reduce postoperative bleeding and need for blood product transfusions in off pump coronary artery bypass grafting as compared to the regular dose of protamine. This was a double-blinded randomised controlled trial where patients posted for off pump CABG meeting the inclusion criteria were included in the study. Ninety patients were randomised to two groups, group F receiving full dose of protamine of 1 mg per mg heparin used, and group L received 0.8 mg per mg. Postoperative activated clotting time, bleeding at 1 h, 4 h, 24 h and total drainage till drains removal and blood product transfusion requirements were noted.Statistical analysis used: SPSS software. Both groups were matched in demographics, preoperative cessation of heparin and aspirin and platelet counts. Both groups received equal heparin dose, activated clotting time before protamine, activated clotting time post protamine in OT and ICU were equal as were the conduits used. There was no significant difference between the groups in post-operative drainage over time or in the need for blood product transfusions. Eighty per cent of the dose of protamine can adequately reverse the heparin used during off pump cardiac surgery without any increase in incidence of postoperative bleeding or need for blood product transfusions.

Clinical Usefulness of Preoperative Physiotherapy in Cardiac Surgery: A Prospective Observational Study

Significant alterations in pulmonary functions have been seen after cardiac surgery, even after considerable and recent advancements in the field of cardiopulmonary surgeries. Postoperative physiotherapy has been proven effective in reducing postsurgical pulmonary complications, but the importance of preoperative physiotherapy is still not well known and is an area of negligence. Seventy-one patients who underwent on pump cardiac surgery were studied prospectively. Patients were enrolled into two groups: group A included 60 patients who performed preoperative exercises and group B included 11 patients who failed to perform preoperative respiratory exercises. Baseline assessment including pulmonary function test was taken before and after the 3rd, 5th, and 7th day of operation. Patients in both groups perform physiotherapy exercises after surgery. The results of the study showed maximum reduction in forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) on the postoperative day (POD) 3 in both groups. On POD 5 and 7 respiratory functions reduced significantly more in group B in comparison to group A. Chest expansion was seen to be significantly more reduced in group B compared to group A on POD 5 and 7. Duration of ICU stay was significantly less in patients included in group A (3.64 days) in comparison to patients in group B (4.18 days). It was concluded that preoperative exercises are important and helpful in regaining the patient's normal respiratory functions, chest expansion, and decreasing the need to stay longer in ICU.

Prognostic value of supar and hs-crp on acute kidney injury following on-pump cardiac surgery

Introduction Acute kidney injury (AKI) is a serious complication after cardio-pulmonary bypass (CPB) surgery, occurring in approximately 20-30% of all patients1. Elevated preoperative levels of the proinflammatory biomarkers soluble urokinase-type plasminogen activating receptor (suPAR) and high-sensitivity C-Reactive Protein (hs-CRP) have previously been associated with occurrence of AKI in selected cardiac surgery populations. Aim of this study was to investigate the relation between suPAR and hs-CRP-concentrations and occurrence of AKI in unselected cardiac surgery patients. Methods Adult patients admitted for elective on-pump cardiac surgery, from August 2012 to June 2018, were included (n=924). Preoperative biobank blood samples were retrospectively analysed for suPAR and hs-CRP levels. We assessed the relationship between suPAR/hs-CRP-values and AKI (any stage), defined by the KDIGO (Kidney Disease: Improving Global Outcomes) criteria, using adjusted logistic regression with both biomarkers evaluated either as a continuous variables (log2-transformed) or as quartiles, with the lowest quartile serving as reference. Further, we performed adjusted logistic regression with the biomarkers as continuous variables (log2-transformed), to assess the following secondary outcomes: KDIGO 1, KDIGO 2-3, and need for renal replacement therapy (RRT). Results AKI (any stage) within 7 days was observed in 327 patients (35.4%) and 26 patients (2.8%) required RRT during hospitalisation. Severity of AKI was 265 (28.7%), 33 (3.6%) and 29 patients (3.1%), for KDIGO stage 1, 2 and 3, respectively. A doubling of suPAR and hs-CRP corresponded to an odds ratio (OR) for AKI of 1.62 (95% CI 1.26-2.09, p 3.42 ng/mL) and 29% in the lowest quartile ( Discussion Elevated preoperative levels of suPAR were associated with increased risk for AKI development evaluated by multiple AKI outcomes. Conversely, increasing hs-CRP-levels were not associated with AKI development. Preoperative assessment of suPAR-concentration may provide prognostic information for AKI development in patients undergoing elective on pump cardiac surgery.

OP03-7 - Long-term quality of life following heart surgery: preliminary findings of a 5-year follow-up study

Health related quality of life (HRQol) not only captures the functional impact of illness but as well reflects overall patient satisfaction with the procedure or treatment. We are presenting preliminary findings of broader research aimed to estimate the longitudinal change and predictors of HRQol dynamics after on pump cardiac surgery.

Use of ringer's lactate solution does not eliminate the risk of strong ion difference related metabolic acidosis following on pump cardiac surgery

Perioperative use of Normal Saline is linked to hyperchloraemic or Strong Ion Difference (SID) related acidosis. It has been suggested, that this can be avoided by the use of balanced crystalloid solutions including Ringer's Lactate (RL). Significant changes in SID were noted previously in cardiac surgery, however recent publication disproved the link between SID and hydrogen ion concentration[1].

ABSTRACT 773

Background and aims: In Belgium, 4 pediatric cardiac centers offer pump cardiac surgery to less than 200 children/center/year. Ecmo is available in each. Aims: As it is now recognized that size matters, we wanted to analyze our results in providing ECMO to patients admitted in PICU, compare them to the literature and identify improvable factors. Methods: We retrospectively reviewed patients supported with ECMO in our PICU between January 2003 and December 2013. We analyzed indications, patient’s characteristics, ECMO course and outcome. Results: 44 children (median age 0.2 year (0.003-10.2) and weight 3.9 kg (2.2–25.0)) were supported with ECMO. ECMO was started after cardiac pump surgery in 32 (73%) and for respiratory or multiple organ failure in 12 (27%). Median duration of ECMO was 4 days (0–21). 38.6% of patients (13/32, 4/12) were weaned off ECMO, 31.8% (11/32, 3/12) leaved PICU and 27.3% (10/32, 2/12) were alive in December 2013. Deceased patients had significant higher initial (8.8 mMol/L +/- 5.2 vs 4.6 +/- 3.3, p= 0.021) and maximal lactate (9.6 mMol/L +/- 5.5 vs 5.3+/- 3.9, p=0.023). Hemorrhage was the most frequent complication (48.8% of cases) and tended to be associated with mortality (53.3% in deceased patients vs 28.6% in survivors, p=0.07). In deceased patients, 37% died after withdraw for neurological reason. Conclusions: Compared to high volume centers, our ECMO patients encountered more complications and higher mortality. We probably keep ECMO for most severe patients. As long as there will be no possibility to centralize pediatric cardiac surgery, we should try to optimize technique and improve selection.

Prospective clinical trial on dosage optimizing of tranexamic acid in non-emergency cardiac surgery procedures

After withdrawal of aprotinin in 2008 only tranexamic acid (TxA, Cyclocapron, Pfitzer, Germany) remains available as antihyperfibrinolytic agent in Europe. Dosage (from 1 g to 20 g) and application strategy (single shot i.v., infusion i.v., topical) reflect an indiscriminate use of TXA in cardiac surgery. We use data analysis of three registries to evaluate safety issues and sufficiency of different TxA dosages in our center. Registry 1: Single shot ultra-low dose TxA (1 g in priming volume). Registry 2: Single shot medium dose TxA (5 g in priming volume). Registry 3: Single shot medium dose TxA (3 g in priming volume) and continuous, weight-adapted administration during cross clamping. Independence of surgeon's preference was achieved by changing dosage every surgery day regardless of operation schedule. Data analysis was carried out on 1182 consecutive, elective patients (1 g TxA n = 415; 3 g + x g TA n = 367; mean TxA dose 4.4 g ± 1.0 g; 5 g TxA n = 400). Patient characteristics were well matched in all three registries (mean age: 69 ± 9.5y, BMI 28.2 ± 4.7, Creatinin 107.5 ± 52.8 μM), as were performed surgical procedures (excluding organ transplantation). Postoperative data showed no significant differences for blood loss and major adverse events (1 g vs. 3 + g vs. 5 g: blood loss: 894 ± 1479 vs. 903 ± 1282 vs. 1004 ± 1604 ml; stroke: 1.5 vs. 1.6 vs. 1.5%; myocardial infarction 2.7 vs. 3.3 vs. 1.3%; 30d mortality 3.9 vs. 4.2 vs. 4.8%, respectively). Secondary endpoints (de novo dialysis, transfusion requirement, ICU and total treatment time) showed no significant differences between registries. Use of 1 g TxA is safe and sufficient for elective patients with on pump cardiac surgery and thus has been established as strategy of choice in our center.

Pulmonary TNFa concentration and wall thickness after on- versus off pump cardiac surgery

Pulmonary TNFa concentration and wall thickness after on- versus off pump cardiac surgery

Is there a difference in circulatory inflammatory response between on- versus off pump cardiac surgery?

Aims: The inflammatory response induced by extracorporeal circulation (ECC) is known to induce and aggravate intra- and postoperative complications. Aim of this study was to evaluate the direct impact of different perfusion modalities on circulatory inflammatory response in a standard experimental model.

Delayed sternal closure: an effective procedure for life-saving in open-heart surgery

To determine the incidence, short term survival and safety of delayed sternal closure following open-heart operation due to myocardial edema, non-surgical bleeding and malignant arrhythmia. We retrospectively reviewed our medical records to identify the patients who underwent delayed sternal closure following open-heart operation and recorded morbidity, mortality postoperative complications of these patients. Among 2698 patients who underwent on- pump cardiac surgery, the sternum was left open in 46 (1.7%) patients, 31 men and 15 women, ranging in age from 2 to 73 years (mean 57.0+/-7.6 years). In 39 patients sternum was left opened following the initial operation and in 7 patients sternum was re-opened due to bleeding or hemodynamic instability after initial surgery. Statistical analysis was accomplished using Chi-square test, Mann Whitney U test and analysis of variances for repeated measurements. The operative procedures were classified as elective in 24 (52.8%), emergency in 10 (22%), urgent in 7 (15.4%), and redo cardiac operations in 5 patients (11%). Bleeding (n=21), hemodynamic instability (n=16), arrest (n=5), and arrhythmia (n=4) were the reasons of delayed sternal closure. The patients had an open sternum for 3.48+/-0.35 days. Time to discharge was 21.5+/-1.6 days after operation and 17.6+/-1.6 days after sternal closure. Mortality within 30 days was 23.9% (7 patients died before closure and the remaining 4 after closure). Complications were mediastinitis (n=2), minor wound infection (n=3) and renal failure (n=5). Delayed sternal closure is a safe and simple method for treating bleeding, arrhythmia and myocardial edema following on pump cardiac surgery. It is anticipated that as cardiac surgeons become more familiar with the technique of delayed sternal closure, the frequency of its use following on pump cardiac surgery may increase.

Successful Use of Bivalirudin as Anticoagulant for ECMO in a Patient With Acute HIT

A patient with myocardial failure after repair of an acute type A aortic dissection had acute heparin-induced thrombocytopenia develop during extracorporeal membrane oxygenation. Heparin was discontinued and the anticoagulant was switched to the direct thrombin inhibitor bivalirudin given with a bolus of 0.5 mg/kg followed by a continuous infusion of 0.5 mg/kg/h. Using this protocol, activated clotting time values ranged from 200 to 220 seconds. After prolonged extracorporeal membrane oxygenation support and recovery of left ventricular function, a right ventricular assist device was implanted during extracorporeal membrane oxygenation support with bivalirudin anticoagulation. For this procedure an additional bolus of 0.25 mg/kg bivalirudin was given, and the infusion rate increased to 1 mg/kg/h to achieve activated clotting time values of 300 to 350 seconds. Surgery was successfully performed with moderate intraoperative and postoperative blood loss and transfusion requirements.

Brain function monitoring during off pump cardiac surgery: the effect of cardiac output on cerebral perfusion in a patient with severe extracranial vascular disease

Zanatta, P.1; Valfrè, C.2; Bosco, E.1; Salandin, V.1; Sarpellon, M.1; Pinto, F.3 Author Information

Underestimated abdominal vascular pathology in a patient with Takayasu arteritis

To describe a 31-year-old female with symptomatic Takayasu disease who was operated for aortic valve replacement. Although she had no preoperative abdominal vascular symptoms, she died on the first postoperative day due to extensive ischemia bowel syndrome. Echocardiography and computed tomography revealed progressive dilatation and thickening of the ascending aorta, severe aortic regurgitation and diminished left ventricular function from 1998 onwards. In 2000 she was operated and a prosthesis was placed end-to-end distally of the sinutubular junction with combined reduction plasty of this junction. After the operation, in time echocardiography and computed tomography showed progressive irregularities and dilatation of the thoracoabdominal aorta and progressive aortic regurgitation. A staged approach of aortic valve replacement and surgery for the thoracoabdominal aorta was planned. At the time of the reoperation in September 2004 the Takayasu inflammation was, after treatment with a maintenance dosage of prednisone and imuran, in a relative quiescent phase. The aortic valve was uneventfully replaced by a mechanical valve. Medical treatment for Takayasu disease never resulted in the patient in completely normal blood values of white blood cell count, C-reactive protein or erythrocyte sedimentation rate. In August 2004, she was admitted because of severe non-specific thoracic pain and hypertension. During hypertension management, she had a short period of diplégia that was assumed to be due to periods of relapsed relative hypotension. Although the computed tomography revealed severe stenosis of the superior mesenteric artery and the celiac trunk, she was free of abdominal complaints and without further abnormal laboratory findings. One day after the aortic valve replacement a dramatic increase of transaminase and lactate-dehydrogenase with extreme metabolic acidosis appeared. Urgent abdominal surgery was performed and extensive ischemia of the liver, gallbladder, small intestine and the proximal part of the colon were found. Because of the extensive regions of ischemia, no surgical interventions were optional. The patient died one day after abdominal exploration. We conclude that in Takayasu disease scheduled for on pump cardiac surgery, vascular workup should be done, and interventional treatment of asymptomatic but potentially critical lesions should be considered.