Shorter Cardiopulmonary Bypass Duration Research Articles

Analysis of risk factors for the development of major adverse cardiovascular and cerebrovascular events in patients after aortic valve replacement with myocardial revascularization

Background. Acquired aortic valve disease and coronary heart disease often occur together, and almost two thirds of patients with aortic valve stenosis have severe coronary heart disease. Given the presence of both pathologies, this cohort of patients requires an individual diagnostic and therapeutic approach. The aim of the study was to analyze risk factors for the development of major adverse cardiovascular and cerebrovascular events (MACCE) in patients after aortic valve replacement with myocardial revascularization. Materials and methods. For this study, a selection of disease histories of adult patients (over 18 years old) who underwent surgical aortic valve replacement (SAVR) together with myocardial revascularization at the State Institution “Heart Institute of the Ministry of Health of Ukraine” from 2018 to 2022 was carried out. Results. We selected 130 case histories of patients who underwent SAVR together with myocardial revascularization: the first group (n = 51) — a combination of SAVR and percutaneous coronary interventions; the second group (n = 79) — a combination of SAVR and coronary artery bypass grafting. The analysis of intraoperative data showed that the duration of cardiopulmonary bypass and aortic cross-clamping in patients of the first group was significantly lower, by 1.5 times (p = 0.0001) and 1.4 times (p = 0.0001), compared to the second group. There was no significant difference between the study groups regarding the frequency of MACCE (p = 0.589). Reliable risk factors for the development of MAССE in the early postoperative period were the evaluation of the operative risk according to the EuroSCORE II scale (odds ratio (OR) 2.13, confidence interval (CI) 1.54–4.48, p = 0.012), the history of myocardial infarction (OR 1.43, CI 1.13–2.45, p = 0.002) and right coronary artery damage (OR 1.79, CI 1.44–3.78, p = 0.021). Conclusions. Patients who underwent percutaneous coronary interventions before SAVR were characterized by a shorter duration of cardiopulmonary bypass and aortic cross-clamping, however, no significant difference in major early postoperative complications was observed between the study groups. In particular, there were no significant differences regarding the frequency of MACCE in the early postoperative period.

Clinical Outcomes of Surgical Revascularization Strategies Guided by Quantitative Flow Ratio in Primary Noncoronary Cardiac Surgery.

Information regarding quantitative flow ratio (QFR) usage in coronary artery bypass grafting (CABG) is lacking. We compared the incidence of postoperative long-term adverse cardiovascular and cerebrovascular events after QFR-guided or coronary angiography-guided adult cardiac surgery with concurrent bypass surgery. This study included 432 patients who underwent cardiopulmonary bypass (CPB) at our institution with at least 1 angiographical coronary artery lesion (diameter stenosis: 30% to 90%) between January 2015 and January 2016. The QFR of each patient was calculated. Patients who only underwent intraoperative coronary revascularization following the principles of optimal revascularization strategy were assigned to group A. Patients with coronary lesions not meeting the above criteria were placed in group B. The average number of distal anastomoses of patients with combined CABG in group B was similar to that in Group A (1.9±1.0 vs. 1.7±0.9; P =0.081). Group A had a shorter CPB duration (114.4±49.2 vs 135.8±55.2 minutes; P <0.001) and shorter aortic cross-clamping time (83.6±36.2 vs 101.1±40.6 minutes; P <0.001). The rates of perioperative mortality and major complications did not differ between groups. Long-term major adverse cardiovascular and cerebrovascular events (MACCEs) were less common in group A than in group B (14.7% vs 29.5%; P <0.001). In primary noncoronary cardiac surgery, despite the similar average numbers of distal anastomoses, the group with target vessels treated using an optimal coronary revascularization strategy presented shorter CPB time and aortic cross-clamping time than the other group. Multivariate analyses also showed a lower incidence of long-term MACCEs.

Analysis of the hemostatic effect of preset wrapping technique for type A aortic dissection with abnormal coagulation.

There are many techniques to reduce anastomotic bleeding for the total arch replacement, but hemostasis is sometimes difficult to achieve after surgery for acute dissection, especially in patients with abnormal coagulation (AC). This study aimed to investigate the hemostatic effect and early efficacy of a pre-set bovine pericardium wrapper in the right heart system shunt for total arch replacement in patients with type A aortic dissection (TAAD) and preoperative AC. A retrospective analysis was conducted on 85 patients with TAAD and AC who underwent total arch replacement between January 2018 and December 2022. The patients were divided into two groups: the preset pericardium group (n=30) and the control group (n=55). There were no significant differences between the two groups in terms of Bentall surgery (ascending aorta replacement with an aortic valve artificial vessel) and cardiac arrest time. However, compared to the control group, the preset pericardium group exhibited a shorter duration of cardiopulmonary bypass (CPB) and operation (P<0.001). Additionally, the preset pericardium group required fewer transfusions of blood products and hemostatic drugs (P<0.05). Moreover, the preset pericardium group had lower 24-hour postoperative mediastinal drainage volume (P<0.001), a lower proportion of bedside hemofiltration (P=0.039), and a shorter duration of mechanical ventilation and stay in the intensive care unit (P=0.014). Although the preset pericardium group showed reductions in in-hospital mortality, re-exploration for bleeding, and neurologic dysfunction, these differences were not statistically significant compared to the control group. This study represents the first investigation into the application of the preset wrapping technique in total arch replacement for TAAD with AC. The results demonstrate that this method can reduce the duration of CPB and operation, decrease postoperative bleeding, and minimize the need for blood transfusion and hemostatic drugs. Consequently, this technique may contribute to early postoperative recovery.

Lung Transplantation on Cardiopulmonary Bypass: Time Matters

<h3>Purpose</h3> The use of cardiopulmonary bypass (CPB) during lung transplantation (LTx) has been linked to higher rates of primary graft dysfunction (PGD) and worse postoperative outcomes. However, the effect of the duration of CPB has not been examined yet. Thus, the aim of our study was to examine the effect of CPB duration on rates of PGD and survival. <h3>Methods</h3> A retrospective cohort study was performed from a prospective database of adult LTx procedures performed at our institute from 1/2008 to 7/2018 (n = 1039). CPB was utilized in 67% of these procedures. Logistic regression fit model was utilized for univariate analysis of PGD at 72 hours. Nonlinear cumulative logistic mixed model was used in analysis of time related PGD grades and the associated risk factors. The survival rates were evaluated by Kaplan-Meier survival -estimate. <h3>Results</h3> Longer duration of CPB was found to be an independent risk factor for severe PGD (Odds ratio, 1.01 per 1 minute increase in CPB duration; <i>P</i> < 0.001). Patients with higher grades of PGD at 72 hours had a significantly longer duration of CPB (Median, 169, 180, 200, and 233 minutes for PGD0, PGD1, PGD2, and PGD3, respectively; <i>P</i> < 0.001, Figure 1A). The incidence of severe PGD at 0, 24, 48, and 72 hours post-LTx were comparable in patients with no CPB and CPB ≤ 3 hours (16%, 9%, 8%, and 8% vs 26%, 11%, 10%, and 10%, respectively) but these incidences were doubled in patients with CPB > 3 hours (55%, 26%, 25%, and 24%, respectively, Figure 1B). Patients with CPB > 3 hours had the lowest 1-year survival rates compared with CPB ≤ 3 hours and no CPB patients (83%, 89% and 90%, respectively; log-rank <i>P</i> = 0.018). <h3>Conclusion</h3> Analysis of more than 1000 LTx data has shown that longer duration of CPB (>3 hours) is associated with severe PGD and worse survival, while shorter duration of CPB (≤ 3 hours) and no CPB outcomes remain comparable. These results suggest that duration of CPB is more important rather than using CPB itself. Future studies investigating CPB in LTx should consider the duration as an important factor that might affect results.

Lung Transplantation on Cardiopulmonary Bypass: Time Matters

The use of cardiopulmonary bypass (CPB) during lung transplantation (LTx) has been linked to higher rates of primary graft dysfunction (PGD) and worse postoperative outcomes. However, the effect of the duration of CPB has not been examined yet. Thus, the aim of our study was to examine the effect of CPB duration on rates of PGD and survival. A retrospective cohort study was performed from a prospective database of adult LTx procedures performed at our institute from 1/2008 to 7/2018 (n = 1039). CPB was utilized in 67% of these procedures. Logistic regression fit model was utilized for univariate analysis of PGD at 72 hours. Nonlinear cumulative logistic mixed model was used in analysis of time related PGD grades and the associated risk factors. The survival rates were evaluated by Kaplan-Meier survival -estimate. Longer duration of CPB was found to be an independent risk factor for severe PGD (Odds ratio, 1.0 per 1 minute increase in CPB duration; P < 0.001). Patients with higher grades of PGD at 72 hours had a significantly longer duration of CPB (Median, 169, 180, 200, and 233 minutes for PGD0, PGD1, PGD2, and PGD3, respectively; P < 0.001, Figure 1A). The incidence of severe PGD at 0, 24, 48, and 72 hours post-LTx were comparable in patients with no CPB and CPB ≤3 hours (16%, 9%, 8%, and 8% vs 26%, 11%, 10%, and 10%, respectively) but these incidences were doubled in patients with CPB > 3 hours (55%, 26%, 25%, and 24%, respectively, Figure 1B). Patients with CPB >3 hours had the lowest 1-year survival rates compared with CPB ≤3 hours and no CPB patients (83%, 89% and 90%, respectively; log-rank P = 0.018). Analysis of more than 1000 LTx data has shown that longer duration of CPB (>3 hours) is associated with severe PGD and worse survival, while shorter duration of CPB (≤3 hours) and no CPB outcomes remain comparable. These results suggest that duration of CPB is more important rather than using CPB itself. Future studies investigating CPB in LTx should consider the duration as an important factor that might affect results.

Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy vs Clamshell Thoracotomy

BackgroundDouble lung transplantation (DLT) remains the gold standard for end-stage lung disease. Although DLT was historically performed via clamshell thoracotomy, recently the median sternotomy has emerged as a viable alternative. As the ideal surgical approach remains unclear, the aim of our study was to compare the short- and long-term outcomes of these 2 surgical approaches in DLT. MethodsWe retrospectively reviewed 192 consecutive adult patients who underwent primary DLT at our institution between 2012 and 2017 (sternotomy, n = 147; clamshell, n = 45). The impact of each surgical approach on post-transplant morbidity was investigated, and the overall survival probability analyses were performed. ResultsThere were no significant differences in recipients’ baseline and donors’ characteristics and bilateral allograft ischemic time. Freedom from primary graft dysfunction, acute rejection episodes, postoperative prolonged ventilator support, tracheostomy, postoperative stroke, and airway dehiscence were comparable between these 2 groups. The duration of cardiopulmonary bypass and operative time were significantly longer in the clamshell thoracotomy group. Postoperative extracorporeal membrane oxygenation usage tended to be more frequent in the clamshell thoracotomy group than the median sternotomy group, despite no statistical significance. Length of hospital and intensive care unit stay were not influenced by the type of incision. There was no significant difference in overall survival between these 2 procedure groups (P = .61, log-rank test). ConclusionsThe median sternotomy approach in DLT decreases operative time and more importantly leads to a shorter duration of cardiopulmonary bypass. The type of surgical approach did not show any statistically significant impact on adult DLT recipients’ morbidity and survival.

Impact of Surgical Approach in Double Lung Transplantation: Median Sternotomy Decreases Operative and Cardiopulmonary Bypass Time Compared to Clamshell Thoracotomy

Purpose Double lung transplantation (DLT) remains the gold standard for end-stage lung disease. While DLT was historically performed via clamshell thoracotomy, recently the median sternotomy has emerged as a viable alternative. As the ideal surgical approach remains unclear, the aim of our study was to compare the short and long-term outcomes of these two surgical approaches in DLT. Methods We retrospectively reviewed 192 consecutive adult patients who underwent primary DLT at our institution between 2012 and 2017 (Sternotomy, n=147; Clamshell, n=45). The impact of each surgical approach on post-transplant morbidity and overall survival probability analysis was performed. Results There were no significant differences in recipients’ baseline and donors’ characteristics and bilateral allograft ischemic time (Table). Freedom from primary graft dysfunction, acute rejection episode, post-operative prolonged ventilator support, tracheostomy, postoperative stroke, and airway dehiscence was comparable between these two groups (p=NS for all). However, the durations of cardiopulmonary bypass (p=0.01) and operative time (p Conclusion The median sternotomy approach in DLT decreases operative time and more importantly leads to a shorter duration of cardiopulmonary bypass. The type of surgical approach did not show any statistically significant impact on adult DLT recipients’ morbidity and survival probability.

Characteristics and operative outcomes for children undergoing repair of truncus arteriosus: A contemporary multicenter analysis

ObjectiveWe sought to describe characteristics and operative outcomes of children who underwent repair of truncus arteriosus and identify risk factors for the occurrence of major adverse cardiac events (MACE) in the immediate postoperative period in a contemporary multicenter cohort. MethodsWe conducted a retrospective review of children who underwent repair of truncus arteriosus between 2009 and 2016 at 15 centers within the United States. Patients with associated interrupted or obstructed aortic arch were excluded. MACE was defined as the need for postoperative extracorporeal membrane oxygenation, cardiopulmonary resuscitation, or operative mortality. Risk factors for MACE were identified using multivariable logistic regression analysis and reported as odds ratios (ORs) with 95% confidence intervals (CIs). ResultsWe reviewed 216 patients. MACE occurred in 44 patients (20%) and did not vary significantly over time. Twenty-two patients (10%) received postoperative extracorporeal membrane oxygenation, 26 (12%) received cardiopulmonary resuscitation, and 15 (7%) suffered operative mortality. With multivariable logistic regression analysis (which included adjustment for center effect), factors independently associated with MACE were failure to diagnose truncus arteriosus before discharge from the nursery (OR, 3.1; 95% CI, 1.3-7.4), cardiopulmonary bypass duration >150 minutes (OR, 3.5; 95% CI, 1.5-8.5), and right ventricle-to-pulmonary artery conduit diameter >50 mm/m2 (OR, 4.7; 95% CI, 2.0-11.1). ConclusionsIn a contemporary multicenter analysis, 20% of children who underwent repair of truncus arteriosus experienced MACE. Early diagnosis, shorter duration of cardiopulmonary bypass, and use of smaller diameter right ventricle-to-pulmonary artery conduits represent potentially modifiable factors that could decrease morbidity and mortality in this fragile patient population.

Factors Associated with Safe Extubation in the Operating Room After On-Pump Cardiac Valve Surgery.

Extubation in the operating room (OR) after cardiac surgery remains controversial due to safety concerns. Its feasibility had been suggested in select patients after off-pump surgery. To review the outcomes of patients extubated in the OR after on-pump cardiac valve surgery (cohort of interest) in comparison with patients extubated conventionally in the intensive care unit (ICU) (control). We hypothesized that the timing of extubation was not associated with postoperative complications. Retrospective review of 272 consecutive patients who had undergone cardiac valve surgery at Jackson Memorial Hospital, Miami, Florida between January 1, 2009 and December 30, 2013. Compared with the control group, patients extubated in the OR had shorter cardiopulmonary bypass (CPB) (87 vs. 113 min, p < 0.0001) and aortic cross-clamp times (60 vs. 78 min, p < 0.0001), lower transfusion requirements (41.38% vs. 57.01%, p = 0.0342), shorter ICU (four vs. five days, p = 0.0002), and hospital stays (7.8 vs. 10 days, p = 0.0151). Mortality, overall rates of complications in all categories, ICU readmissions, and reintubations were similar in both groups. Each additional minute of CPB decreased the odds of extubation in the OR by a factor of 0.988 (odds ratio = 0.988; 95%CI: 0.980, 0.997). Pulmonary perfusion and ventilation during CPB increased the likelihood of extubation in the OR by a factor of 2.45 (odds ratio = 2.453; 95%CI: 1.247, 4.824). In select patients, extubation in the OR after on-pump valve surgery is safe. It is facilitated by shorter duration of CPB and pulmonary perfusion and ventilation during CPB. doi: 10.1111/jocs.12736 (J Card Surg 2016;31:274-281).

Cardiovascular effects of prolonged milrinone inhalation in patients with pulmonary hypertension undergoing mitral valve replacement

Context Inhaled milrinone has short-acting selective pulmonary vasodilator effect. Aims The aim of the study was to investigate the cardiovascular effects of prolonged inhalation of nebulized milrinone on patients with pulmonary hypertension undergoing mitral valve replacement. Settings and design This is a controlled, randomized, double-blinded study. Patients and methods Forty patients were divided into two groups: the milrinone group and the control group. The milrinone group received milrinone nebulization before cardiopulmonary bypass (CPB) as the loading dose at 50 mg/kg, followed by a maintenance dose of 0.5 mg/kg/min, which was continued for 2 h after tracheal extubation. The control group received an equivalent volume of 0.9% sodium chloride. The measured and calculated variables included heart rate, mean arterial blood pressure, central venous pressure, mean pulmonary artery pressure (mPAP), pulmonary capillary wedge pressure, cardiac index (CI), pulmonary vascular resistance (PVR), and systemic vascular resistance. The time points of measurements and calculations were as follows: at T 0 - after anesthesia induction and before sternotomy; at T 1 - 20 min after CPB cessation; at T 2 - 1 h after CPB cessation; at T 3 - 3 h after CPB cessation; at T 4 - 1 h after tracheal extubation; and at T 5 - 1 h after milrinone discontinuation. The duration of CPB and time of tracheal extubation were recorded. Results The milrinone group showed significant reduction in mPAP (T 2 to T 4 readings), pulmonary capillary wedge pressure (T 3 reading), and PVR (T 2 to T 4 readings), increase in CI (T 3 and T 4 readings), and shorter CPB duration and tracheal extubation time. Conclusion Prolonged inhalation of nebulized milrinone proved to be feasible in patients with pulmonary hypertension (PAH) undergoing mitral valve replacement. It decreased PVR and mPAP while increasing CI. This helped shorter CPB duration and earlier tracheal extubation.

Necessity of Temporary Epicardial Pacing Wires After Surgery for Congenital Heart Disease

Temporary epicardial pacing wires are commonly placed in patients undergoing surgery for congenital heart disease. Though often helpful, these wires are not without risk. We aimed to identify characteristics that would obviate placement of temporary epicardial pacing wires in this patient population. A prospective observational study was performed on patients admitted to the pediatric intensive care unit after surgery for congenital heart disease between October 2011 and October 2012. Logistic regression analysis was performed to identify independent predictors of patients in whom wires were not helpful postoperatively. Wires were placed in 213 of 249 patients. Wires were helpful in 50 patients; 23 for diagnostic purposes only, 17 for therapeutic purposes only, and 10 for both. On logistic regression analysis, absence of intraoperative arrhythmias (p < 0.01), lower arteriovenous O2difference (p < 0.01), and shorter duration of cardiopulmonary bypass (p= 0.050) were significant predictors of patients in whom wires were not helpful postoperatively. Further, the predicted probability based on logistic regression model using these 3 variables correctly identified 93% of patients who did notneed pacing wires. Four complications (1.9%) related to wires occurred, including 1 episode of life-threatening bleeding that was found, during emergent exploration, to be due to atrial perforation at the wire insertion site. Temporary epicardial pacing wires are not necessary in many patients recovering from surgery for congenital heart disease. A conservative approach to their use may therefore be warranted.

Right Aortic Arch and Kommerell’s Diverticulum Repaired without Reconstruction of Aberrant Left Subclavian Artery

Right aortic arch with Kommerell's diverticulum is a very rare situation. Surgical treatment is recommended for symptomatic patients or asymptomatic patients with a large diverticulum. However planning the strategy of operation is difficult without a 3D imaging. We report a case of a 57-year-old man with right aortic arch, Kommerell's diverticulum, and aberrant left subclavian artery. After a 3D-CT imaging, the patient underwent descending aortic replacement without reconstruction of aberrant left subclavian artery. After operation, there was no signs or symptoms of ischemia of the left arm. If the reconstruction of the aberrant subclavian artery was too difficult, closing its orifice is an acceptable decision. It has been found advantageous because of a decrease blood loss and a shorter cardiopulmonary bypass duration. If an ischemia of the arm is noticed, additional reconstruction will have to be considered. 3D-CT imaging was very useful to have a proper orientation and plan for the operative strategy.

Early extubation of the trachea after repair of secundum-type atrial septal defects in children.

To investigate the role of anaesthetic management in early extubation of the trachea in children after closure of a secundum-type atrial septal defect (ASD II), a retrospective chart review for a two-year period was performed. We identified 36 children who underwent surgical repair of an isolated ASD II. In 19 children (53%) the tracheas were extubated in the operating room immediately after surgery and in 17 patients (47%) the tracheas remained intubated and the lungs were ventilated in the Intensive Care Unit. There was no difference in age (69.5 +/- 33.8 vs 72.9 +/- 45.0 mo) or weight (19.5 +/- 8.1 versus 20.5 +/- 12.7 kg) between the two groups (mean +/- SD). Children in the extubated group had a shorter duration of cardiopulmonary bypass (43.4 +/- 7.8 min) than those remaining intubated (31.7 +/- 12.7 min) (P < 0.05). The children whose tracheas were extubated early received a lower perioperative fentanyl dose (5.9 +/- 6.4 micrograms.kg-1) than those remaining intubated (35.1 +/- 8.5 micrograms.kg-1). Those children in the extubated group had a lower hourly requirement for morphine by infusion (13.6 +/- 5.7 vs 18.2 +/- 5.4 micrograms.kg-1.hr-1) and a shorter stay (20.5 +/- 3.7 versus 29.0 +/- 11.2 hr) in the Intensive Care Unit. Re-intubation of the trachea was not required in any of the children and no deaths occurred. Early extubation after ASD II repair is safe and, given the results of this study, may offer certain advantages over prolonged intubation and ventilation in these children.