Vasoactive-inotropic Score Research Articles

Electrical cardiometry significance in postoperative cardiac ICU; a single center study

BackgroundHemodynamic monitoring is a cornerstone of critical care; in fact, the techniques available for this purpose are either unreliable or operator-dependent or intermittent (echocardiography) and invasive (thermodilution). Objectives: To evaluate the effectiveness of electrical cardiometry (EC) in assessing hemodynamics in pediatric postoperative cardiac intensive care unit (ICU) and the agreement between EC and trans-thoracic echocardiography (TTE) as bedside tools for hemodynamic monitoring and early diagnosis of cardiovascular compromise. We included 70 pediatric patients from the postoperative cardiac ICU. All participants underwent history-taking and clinical examination. emphasising vital signs, manifestations or signs of hemodynamic instability, calculation of RACH score and vasoactive inotropic score. EC was applied for all patients, and TTE.ResultsThe study included 40 males and 30 females with a mean age of 2.6 ± 3.49 years, ranging between 2 weeks and 13 years, with a male to female ratio of 1.3:1. The median of EC parameters were comparable to TTE parameters stroke volume (SV) (9 vs. 8 p = 0.2), stroke index (SI) (23.5 vs. 22 p = 0.2), cardiac output (CO) (1.25 vs. 1.1 p = 0.3), and cardiac index (CI) (3.2 vs. 3.15 p = 0.2). Hemodynamic parameters correlated significantly between EC and echocardiography, with significantly observed agreement between them. Four equations were postulated successfully based on a linear regression model to predict echocardiographic hemodynamic parameters in comparable groups of children, i.e., SV, SI, CO, and CI.ConclusionEC is an excellent alternative to echocardiography in hemodynamic assessment of cardiac patients in the postoperative ICU.

Предикторы госпитальной летальности при экстренном хирургическом лечении острейшего расслоения аорты типа А по Стенфорду в условиях искусственного кровообращения: ретроспективное когортное исследование

INTRODUCTION: Acute Stanford type A aortic dissection is one of the most severe cardiovascular diseases with high in-hospital mortality. OBJECTIVE: To establish predictors of in-hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under conditions of artificial circulation and to determine their threshold values. MATERIALS AND METHODS: Study design: retrospective, cohort, single-center. Inclusion criteria: surgical intervention with cardiopulmonary bypass, confirmed diagnosis of acute Stanford type A aortic dissection, age > 18 years. The study included 51 patients: 42 men and 9 women aged from 35 to 77 years, median 59 years [47; 65]. All patients (n = 51) were treated in 2022 and were divided into 2 groups depending on the outcome: group 1 (n = 27) included those who died in the intensive care unit within 30 days, group 2 (n = 24) included survived and discharged patients. The endpoint of trial was 30-day in-hospital mortality. RESULTS: Postoperative Sequential Organ Failure Assessment (SOFA) score > 7, Acute Physiology And Chronic Health Evaluation (APACHE) II score > 19, and Vasoactive-inotropic score (VIS) > 10, cardiopulmonary bypass time > 177 minutes, and total hypothermic circulatory arrest time > 30 minutes were associated with an increased risk of 30-day in-hospital mortality. CONCLUSIONS: Statistically significant predictors of hospital mortality in the treatment of patients with acute Stanford type A aortic dissection under cardiopulmonary bypass are the SOFA index, the APACHE II index and the VIS index after the end of surgery, as well as the time of cardiopulmonary bypass and the time of total hypothermic circulatory arrest.

Evaluating Impact of Surgical Myocardial Revascularization on Global Left Ventricular Systolic Function and Immediate Postoperative Outcome using Transesophageal Echocardiography

Abstract Background and Aims: Surgical myocardial revascularization is supposed to improve the global left ventricular (LV) function by improving the blood supply in significantly occluded coronary arteries. Transesophageal echocardiography (TEE) provides an excellent opportunity to evaluate cardiac function in operating room. Present study was aimed at evaluating impact of surgical myocardial revascularization on global LV systolic function. Comparison of LV fractional shortening (LV-FS), fractional area change (LV-FAC), ejection fraction (LV-EF), indexed LV volumes (indexed LV volumes at end diastole, LV volumes at end systole) and “Tei” (Myocardial performance) index obtained prior and after surgical myocardial revascularization was done for quantitative analysis. Also, the determinants of immediate postoperative outcome were evaluated based on need of pharmacological and/or mechanical cardiovascular support, mechanical ventilation, intensive care unit (ICU) stay, morbidity and mortality in immediate postoperative period. These outcome measures were correlated with baseline values of TEE derived echo indices. Methods: One hundred and ten subjects with significant coronary artery disease scheduled for elective myocardial revascularization surgery. Fourteen subjects were excluded due to presence of either hemodynamic instability requiring either pharmacological or mechanical cardiovascular support, before coronary revascularization (n = 6), presence of Grade III mitral regurgitation (MR) in baseline TEE (n = 2) and arrythmias (n = 6). Ninety six subjects were evaluated for global LV systolic function using TEE before and after surgical revascularization. Subjects were followed in ICU for the outcome. Immediate postoperative outcome was measured as “good” or “poor” based on vasoactive inotropic score, requirement of Intra-aortic balloon counter pulsation (IABP) and mechanical cardiovascular support (VA-ECMO) to maintain cardiac output, duration of mechanical ventilation, postoperative ICU stay, morbidity and mortality. Results: In 96 subjects analyzed, there was a significant improvement in TEE derived LV-FS (38.60 ± 16.38 vs. 31.31 ± 13.14) (P = 0.002), FAC (51.94 ± 16.06 vs. 43.99 ± 16.02) (P ≤ 0.001), EF (53.08 ± 9.97 vs. 46.71 ± 7.53) (P < 0.00001), LV end diastolic volume index (34.84 ± 13.43 vs. 40.08 ± 17.22) (P = 0.0188) and “Tei” index (0.47 ± 0.13 vs. 0.53 ± 0.13) (P = 0.0007). Thirty three subjects required either prolonged stay in ICU (>7 days), (n = 20) and/or mechanical ventilatory support (>24 h), (n = 10) and/or mechanical cardiovascular support (IABP/VA ECMO placement), (n = 7) and/or suffered mortality (n = 2) in postoperative period were categorized as “poor” outcome. Presence of type II diabetes mellitus, Chronic obstructive pulmonary disease (COPD), higher grade of ischemic MR, larger LV end diastolic volume, use of cardiopulmonary bypass and allogenic blood transfusion during surgery were the determinants of “poor” outcome. Conclusion: Surgical myocardial revascularization improved global LV systolic function irrespective of baseline LV EF. Immediate postoperative outcome was strongly determined by presence of diabetes, COPD, higher grade of ischemic MR and larger LV end diastolic volumes. Preoperative (Baseline) LV EF and myocardial performance index did not determine “poor” postoperative outcome following surgical myocardial revascularization in subjects with LVEF >35%.

Influence of blood pressure targets on inflammation and associations between inflammatory markers and vasopressor usage after cardiac arrest - a substudy of a randomized clinical trial

Abstract Background Following resuscitation from cardiac arrest, a profound systemic inflammatory response may develop. In observational studies of critically ill patients an association between levels of inflammation and vasopressor usage has been found. Higher levels of inflammation may lead to higher vasopressor needs due to vasoplegia and cardiac dysfunction, however, catecholamines, including vasopressors also have immune modulatory effects. In the Blood Pressure and Oxygenation Targets in Post resuscitation Care (BOX) trial patients were randomized to a high or low blood pressure target, and vasopressor usage was increased in the high blood pressure target group. Therefore, the inflammatory response evoked by cardiac arrest, may have been altered by differences in vasopressor usage according to blood pressure target in this trial. Purpose To determine if differences in vasopressor and inotropy usage associated with randomization to a high compared to a low blood pressure target affects the inflammatory response after OHCA, and to investigate the association between inflammation and vasopressor and inotropy usage. Methods In the BOX trial, comatose OHCA patients with a presumed cardiac etiology were randomized to a blinded intervention of either a high (77mmHg) or a low blood pressure target (63mmHg). The inflammatory markers of leukocytes and CRP were measured at 0, 24, 48, and 72 hours. The average Vasoactive-Inotropic Score (VIS) was determined during initial 72 hours. The associations between average CRP, leukocytes, and VIS during initial 72 hours were determined by Spearman’s correlation analysis. Results The BOX trial included 789 resuscitated comatose OHCA patients, and 788 patients had at least 1 measurement of leukocytes and CRP. The median age was 64 (IQR 54-73), females constituted 19%, 1 year mortality was 36%. There was no difference in leukocytes and CRP at admission between the high and low blood pressure target groups (Figure 1). Leukocytes were slightly higher at 24 hours (p<0.01) in the high blood pressure target group, but no group differences were found at 48 and 72 hours, and CRP levels did not differ at 24, 48, or 72 hours. The average VIS was 19 (11-32) and 11 (5-19), p<0.01, in the two groups, with VIS being consistently higher at all timepoints beyond ICU admission (all p<0.01, data not shown) in patients with a high blood pressure target. Both average CRP and leukocytes were weakly correlated with average VIS at 0-72 hours for both blood pressure targets, r=0.17 and r=0.20, respectively for a high target (both p<0.01), and r=0.17 and r=0.20, respectively for a low target (both p<0.01). Conclusions In conclusion, increased vasopressor and inotropy usage in this randomized, blinded study of blood pressure targets after OHCA, did not lead to clinically relevant changes in inflammation. Inflammatory markers and VIS were correlated to a similar degree for both blood pressure targets.Figure 1, LeukocytesFigure 2, CRP

Is it useful to washing stored red blood cells in cardiopulmonary bypass priming fluid for neonatal cardiac surgery

Abstract Background The small blood volume and immature physiology of neonates necessitate careful consideration of the priming fluid composition during cardiopulmonary bypass (CPB) surgery, as it has a substantial impact on their physiologic stability. This study aimed to investigate the impact of allogeneic stored RBCs processed by an autotransfusion system into the CPB priming fluid for neonatal cardiac surgery. Methods This retrospective cohort study investigated the effects of incorporating unwashed (n=56) or washed (n=45) RBCs into the CPB priming fluid for elective neonatal cardiac surgery. We compared perioperative blood parameters, inflammatory mediators, coagulation indicators, vasoactive inotrope score (VIS), other relevant blood parameters and clinical outcomes between the two groups. The regression models were employed to evaluate the independent association between RBCs washing and prognostic outcomes. Results The autotransfusion system can effectively improve the quality of stored RBCs. During CPB, washed group exhibited higher peak hematocrit (P < 0.01), peak hemoglobin (P = 0.04), increased oxygen delivery index during rewarming (P < 0.05). The washed group exhibited significantly lower early postoperative lactate levels and VIS scores (P < 0.05). Despite demonstrating fluctuations in inflammatory (IL-6, IL-8, IL-10）and coagulation parameters(DD, FIB, FDP) compared to baseline, the two groups exhibited no significant divergence. Notably, the washed group experienced a lower incidence of hyperlactacidemia and delayed sternal closure at weaning from CPB. Conclusions The addition of washed allogeneic stored RBCs to neonatal CPB priming fluid significantly attenuated postoperative lactate elevation and lowered VIS without improving early alterations in the inflammatory and coagulation systems.

Echocardiographic evaluation of ventricular performance in VA-ECMO weaning: results from a observational monocentric prospective study

Abstract Background Although temporary mechanical circulatory support (MCS) devices are increasingly used in the management of cardiogenic shock (CS), several open question regarding the kind of support and timing of institution/weaning remains open. Echocardiography is widely applied to drive the weaning process and decision although there are no standardized protocols for the trial nor accordance on the parameters to apply. Purpose We sought to evaluate the overall accuracy of echocardiographic indices in predicting successful weaning from VA ECMO in patients with CS. Specifically, we tested total isovolumic time (tIVT), an index of ventricular performance, and longitudinal function (MAPSE) on top of the commonly used parameters (left ventricular ejection fraction, LVEF; left ventricular velocity time integral, LV VTI; TAPSE; right ventricular S’ at tissue Doppler imaging, RV S’). Methods Monocentric prospective study on adults receiving VA-ECMO due to refractory CS and/or cardiac arrest (CA) from 2012 to 2020. Echocardiography was performed at VA-ECMO placement and during the weaning trials. Weaning trials were performed daily, starting 48 hours after VA-ECMO institution, when patients were hemodynamically stable: mean arterial pressure >65 mmHg, no or minimum adrenergic support (vasoactive inotropic score <10), heart rate <110 bpm, lactate <2 mmol/L, and no signs of respiratory distress. Weaning trials were performed with a stepwise decrease of VA-ECMO blood flow until reaching 1 or 1.5 L/min under adequate anticoagulation. Successful weaning was defined as removal of VA-ECMO with no requirement for further MCS in the following 30 days. Results 76 patients were enrolled (23.8% female, 54.2±10.6 years-old), 52.6% due to CA. Median duration of VA-ECMO was 58 hours; 47 (61.8%) had intra-aortic balloon pump (IABP) inserted upfront. In-hospital mortality was 62.4% overall, 40% for CS without CA. 6 of the 32 weaned patients died for multiorgan failure due to septic shock. The baseline echocardiographic parameters associated with successful weaning were (table): stroke volume >13.9 mL (p 0.002), tIVT >23.6 min/sec (p 0.053), LV VTI >6.6 cm (p<0.001), MAPSE >6.15 mm (p 0.001), TAPSE >11 mm (p 0.023), RV S’ >10 cm/s (p 0.012). LVEF did not reach the statistical significance. Figure shows Kaplan-Meier analysis on echocardiographic indices collected at time of cannulation (panel A) and during the last weaning trial (panel B). Conclusions Echocardiography is pivotal in defining cardiac recovery and monitoring the weaning trial. Indices reflecting ventricular performance and delivered flow from LV were associated with weaning success both at VA-ECMO institution and throughout the weaning trials. Considering the known limitations of LVEF (heart rate, loading and left ventricular dyssynchrony dependence), tIVT and MAPSE should be introduced in the standard evaluation of patients in the acute setting.TableFigure

Diastolic shock index: a novel prognostic parameter unveiling insights into vasodilatory cardiogenic shock

Abstract Introduction Systemic vasodilation is an increasingly acknowledged feature in cardiogenic shock (CS), defining a subset of patients with low systemic vascular resistances and higher vasopressor requirements. While a diastolic shock index (DSI) above 2.0 predicts vasoplegia and mortality in septic shock, its cut-off and prognostic significance in CS remain unclear. Our study aimed to characterize vasoplegia in CS using the DSI and assess its impact on prognosis. Methods Single-center retrospective cohort study on Cardiac Intensive Care Unit (CICU) admissions for CS from January 2017 to October 2023. Data included patient variables, CS features, vasoactive drugs, mechanical circulatory support, and 30-day mortality. DSI (heart rate (HR) to invasive diastolic blood pressure (DBP) ratio) impact on 30-day all-cause mortality was assessed with univariate Cox regression. Optimal DSI cut-off for adverse outcomes was determined through ROC curve analysis, and survival based on this cut-off was analyzed using Kaplan-Meier curves. Results 185 patients (mean age 59 ± 12 years, 63% male) were included. Acute myocardial infarction-related CS (47%) and heart failure-related CS (29%) were predominant. According to SCAI classification, 86% were class C, 22% class D, and 4% class E, with 26% experiencing previous cardiac arrest. Median Vasoactive-Inotropic Score (VIS) was 48 (IQR 21-85), and 25% used mechanical circulatory support. At admission, median HR was 105 bpm (IQR 90-125), DBP was 60 mmHg (IQR 55-65), and DSI was 1.71 (IQR 1.31-2.18). Thirty-day all-cause mortality was 36% (n=67), with median time to death of 4 days (IQR 1-10). DSI at 30 days predicted mortality (OR 1.42, 95%CI 1.06-1.91, p=0.020). DSI showed fair discriminative power for 30-day mortality (C-Statistic 0.60, 95% CI 0.51-0.68, p=0.031) with a cut-off of 2.2. Patients with DSI >2.2 exhibited heightened likelihood of prior cardiac arrest (38% vs. 20%, p=0.032), and higher serum lactate (5.5 vs. 3.9 mmol/L, p=0.008), and serum creatinine (2.64 vs. 1.88 mg/dL, p=0.003) at admission. Despite higher VIS at 48 hours (120±136 vs. 65±93.9, p=0.04), MCS need did not significantly differ. This group had superior 30-day mortality risk (log-rank p=0.011). Conclusion In our cohort, the admission Diastolic Shock Index (DSI) emerged as a promising identifier for CS vasoplegic patients and was a predictor of a higher risk for mortality. A DSI above 2.2 identified a subset of patients with previous cardiac arrest and higher lactate levels, enlightening possible risk factors associated with vasoplegia. Further studies are warranted to establish the robustness of this novel prognostic parameter in CS patients and its therapeutic implications.

TAVI for treating severe aortic valve disease in cardiogenic shock: a single centre experience

Abstract Introduction Recent evidence shows the safety and efficacy of TAVI in patients with aortic valve disease (AVD) presenting in cardiogenic shock (CS). However, there is limited data regarding CS management in the cardiac intensive care unit (CICU) and its outcomes. We aimed to describe the CS features, pre-TAVI management and short-term clinical outcomes of a cohort of CS patients (pts) submitted to TAVI. Methods Single-centre retrospective registry of consecutive pts with AVD undergoing TAVI in CS, from January 2020 to October 2023. CS was defined as pre-procedural hypotension/hypoperfusion requiring vasoactive drugs or mechanical circulatory support (MCS) devices. The severity of CS was defined according to the SCAI classification. Procedural related outcomes according to the VARC-3 criteria and 30-day mortality were assessed. Results A total of 16 pts (1% of our global TAVI cohort, 62% male, mean age 79±5 years) meet the inclusion criteria. The majority (n=13) presented severe aortic stenosis, two had degenerated aortic bioprosthesis with severe regurgitation and one had native valve severe regurgitation. 6 pts (38%) had isolated left ventricle (LV) dysfunction and 10 (62%) had biventricular dysfunction. The admission LVEF was 33±8% and the mean transaortic gradient for those with aortic stenosis was 46±13mmHg. The EuroSCORE II estimated for a single non-CABG emergency procedure was 37±15%. All patients were refused for surgical treatment upon Heart Team discussion. At admission, 12 (75%) patients presented in CS SCAI-C, 1 (6%) in SCAI-D and 3 (19%) in SCAI-E. These last 3 patients presented in cardiac arrest upon admission to the CICU (time to ROSC from 2 to 15 minutes). The peak lactate level at 48 hours was 3.4 mmol/L [2.1-5.1] and the highest Vasoactive-Inotropic Score (VIS) during admission was 21 [11-45]. None of the patients needed MCS pre-TAVI. 5 (31%) patients required invasive mechanical ventilation and 5 (31%) renal replacement therapy. Median time between CICU admission and transfemoral TAVI was 2.5 days [IQR 1-7]. Procedural success was 100%, with 57% receiving a balloon-expandable and 43% a self-expandable valve. Post-TAVI CICU length of stay was 6 days [IQR 5-9]. Most common procedural complication were the need for permanent pacemaker implantation (n=2, 12%) and access-related bleeding (n=2, 12%). Hospital length-of-stay was 20±15 days. Thirty-day mortality was 12% (n=2). Conclusion In this cohort of CS patients selected for TAVI treatment, procedural success was achieved in all cases. While complications were similar to the general TAVI population, in-hospital mortality remained high but very acceptable. These results suggest that, if correctly selected, aortic valve disease patients in CS represent a niche for whom brief stabilization and urgent percutaneous valve treatment might impact their dismal prognosis.

Microaxial Flow Pump Hemodynamic and Metabolic Effects in Infarct-Related Cardiogenic Shock

Mechanical circulatory support with a microaxial flow pump (MAFP) has been shown to improve survival in ST-elevation myocardial infarction-induced cardiogenic shock (STEMI-CS). Understanding the impact on hemodynamic stability over time is crucial for optimizing patient treatment. To determine if an MAFP reduces the need for pharmacological circulatory support without compromising hemodynamics compared with standard care in STEMI-CS. This was a substudy of the Danish-German (DanGer) Shock trial, an international, multicenter, open-label randomized clinical trial. Patients from 14 heart centers across Denmark, Germany, and the UK were enrolled. Inclusion criteria for the trial were STEMI and systolic blood pressure less than 100 mm Hg or ongoing vasopressor treatment, left ventricular ejection fraction less than 45%, and arterial lactate level greater than 2.5 mmol/L. Of the enrolled patients, after exclusions from death in the catheterization laboratory or immediately on intensive care unit (ICU) admission, the remaining patients had serial recordings of hemodynamics, arterial lactate, and use of vasoactive drugs. Patients who were in comas after cardiac arrest and patients with mechanical complications or right ventricular failure were excluded. Data were analyzed from May to September 2024. MAFP and standard of care or standard of care alone. Hemodynamic status in terms of heart rate and blood pressure, metabolic status in terms of arterial lactate concentration, and vasoactive-inotropic score (VIS). The clinical events during the first 72 hours were as follows: death from all causes, escalation of mechanical circulatory support, and discharge alive from the ICU. From 355 enrolled patients, 324 (mean [IQR] age, 68 [58-75] years; 259 male [80%]) underwent ICU treatment (169 [52%] in the MAFP group, 155 [48%] in the standard-care group). Baseline characteristics were balanced. There was no difference in heart rate between groups, and mean arterial pressure was above the treatment target of 65 mm Hg in both groups but was achieved with a lower VIS in the MAFP group. No difference in arterial lactate level was found between groups at randomization, but on arrival to the ICU, the MAFP group had significantly lower arterial lactate levels compared with the standard-care group (mean difference, 1.3 mmol/L; 95% CI, 0.7-1.9 mmol/L), a difference that persisted throughout the first 24 hours of observation. The MAFP group achieved lactate normalization (<2 mmol/L) 12 hours (95% CI, 5-18 hours) before the standard-care group. Use of a MAFP reduces the use of vasopressors and inotropic medication while maintaining hemodynamic stability and achieving faster normalization of lactate level in patients with STEMI-CS. ClinicalTrials.gov Identifier: NCT01633502.

Lower Levels of Vitamin D Are Associated with Higher Vasoactive–Inotropic Scores in Major Cardiac Surgery

Background: The vasoactive–inotropic score (VIS) predicts unfavorable outcomes after cardiac surgery in both children and adults. In our adult population, we investigated whether preoperative levels of vitamin D can predict the VIS and whether both vitamin D and the VIS can predict adverse outcomes following major heart surgery. Methods: Between 1 October 2021 and 28 February 2022, 300 patients underwent major cardiac surgery at our institution. Eighty-three of them had their 25-OH vitamin D levels measured before surgery. For this cohort, we calculated the VIS based on doses of vasoactive and inotropic medications administered post-surgery. Utilizing receiver operating curves, the predictive accuracy of vitamin D levels and the VIS in predicting acute kidney injury was assessed. Results: The median age of the cohort was 66 (IQR 61–71) years, with 59% being male and a median BMI of 28.4 (IQR 25.2–31.6). The most common procedures were aortic valve replacement, mitral valve replacement, coronary artery bypass grafting, aortic valve and ascending aorta repair, and ASD correction. There was a significant difference in the postoperative VIS between patients with vitamin D deficiency, i.e., &lt;20 ng/mL, and patients with vitamin D values &gt; 20 ng/mL (3.5 vs. 1.3 p &lt; 0.04). We also found a significant correlation between the VIS and the days of hospitalization (r = 0.335; p = 0.002), the days of stay in the intensive care unit (r = 0.547; p &lt; 0.00001), and the mechanical ventilation time (r = 0.327; p = 0.025). Both vitamin D levels and the VIS predicted postoperative acute kidney injury (p &lt; 0.05). Conclusions: Vitamin D deficiency is correlated with the VIS in adults undergoing major cardiac surgery. Both vitamin D levels and the VIS can predict unfavorable postoperative outcomes.

A prospective cohort study comparing monitored anesthesia care and intubated general anesthesia in cardiac surgery involving cardiopulmonary bypass

BackgroundThe aim of this study is to assess the feasibility and safety of monitored anesthesia care (MAC) versus intubated general anesthesia (IGA) for patients undergoing elective cardiac surgery with cardiopulmonary bypass (CPB).MethodsThis prospective observational study included patients scheduled for cardiac surgery involving CPB at our institution between April 2012 and February 2017. The enrolled patients were categorized into MAC and IGA groups. MAC involved local anesthesia at the sternotomy site, sedation with dexmedetomidine, analgesia with remifentanil/sufentanil, and electroacupuncture (EA). Eleven patients underwent MAC, and 13 patients received IGA. There were no instances of conversion from MAC to IGA, and both groups exhibited no major complications. The demographic characteristics, baseline parameters, and operative variables were comparable between the two groups.ResultsIntraoperative opioid consumption was significantly lower in the MAC group compared to the IGA group (P < 0.001). The time to oral intake of liquids was significantly shorter in the MAC group (2.14 ± 0.90 h) compared to the IGA group (22.31 ± 3.33 h) (P < 0.001). Furthermore, the intensive care unit length of stay (ICU-LOS) and perioperative vasoactive-inotropic score (VIS) were significantly reduced in the MAC group compared to the IGA group (P < 0.001).ConclusionsMAC emerges as a safe and viable alternative to general anesthesia for specific patient groups undergoing cardiac surgery with CPB. Furthermore, it may enhance postoperative recovery and minimize postoperative complications compared to IGA.

Short-term neurologic outcomes in pediatric extracorporeal membrane oxygenation are proportional to bleeding severity graded by a novel bleeding scale.

This study aimed to characterize the severity of bleeding and its association with short-term neurologic outcomes in pediatric ECMO. Multicenter retrospective cohort study of pediatric ECMO patients at 10 centers utilizing the Pediatric ECMO Outcomes Registry (PEDECOR) database from December 2013-February 2019. Subjects excluded were post-cardiac surgery patients and those with neonatal pathologies. A novel ECMO bleeding scale was utilized to categorize daily bleeding events. Poor short-term neurologic outcome was defined as an unfavorable Pediatric Cerebral Performance Category (PCPC) or Pediatric Overall Performance Category (POPC) (score of >3) at hospital discharge. This study included 283 pediatric ECMO patients with a median (interquartile range [IQR]) age of 1.3years [0.1, 9.0], ECMO duration of 5days [3.0, 9.5], and 44.1% mortality. Unfavorable PCPC and POPC were observed in 48.4% and 51.3% of patients at discharge, respectively. Multivariable logistic regression analysis included patient's age, cannulation type, duration of ECMO, need for cardiopulmonary resuscitation, acute kidney injury, new infection, and vasoactive-inotropic score. As the severity of bleeding increased, there was a corresponding increase in the likelihood of poor neurologic recovery, shown by increasing odds of unfavorable neurologic outcome (PCPC), with an adjusted odds ratio (aOR) of 0.77 (confidence interval [CI] 0.36-1.62), 1.87 (0.54-6.45), 2.97 (1.32-6.69), and 5.56 (0.59-52.25) for increasing bleeding severity (grade 1 to 4 events, respectively). Similarly, unfavorable POPC aOR (CI) was 1.02 (0.48-2.17), 2.05 (0.63-6.70), 5.29 (2.12-13.23), and 5.11 (0.66-39.64) for bleeding grade 1 to 4 events. Short-term neurologic outcomes in pediatric ECMO are proportional to the severity of bleeding events. Strategies to mitigate bleeding events could improve neurologic recovery in pediatric ECMO.

Hemodynamic Support With the Impella 5.5 Acute Mechanical Circulatory Support Device.

The Impella 5.5 is increasingly used as a bridge to recovery or heart replacement therapies despite lack of clinical trial evidence. We report real-world outcomes and hemodynamic effects of 150 consecutive patients from a single, high-volume center. Primary outcome was incidence of recovery, durable left ventricular assist device (LVAD), or heart transplant compared with incidence of death at 90 days. Secondary outcomes included hemodynamic trends and upgrade to veno-arterial extracorporeal membrane oxygenation (VA-ECMO) support. The composite endpoint occurred in 59.3% and death in 18.8% of patients (incidence rate ratio: 8.1 [95% confidence interval {CI}: 5.4-12.2], p < 0.001). Decreases in pulmonary artery diastolic pressure (PADP) (p = 0.026), estimated pulmonary effective arterial elastance (Ea) (p < 0.001), and vasoactive-inotropic score (VIS) (p < 0.001) occurred during Impella 5.5 support. Pulmonary artery diastolic pressure correlated with estimated Ea (p < 0.001), suggesting improved right ventricle (RV) afterload with left ventricle (LV) unloading. Veno-arterial extracorporeal membrane oxygenation upgrade occurred in 11.3% of patients who had higher baseline right atrial pressure (RAP) (16.0 [9.0-20.5] vs. 9.0 [7.0-12.0], p = 0.022), PADP (28.5 [25.0-31.0] vs. 23.0 [18.0-28.0], p = 0.011), and lower pulmonary artery pulsatility index (PAPi) (1.45 [0.82-3.45] vs. 2.5 [1.65-3.86], p = 0.029). Upgrade patients had higher repeated measures trends in RAP (p < 0.001) and PADP (p = 0.015). The Impella 5.5 improved hemodynamics and effectively bridged to recovery or heart replacement therapies. Co-existing RV dysfunction can be supported on Impella 5.5 with careful hemodynamic trend monitoring.

Comparative outcomes of cardioplegic arrest versus beating heart in pediatric undergoing extracardiac total cavopulmonary connection

BackgroundTotal cavopulmonary connection (TCPC) is a definitive palliative procedure for functionally univentricular congenital heart disease. The study aims to compare the impact of on-pump cardioplegic arrest and on-pump beating heart cardiopulmonary bypass (CPB) on the prognosis of pediatric patients undergoing extracardiac TCPC.MethodsThe medical data of patients (< 18 years) who underwent extracardiac TCPC with CPB between January 2008 and December 2020 in the cardiac surgery center were retrospectively analyzed. Depending on CPB strategies, the patients were assigned to the beating-heart (BH) and cardioplegic arrest (CA) groups. Data including baseline characteristics, intra/postoperative variables, and clinical outcomes were collected for analysis with 1:1 propensity score matching and multivariable stepwise logistic regressions.ResultsFifty-seven matched patient pairs were obtained. No significant difference existed between the two groups in the in-hospital mortality (3.5% vs. 1.8%, P = 1) and one-year survival rate (100% vs. 96.4%, P = 0.484). The BH group had significantly less intraoperative platelet transfusion (10 mL vs. 150 mL, P = 0.019) and blood loss (100 mL vs. 150 mL, P = 0.033) than the CA group. The CA group had significantly higher vasoactive-inotropic scores (P < 0.05) and longer postoperative ICU stays (2.0 d vs. 3.7 d, P = 0.017). No significant difference existed between the two groups in the incidence of postoperative adverse events.ConclusionAlthough both CPB strategies are safe and feasible for extracardiac TCPC, the BH technique would cause less intraoperative platelet transfusion and blood loss, and achieve faster early-term postoperative recovery.

Role of Prophylactic N-Acetylcysteine Supplementation on Postoperative Outcomes in Patients Undergoing Elective Double-Valve Replacement (Aortic and Mitral Valve).

The incidence of postoperative liver dysfunction is high in patients undergoing double-valve replacement - mitral and aortic valve replacement (DVR). This study aims to evaluate N-acetylcysteine's free radical scavenging property (NAC) to prevent postoperative liver dysfunction in these patients, thus affecting overall clinical outcomes. A single-center, prospective, randomized, double-blinded interventional study of 60 patients divided into two groups of 30 each. Group N received prophylactic intravenous NAC, and Group C received volume-matched 5% dextrose. Data comprised demographics, liver function tests (LFT), renal function tests (RFT), vasoactive-inotropic scores (VIS) score, and C-reactive protein (CRP) at various time intervals. Postoperative parameters such as ventilation duration, length of stay in ICU (LOS-ICU), length of hospital stay (LOHS), atrial fibrillation (AF), acute kidney injury (AKI) requiring hemodialysis, and mortality were noted. Statistical analysis was performed with the Student's t-test and Chi-square test (SPSS 22 software). All postoperative LFT parameters (total bilirubin, serum glutamic oxaloacetic transaminase (SGOT), serum glutamic pyruvate transaminase (SGPT), and alkaline phosphatase (ALP)) were significantly lower (P < 0.05) at 24, 48, and 72 hours in Group N compared to Group C. RFT and VIS scores were lower in Group N; however, were not statistically significant except for Serum Creatinine at 48 hours (P = 0.0478). Ventilation duration (P = 0.0465) and LOS-ICU (P = 0.0431) were significantly lower in Group N. Other outcomes like AF, LOHS, and mortality were lower in Group N but were not statistically significant. Our study showed that prophylactic administration of NAC in patients undergoing DVR is associated with a reduction in the incidence of postoperative liver dysfunction with a positive impact on postoperative outcomes.

The Impact of a Residual Atrial Communication in Patients Undergoing Complete Repair for Tetralogy of Fallot: A Propensity Score Matched Analysis

Surgeons may leave a residual atrial-level communication during complete repair of Tetralogy of Fallot (TOF) in anticipation of restrictive right ventricle physiology or as routine practice. We investigated the impact of closing the interatrial communication at the time of definitive TOF repair. We retrospectively reviewed TOF patients who underwent definitive repair at <12 months of age between June 2000 and January 2023. Propensity score matching identified 82 patients with a patent interatrial communication and 50 with no interatrial communication on postoperative echocardiography (as-treated analysis). The primary endpoint was maximum vasoactive-inotropic score (VIS) as a surrogate for low cardiac output syndrome. A total of 132 patients (median age: 3.5[IQR,1.8-5.8] months) were matched. There was no difference in maximum VIS (patent interatrial communication: 5.0[IQR, 4.8-9.0] vs. no interatrial communication: 6.0[IQR, 5.0-8.0], P=0.78). Additionally, duration of inotrope therapy (3.0[IQR, 2.0-4.0] vs 3.0[IQR, 1.3-4.0] days, P=0.57), peak lactate (2.2[IQR, 1.9-3.0] vs. 2.3[IQR, 1.9-3.2] mmol/L, P=0.58), time to lactate clearance (0.2[IQR, 0.0-0.3] vs. 0.1[IQR, 0.0-0.3] days, P=0.57), chest tube duration (4.0[IQR,3.0-6.0] vs 4.0[IQR, 3.0-5.0] days, P=0.23), and length of intensive care stay (5.0[IQR, 3.0-7.0] vs. 5.0[IQR, 3.0-7.0] days, P=0.71) were similar. Median follow-up was 5.5[IQR, 2.7-9.9] years. Among patients with a residual communication, patency rates were 93.6% and 53.7% at discharge and latest follow-up, respectively, with most having bidirectional shunting across the defect. Closure of the atrial-level communication during complete TOF repair does not significantly impact the immediate postoperative course or mid-term outcomes. Further investigation is warranted to better understand how patency influences long-term outcomes.

Perioperative hemodynamic parameters monitored by three noninvasive technologies in children with congenital heart disease: A prospective study

AbstractThis study aims to compare the efficiencies of three noninvasive technologies in monitoring the perioperative hemodynamics of children with congenital heart disease (CHD) including ventricular septal defects with or without atrial septal defects. Three noninvasive technologies included transthoracic echocardiography (TTE), electrical cardiometry (EC), and vasoactive inotropic score (VIS). Parameters included left ventricular ejection fraction (LVEF) and cardiac index (cardiac index monitored by ultrasound, uCI) in TTE, cardiac index (cardiac index monitored by electrical cardiometry, eCI) and systemic vascular resistance index (SVRI) in EC, and VIS. Seventy‐four children were eligible. Three types of adverse events (AEs) related to disease activity and prognosis were observed, including cardio‐pulmonary resuscitation in five cases (5/74, 6.76%), hypoxic‐ischemic brain damage in four cases (4/74, 5.41%) and hemopurification in four cases (4/74, 5.41%). Except for LVEF, eight parameters (VISmax [maximum VIS], VISmea [mean VIS], uCImea [mean uCI], uCImin [minimum uCI], eCImea [mean eCI], eCImin [minimum eCI], SVRImea [mean SVRI], and SVRImin [minimum SVRI]) showed predictive value for any AE (p &lt; 0.05). VISmea, uCImea, and eCImea demonstrated the highest accuracy and linear associations (AUROC &gt; 0.9, p = 0.00). Linear associations also existed between the three groups of parameters and the duration of mechanical ventilation (MV) and the length of stay (LOS) in the intensive care unit (ICU). The duration of MV and the LOS in the ICU increased as VISmea rose, or uCImea and eCImea fell (p &lt; 0.05). LVEF in TTE could not predict any AE (p &gt; 0.05) and not fully reflect the cardiovascular function. Therefore, most parameters obtained in TTE, EC, and VIS can reflect the perioperative hemodynamics of children with CHD, with VISmea, uCImea, and eCImea being most accurate.

Characteristics of initiation timing and anticoagulation of continuous renal replacement therapy in patients following cardiac surgery: A retrospective analysis of 28 patients.

Continuous renal replacement therapy (CRRT) used in cardiac surgery-associated acute kidney injury (CSA-AKI) may have different characteristics from other diseases. We reviewed the medical records of patients with CSA-AKI requiring CRRT who underwent cardiac surgery from January 2020 to September 2021. Patients with AKI caused by other reasons who received CRRT during the same period were also evaluated. A total of 28 patients with CSA-AKI and 12 patients with AKI caused by other reasons were enrolled in this study. Compared with AKI patients caused by other reasons, patients with CSA-AKI were found to have lower mean arterial pressure, higher level of bilirubin, higher vasoactive-inotropic score, and larger daily diuretic dosage. The patients with CSA-AKI were prescribed CRRT earlier than the patients with AKI caused by other reasons. There was a significant difference in the CRRT anticoagulation method between patients with CSA-AKI and patients with AKI caused by other reasons. Six patients with CSA-AKI were treated with regional citrate anticoagulation (RCA), and the other 22 patients were treated with low molecular weight heparin or without anticoagulants. The timing of CRRT initiation in patients with CSA-AKI is earlier than that in patients with AKI caused by other reasons. Although RCA is recommended as the preferred anticoagulant for patients without contraindications, patients with CSA-AKI often have circulatory dysfunction and severe liver damage, so the risk of citrate accumulation is greater, whether to use RCA should be determined according to the individual condition of the patient.

Combining the vasoactive-inotropic score with lactate levels to predict mortality in post-cardiotomy patients supported with venoarterial extracorporeal membrane oxygenation.

Our goal was to determine the predictive role of the combined assessment of the vasoactive-inotropic score (VIS) and lactate levels for the prognosis of patients with postcardiotomy cardiogenic shock (PCS) requiring venoarterial extracorporeal membrane oxygenation (VA-ECMO). The data of adult patients with PCS requiring VA-ECMO between January 2015 and December 2018 at a tertiary hospital were analysed retrospectively. The incidence of in-hospital mortality and other clinical outcomes was analysed. The associations of the VIS and the lactate concentration and in-hospital mortality were assessed using logistic regression analysis. A total of 222 patients were included and divided into 4 groups according to the cut-off points of the VIS (24.3) and the lactate level (6.85 mmol/L). The in-hospital mortality rates were 37.7%, 50.7%, 54.8% and 76.5% for the 4 groups (P < 0.001), and the rates of successful weaning off VA-ECMO were 73.9%, 69%, 61.3% and 39.2%, respectively (P = 0.001). Groups 1 and 2 exhibited significant differences compared to group 4 in both in-hospital mortality and weaning rates (P < 0.05). There was a statistically significant difference in the incidence of multiple organ dysfunction between group 1 and group 4 (P < 0.05). Groups 1, 2 and 3 demonstrated significantly improved cumulative 30-day survival compared with group 4 (log-rank test, P < 0.05). Logistic regression analysis revealed that age, a VIS > 24.3 and lactate levels > 6.85 mmol/L were independently predictive of in-hospital mortality. Among patients with PCS requiring VA-ECMO, the initiation before reaching a VIS > 24.3 and lactate levels > 6.85 mmol/L was associated with improved in-hospital and 30-day outcomes, suggesting that the combined assessment of the VIS and lactate levels may be instructive for determining the initiation of VA-ECMO.

Is it useful to wash stored red blood cells in cardiopulmonary bypass priming fluid for neonatal cardiac surgery? A single-centre retrospective study.

Neonatal cardiac surgery requires careful consideration of cardiopulmonary bypass (CPB) priming fluid composition due to small blood volume and immature physiology. This study investigated the impact of allogeneic stored red blood cells (RBCs) processed using an autotransfusion system in CPB priming fluid for neonates. We compared perioperative parameters, inflammatory mediators, coagulation indicators, vasoactive-inotropic score (VIS) and clinical outcomes between neonates receiving unwashed (n = 56) and washed (n = 45) RBCs in CPB priming fluid. Regression models were used to assess the independent association between RBC washing and patient outcomes. The autotransfusion system improved stored RBC quality. The washed group showed higher peak haematocrit (p < 0.01) and haemoglobin levels (p = 0.04) during CPB, an increased oxygen delivery index during rewarming (p < 0.05) and lower postoperative lactate levels and VIS (p < 0.05). Inflammatory (IL-6, IL-8 and IL-10) and coagulation parameters (D-dimer, fibrinogen and fibrin degradation product) fluctuated compared with baseline but did not significantly differ between groups. The washed group had a lower incidence of hyperlactacidaemia and delayed sternal closure at CPB weaning. Adding washed allogeneic stored RBCs to neonatal CPB priming fluid reduced postoperative lactate elevation and VIS without early improvement in the inflammatory and coagulation systems.