Effects of a comprehensive blood-sparing approach using body weight-adjusted miniaturized cardiopulmonary bypass circuits on transfusion requirements in pediatric cardiac surgery.
J Thorac Cardiovasc Surg. 2012 Feb 1;
Authors: Redlin M, Habazettl H, Boettcher W, Kukucka M, Schoenfeld H, Hetzer R, Huebler M
Abstract
OBJECTIVES: Transfusion-free pediatric cardiac surgery remains a challenge, mainly owing to the mismatch between the cardiopulmonary bypass (CPB) priming volume and the infants’ blood volume. Within a comprehensive blood-sparing approach, we developed body weight-adjusted miniaturized CPB circuits with priming volumes of 95, 110, and 200 mL for, respectively, infants weighing less than 3 kg, 3 to 5 kg and 5 to16 kg. We analyzed the effects of this approach on transfusion requirements and risk factors predisposing for blood transfusion. METHODS: A total of 288 children with body weights between 1.7 and 15.9 kg were included and divided into 3 groups: No transfusion, postoperative transfusion only, and intraoperative and postoperative transfusion. Groups were compared by analysis of variance or analysis of variance on ranks. Risk factors predisposing for transfusion were identified by multivariate logistic regression. RESULTS: Of the infants, 24.7% required no transfusion, 23.6% received postoperative transfusion only and 51.7% received intraoperative and postoperative transfusion. Groups differed by age, body weight, and size and by duration of surgery, CPB, and aortic crossclamp (P < .00001). Body weight (P < .00001), CPB duration (P < .00001), and persisting cyanosis (P = .03) were predictors of intraoperative and postoperative transfusion, whereas body weight (P = .00095), reoperations (P = .0051), and cyanotic heart defects (P = .035) were associated with postoperative transfusion only. CONCLUSIONS: Our blood-sparing approach allows for transfusion-free surgery in a substantial number of infants. The strongest predictors of transfusion requirement, body weight and complexity of surgery as reflected by CPB duration, are not amenable to further improvements. Better preservation of the coagulatory system might allow for reduction of postoperative transfusion requirements.
PMID: 22305547 [PubMed - as supplied by publisher]
Totally endoscopic robotic ventricular septal defect repair in the adult.
J Thorac Cardiovasc Surg. 2012 Feb 1;
Authors: Gao C, Yang M, Wang G, Xiao C, Wang J, Zhao Y
Abstract
OBJECTIVE: We have previously reported total endoscopic ventricular septal defect repair in the adult using the da Vinci S Surgical System. The optimal results encouraged us to extend the use of this technology to more complicated patients with ventricular septal defect. METHODS: From January 2009 to July 2010, 20 patients underwent total endoscopic robotic ventricular septal defect repair. The average patient age was 29.0 ± 9.5 years (range, 16-45). Of the 20 patients, 9 were female and 11 were male. The echocardiogram demonstrated that the average diameter of the ventricular septal defect was 6.1 ± 2.8 mm (range, 2-15), and 4 patients had concomitant patent foramen ovale. Ventricular septal defect closure was directly secured with interrupted mattress sutures in 14 patients and patched in 6 patients. All the procedures were completed using the da Vinci robot by way of 3 port incisions and a 2.0- to 2.5-cm working port in the right side of the chest. RESULTS: All patients were operated on successfully. The mean cardiopulmonary bypass and mean crossclamp time was 94.3 ± 26.3 minutes (range, 70-140) and 39.1 ± 12.9 minutes (range, 22-75), respectively. The mean operation time was 225.0 ± 34.8 minutes (range, 180-300). The postoperative transesophageal echocardiogram demonstrated an intact ventricular septum. No residual left-to-right shunting and no permanently complete atrioventricular dissociation was found postoperatively. The mean hospital stay was 5 days. No residual shunt was found during a mean follow-up of 7 months (range, 1-22). The patients returned to normal function within 1 week without any complications. CONCLUSIONS: Total endoscopic robotic ventricular septal defect repair in adult patients is feasible, safe, and efficacious.
PMID: 22305549 [PubMed - as supplied by publisher]
Implantation of fetal rat lung fragments into bleomycin-induced pulmonary fibrosis.
J Thorac Cardiovasc Surg. 2012 Feb 1;
Authors: Toba H, Sakiyama S, Kenzaki K, Kawakami Y, Uyama K, Bando Y, Tangoku A
Abstract
OBJECTIVE: Pulmonary fibrosis is a life-threatening disease that results in progressive respiratory failure. We have suggested the possibility of fetal lung tissue as an option for further investigation into lung regeneration. The objective was to prove whether fetal lung fragments can survive and differentiate in fibrotic lung. METHODS: Lewis rats were administered bleomycin and used as recipients after 3 or 4 weeks. Day 17 fetal lung tissue from green fluorescent protein Lewis rats was used as donor material. Donor lungs were removed, cut into small pieces, and implanted into the recipients’ left lung. The recipients received cyclosporin to prevent immune response to green fluorescent protein and were killed after 1, 2, 4, 8, and 12 weeks and histologically evaluated. Furthermore, the expression of thyroid transcription factor-1 and Clara cell secretory protein in the implanted fetal lung tissue was immunohistologically evaluated. RESULTS: Fibrotic changes were recognized for a long period of time in the recipient lungs. The implanted fetal lung fragments could be clearly distinguished from recipient lungs because of the luminescence of grafts. Fetal lung fragments could survive in the recipient lungs with fibrotic changes. The air spaces of implanted fetal lungs were narrow at 1 and 2 weeks but expanded with the passage of time. The connection between the recipient lung and the implanted fetal lung was recognized, particularly in the peripheral grafts. The expression patterns of thyroid transcription factor-1 and Clara cell secretory protein in implanted lungs resembled those in the process of normal lung morphogenesis. CONCLUSIONS: Fetal rat lung fragments could survive and differentiate in bleomycin-induced completely fibrotic lung.
PMID: 22305550 [PubMed - as supplied by publisher]
Diagnosis of infection in patients undergoing extracorporeal membrane oxygenation: A case-control study.
J Thorac Cardiovasc Surg. 2012 Feb 1;
Authors: Pieri M, Greco T, De Bonis M, Maj G, Fumagalli L, Zangrillo A, Pappalardo F
Abstract
OBJECTIVE: Diagnosis of infection in patients receiving extracorporeal membrane oxygenation is challenging in clinical practice but represents a crucial aspect of the upgrading of therapeutic options. The aim of this study was to analyze the role of C-reactive protein and procalcitonin in the diagnosis of infection in patients requiring extracorporeal membrane oxygenation and to assess the difference between venovenous and venoarterial extracorporeal membrane oxygenation settings. METHODS: A case-control study was performed on 27 patients. Serum values of procalcitonin and C-reactive protein were analyzed according to the presence of infection. RESULTS: Forty-eight percent of patients had infection. Gram-negative bacteria were the predominant pathogens, and Candida albicans was the most frequent isolated microorganism. Procalcitonin had an area under the curve of 0.681 (P = .0062) for the diagnosis of infection in the venoarterial extracorporeal membrane oxygenation group but failed to discriminate infection in the venovenous extracorporeal membrane oxygenation group (P = .14). The area under the curve of C-reactive protein was 0.707 (P < .001) in all patients receiving extracorporeal membrane oxygenation. In patients receiving venoarterial extracorporeal membrane oxygenation, procalcitonin had good accuracy with 1.89 ng/mL as the cutoff (sensitivity = 87.8%, specificity = 50%) and C-reactive protein with 97.70 mg/L as the cutoff (sensitivity = 85.3%, specificity = 41.6%). The procalcitonin and C-reactive protein combined assay had a sensitivity of 87.2% and specificity of 25.9%. Four variables were identified as statistically significant predictors of infection: procalcitonin and C-reactive protein combined assay (odds ratio, 1.184; P < .001), age (odds ratio, 0.980; P < .001), presence of infection before extracorporeal membrane oxygenation implantation (odds ratio, 1.782; P < .001), and duration of extracorporeal membrane oxygenation support (odds ratio, 1.056; P < .001). CONCLUSIONS: Traditional and emerging inflammatory biomarkers, especially if compounded in the procalcitonin and C-reactive protein combined assay, can aid in the diagnosis of infection in patients undergoing venoarterial extracorporeal membrane oxygenation.
PMID: 22305552 [PubMed - as supplied by publisher]
Chronic performance of a novel radiofrequency ablation device on the beating heart: Limitations of conduction delay to assess transmurality.
J Thorac Cardiovasc Surg. 2012 Feb 1;
Authors: Lee AM, Aziz A, Clark KL, Schuessler RB, Damiano RJ
Abstract
OBJECTIVE: The creation of consistently transmural lesions with epicardial ablation on the beating heart has represented a significant challenge for current technology. This study examined the chronic performance of the AtriCure Coolrail device (AtriCure Inc, West Chester, Ohio), an internally cooled, bipolar radiofrequency ablation device designed for off-pump epicardial ablation. The study also examined the reliability of using acute intraoperative conduction delay to evaluate lesion integrity. METHODS: Seven swine underwent median sternotomy. The right atrial appendage and inferior vena cava were isolated with a bipolar radiofrequency clamp. Linear ablation lines were created between these structures with the AtriCure Coolrail. Paced activation maps were recorded with epicardial patch electrodes acutely before and after ablation and after keeping the animals alive for 4 weeks. The conduction time across the linear ablation was calculated from these maps. The lesions were histologically evaluated with trichrome staining. RESULTS: Only 76% of cross-sections of Coolrail lesions were transmural, and only 1 of 12 ablation lines was transmural in every cross-section examined. Mapping data were available in 5 of the animals. Significant conduction delay was present after the creation of each line of ablation acutely; however, after 4 weeks, conduction time returned to preablation values, demonstrating lack of transmurality. CONCLUSIONS: The AtriCure Coolrail failed to reliably create transmural lesions. Although the Coolrail was able to create acute conduction delay, its failure to transmurally ablate the atrial myocardium left gaps along the length of the lesion, which resulted in neither chronic conduction block nor delay across any line of ablation.
PMID: 22305553 [PubMed - as supplied by publisher]
OBJECTIVE: Repair of mitral regurgitation (MR) due to bileaflet prolapse poses many technical challenges. The late outcomes after repair are also not well characterized in this population. Published series have often included patients with mixed causes of prolapse and/or lack long-term echocardiographic follow-up. Myxomatous disease represents an important cause of bileaflet prolapse and MR and, thus, served as the focus of the present study. METHODS: A total of 142 patients, mean age 60.4 ± 13.2 years, underwent mitral valve (MV) repair of bileaflet prolapse due to myxomatous disease from 2001 to 2010. Concomitant coronary artery bypass grafting was performed in 16 patients (11%). All patients were followed up by a dedicated MV clinic with a follow-up interval that extended up to 8.6 years. RESULTS: No hospital deaths occurred. Ring annuloplasty was used for all patients. Additional MV repair techniques included chordal transfer in 73, a hybrid-flip-over technique in 23, polytetrafluoroethylene neochords in 26, edge-to-edge repair in 11, and commissuroplasty in 9. Prolapse involving more than 1 posterior leaflet scallop was observed in 103 patients (73%), and prolapse of more than 1 anterior leaflet scallop was observed in 76 (54%). During follow-up, 4 patients had MR grade 2+ or greater, and 2 patients required subsequent MV reoperation. The 5-year survival, freedom from recurrent MR (≥2+), and freedom from MV reoperation was 95.2% ± 2.8%, 92.6% ± 3.9%, and 94.0% ± 4.9%, respectively. CONCLUSIONS: MV repair of bileaflet prolapse due to myxomatous disease is safe and durable. Successful repair often requires a combination of surgical repair techniques.
PMID: 22306213 [PubMed - as supplied by publisher]
Extending the scope of mitral valve repair in active endocarditis.
J Thorac Cardiovasc Surg. 2012 Feb 3;
Authors: de Kerchove L, Price J, Tamer S, Glineur D, Momeni M, Noirhomme P, Elkhoury G
Abstract
OBJECTIVE: During the last 2 decades, we have applied a repair-oriented surgical approach to patients with active mitral valve endocarditis. We retrospectively analyzed the long-term outcomes with this repair-oriented approach. METHOD: Between 1991 and 2010, 137 patients underwent operation for active mitral valve endocarditis; of these, 109 patients (80%) had mitral valve repair and represent the study cohort. Repair techniques without patch extension (no-patch techniques) include triangular or quadrangular resection (n = 49), sliding plasty (n = 24), neochordae (n = 18), chordal transfer (n = 12), and others (n = 5). Repair techniques using patch extension (patch techniques) included pericardium (n = 42), tricuspid autograft (n = 8), flip-over technique (n = 7), and partial mitral valve homograft (n = 5). Patches were used in 67 patients (61%). Ring annuloplasty was performed in 60 patients, and a pericardial band was used in 13 patients. Clinical and echocardiographic follow-up were performed. Median follow-up was 48 months. RESULTS: Hospital mortality was 16%. At 8 years, overall survival was 62% ± 10% with no differences between patients with or without patch repair (P = .5). Freedom from mitral valve repair failure was 81% ± 14% in patients with patch repair and 90% ± 10% in patients without patch repair (P = .09). The rate of thromboembolic or bleeding event was 1% per patient-year, and the rate of endocarditis recurrence was 0.3% per patient-year. Univariable predictors of mortality were age more than 70 years (P < .0001), perivalvular abscess (P = .002), diabetes mellitus (P = .0002), and renal failure (P = .04). Predictors of repair failure were renal failure (P = .035) and perivalvular abscess (P = .033). CONCLUSIONS: In active mitral valve endocarditis, a repair-oriented surgical approach achieves a reparability rate of 80% with acceptable morbidity and good long-term results. The use of patch techniques offers a durability rate that approximates the rate obtained with the no-patch techniques.
PMID: 22306214 [PubMed - as supplied by publisher]
Effects of institutional volumes on operative outcomes for aortic root replacement in North America.
J Thorac Cardiovasc Surg. 2012 Feb 3;
Authors: Hughes GC, Zhao Y, Rankin JS, Scarborough JE, O’Brien S, Bavaria JE, Wolfe WG, Gaca JG, Gammie JS, Shahian DM, Smith PK
Abstract
OBJECTIVES: Hospital procedure volume has been strongly associated with postoperative mortality for a number of complex cardiovascular procedures. Although not yet described, a similar relationship might be expected for surgical procedures involving the aortic root and/or ascending aorta. The present study sought to evaluate the relationship between the volume of aortic root replacement procedures and the operative results for centers in North America. METHODS: Patient-level data for 13,358 elective aortic root and aortic valve-ascending aortic procedures performed from 2004 through 2007 were obtained from 741 North American hospitals participating in the Society of Thoracic Surgeons Adult Cardiac Surgery Database. Marginal logistic regression modeling was used for risk adjustment. The hospital procedure volume was the primary predictor variable. Patient demographics, comorbid conditions, and operative characteristics were included as the predictor variables for risk adjustment. The primary outcome measures included unadjusted operative mortality and adjusted odds ratio for mortality. RESULTS: The preoperative patient risk profiles were similar at all center volume levels, and the overall unadjusted operative mortality was 4.5%. The unadjusted operative mortality increased with decreasing case volume, from 3.4% in the highest volume centers to 5.8% in the lowest volume centers. Whether hospital volume was assessed as a categorical or continuous variable, its relationship with the adjusted odds ratio for mortality was nonlinear. A negative association was seen between the hospital procedural volume and adjusted odds ratio for mortality (P < .001) that was most pronounced among hospitals performing fewer than 30 to 40 procedures annually. CONCLUSIONS: Patients undergoing elective aortic root or combined aortic valve-ascending aortic surgery at North American hospitals that performed fewer than 30 to 40 of such procedures annually have greater risk-adjusted mortality than those undergoing surgery in higher volume hospitals. Causative factors for this inverse association between hospital volume and mortality deserve additional analysis.
PMID: 22306215 [PubMed - as supplied by publisher]
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