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<1>
Accession Number
2011322519
Authors
El-Tahan M.R. El Ghoneimy Y.F. Regal M.A. El Emam H.
Institution
(El-Tahan, El Emam) Department of Anaesthesia and Surgical Intensive Care
Unit, King Fahd Hospital of the University of Dammam, Al Khubar, Saudi
Arabia
(El Ghoneimy, Regal) Department of Cardiothoracic Surgery, King Fahd
Hospital of the University of Dammam, Al Khubar, Saudi Arabia
(El-Tahan) Department of Anaesthesiology, University of Dammam, Dammam,
P.O. 40289, Al Khubar 31952, Saudi Arabia
Title
Comparative study of the non-dependent continuous positive pressure
ventilation and high-frequency positive-pressure ventilation during
one-lung ventilation for video-assisted thoracoscopic surgery.
Source
Interactive Cardiovascular and Thoracic Surgery. 12 (6) (pp 899-902),
2011. Date of Publication: June 2011.
Publisher
European Association for Cardio-Thoracis Surgery (3 Park Street, Windsor,
Berkshire SL4 1LU, United Kingdom)
Abstract
The application of volume controlled high-frequency positive-pressure
ventilation (HFPPV) to the non-dependent lung (NL) may have comparable
effects to continuous positive-airway pressure (CPAP) on the surgical
conditions during one-lung ventilation (OLV) for video-assisted
thoracoscopic surgery (VATS). After local Ethics Committee approval and
informed consent, we randomly allocated 30 patients scheduled for elective
VATS after the first 15 min of OLV to ventilate the NL with CPAP of 2 cm
H₂O (NL-CPAP₂) and HFPPV using tidal volume 2 ml/kg,
inspiratory to expiratory ratio <0.3 and respiratory rate 60/min
(NL-HFPPV) for 30 min, each in a randomized crossover order.
Intraoperative adequacy of surgical conditions was evaluated using a
visual analog scale and the changes in hemodynamic and arterial oxygen
were recorded. The application of NL-CPAP₂ and NL-HFPPV
resulted in more improved arterial oxygenation than during OLV for VATS
(P<0.001). The operative field was much better during the application of
NL-CPAP₂ than during NL-HFPPV (P<0.001). We concluded that the
application of CPAP to the NL during OLV offers good quality of operative
field and improved arterial oxygenation for VATS. 2011 Published by
European Association for Cardio-Thoracic Surgery. All rights reserved.

<2>
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Accession Number
2011325736
Authors
Blackshear J.L. Cutlip D.E. Roubin G.S. Hill M.D. Leimgruber P.P. Begg
R.J. Cohen D.J. Eidt J.F. Narins C.R. Prineas R.J. Glasser S.P. Voeks J.H.
Brott T.G.
Institution
(Blackshear, Brott) Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL
32224, United States
(Cutlip) Beth Israel Deaconess Medical Center, Harvard Clinical Research
Institute, Boston, MA, United States
(Roubin) Lenox Hill Hospital, New York, NY, United States
(Hill) University of Calgary, Calgary Stroke Program, Foothills Hospital,
Calgary, AB, Canada
(Leimgruber) Providence Spokane Heart Institute, Spokane, WA, United
States
(Begg) Heritage Valley Health System, Heart and Vascular Center, Beaver,
PA, United States
(Cohen) Saint Luke's MidAmerica Heart and Vascular Institute, Kansas City,
MO, United States
(Eidt) University of Arkansas for Medical Science, Little Rock, United
States
(Narins) University of Rochester Medical Center, Rochester, NY, United
States
(Prineas) Wake Forest University School of Medicine, Winston-Salem, NC,
United States
(Glasser, Voeks) University of Alabama, Birmingham, United States
Title
Myocardial infarction after carotid stenting and endarterectomy: Results
from the carotid revascularization endarterectomy versus stenting trial.
Source
Circulation. 123 (22) (pp 2571-2578), 2011. Date of Publication: 07 Jun
2011.
Publisher
Lippincott Williams and Wilkins (530 Walnut Street, Philadelphia PA
19106-3621, United States)
Abstract
Background: The Carotid Revascularization Endarterectomy Versus Stenting
Trial (CREST) found a higher risk of stroke after carotid artery stenting
and a higher risk of myocardial infarction (MI) after carotid
endarterectomy. Methods and results: Cardiac biomarkers and ECGs were
performed before and 6 to 8 hours after either procedure and if there was
clinical evidence of ischemia. In CREST, MI was defined as biomarker
elevation plus either chest pain or ECG evidence of ischemia. An
additional category of biomarker elevation with neither chest pain nor ECG
abnormality was prespecified (biomarker+ only). Crude mortality and
risk-adjusted mortality for MI and biomarker+ only were assessed during
follow-up. Among 2502 patients, 14 MIs occurred in carotid artery stenting
and 28 MIs in carotid endarterectomy (hazard ratio, 0.50; 95% confidence
interval, 0.26 to 0.94; P=0.032) with a median biomarker ratio of 40 times
the upper limit of normal. An additional 8 carotid artery stenting and 12
carotid endarterectomy patients had biomarker+ only (hazard ratio, 0.66;
95% confidence interval, 0.27 to 1.61; P=0.36), and their median biomarker
ratio was 14 times the upper limit of normal. Compared with patients
without biomarker elevation, mortality was higher over 4 years for those
with MI (hazard ratio, 3.40; 95% confidence interval, 1.67 to 6.92) or
biomarker+ only (hazard ratio, 3.57; 95% confidence interval, 1.46 to
8.68). After adjustment for baseline risk factors, both MI and biomarker+
only remained independently associated with increased mortality.
Conclusions: In patients randomized to carotid endarterectomy versus
carotid artery stenting, both MI and biomarker+ only were more common with
carotid endarterectomy. Although the levels of biomarker elevation were
modest, both events were independently associated with increased future
mortality and remain an important consideration in choosing the mode of
carotid revascularization or medical therapy. 2011 American Heart
Association, Inc.

<3>
Accession Number
2011336310
Authors
Myers K. Hajek P. Hinds C. McRobbie H.
Institution
(Myers, Hajek, Hinds, McRobbie) Queen Mary University of London, Barts and
The London School of Medicine and Dentistry, London, England, United
Kingdom
Title
Stopping smoking shortly before surgery and postoperative complications: A
systematic review and meta-analysis.
Source
Archives of Internal Medicine. 171 (11) (pp 983-989), 2011. Date of
Publication: June 13, 2011.
Publisher
American Medical Association (515 North State Street, Chicago IL 60654,
United States)
Abstract
Objective: To examine existing smoking studies that compare surgical
patients who have recently quit smoking with those who continue to smoke
to provide an evidence-based recommendation for front-line staff. Concerns
have been expressed that stopping smoking within 8 weeks before surgery
may be detrimental to postoperative outcomes. This has generated
considerable uncertainty even in health care systems that consider smoking
cessation advice in the hospital setting an important priority. Smokers
who stop smoking shortly before surgery (recent quitters) have been
reported to have worse surgical outcomes than early quitters, but this may
indicate only that recent quitting is less beneficial than early quitting,
not that it is risky. Design: Systematic review with meta-analysis. Data
Sources: British Nursing Index (BNI), The Cochrane Library database,
Cumulative Index to Nursing and Allied Health Literature (CINAHL), Embase,
Medline, PsycINFO to May 2010, and reference lists of included studies.
Study Selection: Studies were included that allow a comparison of
postoperative complications in patients undergoing any type of surgery who
stopped smoking within 8 weeks prior to surgery and those who continued to
smoke. Data Extraction: Two reviewers independently screened potential
studies and assessed their methodologic quality. Data were entered into 3
separate meta-analyses that considered all available studies, studies with
a low risk of bias that validated self-reported abstinence (to assess
possible benefits), and studies of pulmonary complications only (to assess
possible risks). Results were combined by using a random-effects model,
and heterogeneity was evaluated by using the I² statistic.
Results: Nine studies met the inclusion criteria. One found a beneficial
effect of recent quitting compared with continuing smoking, and none
identified any detrimental effects. In meta-analyses, quitting smoking
within 8 weeks before surgery was not associated with an increase or
decrease in overall postoperative complications for all available studies
(relative risk [RR], 0.78; 95% confidence interval [CI], 0.57-1.07), for a
group of 3 studies with high-quality scores (RR, 0.57; 95% CI, 0.16-2.01),
or for a group of 4 studies that specifically evaluated pulmonary
complications (RR, 1.18; 95% CI, 0.95-1.46). Conclusions: Existing data
indicate that the concern that stopping smoking only a few weeks prior to
surgery might worsen clinical outcomes is unfounded. Further larger
studies would be useful to arrive at a more robust conclusion. Patients
should be advised to stop smoking as early as possible, but there is no
evidence to suggest that health professionals should not be advising
smokers to quit at any time prior to surgery. 2011 American Medical
Association. All rights reserved.

<4>
Accession Number
2011331920
Authors
Rastogi S. Verma M.
Institution
(Rastogi, Rastogi, Verma) Division of Neonatology, Maimonides Infants and
Children's Hospital of Brooklyn, Maimonides Medical Center, Brooklyn, NY,
United States
(Rastogi) Division of Pediatric Cardiology, Department of Pediatrics,
Children's Hospital of Montefiore, Bronx, NY, United States
Title
Systemic review of BNP and NT-proBNP levels in diagnosis and response to
treatment of patent ductus arteriosus in preterm neonates.
Source
Journal of Neonatal-Perinatal Medicine. 4 (2) (pp 83-88), 2011. Date of
Publication: 2011.
Publisher
IOS Press (Nieuwe Hemweg 6B, Amsterdam 1013 BG, Netherlands)
Abstract
There are inconsistencies in the diagnosis of hemodynamically significant
Patent Ductus Arteriosus (hsPDA) and the decision to treat it in preterm
neonates. Since hsPDA is related to poor outcomes, there is need for an
easier, inexpensive and point of care method to diagnose and evaluate the
effect of treatment on hsPDA. While echocardiography is the gold standard
for the diagnosis and evaluation of treatment, it has certain pitfalls
including a lack of universal availability, and when available, has
significant intra and inter-observer variability. Recently, the detection
of natriuretic peptides and their correlation to the size of PDA provides
a possibility for development of a simple bedside test for the diagnosis
and management of hsPDA for the intensivists treating preterm neonates.
There are certain aspects of natriuretic peptides including its
associations with gestational age, days of life, presence of
co-morbidities and the type of assay performed that need to be studied
further before it can be used as a routine bedside test. The aim of this
review is to analyze the existing literature on the use of natriuretic
peptide in the diagnosis and management of hsPDA in preterm neonates and
its strengths and limitations. 2011 - IOS Press and the authors. All
rights reserved.

<5>
Accession Number
2011334836
Authors
Brevoord D. Hollmann M.W. De Hert S.G. van Dongen E.H.P.A. Heijnen
B.G.A.D.H. de Bruin A. Tolenaar N. Schlack W.S. Weber N.C. Dijkgraaf
M.G.W. de Groot J.R. de Mol B.A.J.M. Driessen A.H.G. Momeni M. Wouters P.
Bouchez S. Hofland J. Luthen C. Meijer-Treschan T.A. Pannen B.H. Preckel
B.
Institution
(Brevoord, Hollmann, De Hert, Schlack, Weber, Preckel) Department of
Anaesthesiology, Laboratory of Experimental Intensive Care and
Anaesthesiology (L.E.I.C.A.), Academic Medical Centre Amsterdam,
Netherlands
(van Dongen, Heijnen, de Bruin, Tolenaar) Department of Anaesthesiology,
St. Antonius Ziekenhuis, Nieuwegein, Netherlands
(Dijkgraaf) Clinical Research Unit, Academic Medical Centre Amsterdam,
Netherlands
(de Groot) Department of Cardiology, Academic Medical Centre Amsterdam,
Netherlands
(de Mol, Driessen) Department of Cardiothoracic Surgery, Academic Medical
Centre Amsterdam, Netherlands
(Momeni) Department of Anaesthesiology, UCL Brussels, Belgium
(Wouters, Bouchez) Department of Anaesthesiology, UZ Gent, Belgium
(Hofland, Luthen) Department of Anaesthesiology, Erasmus Medical Centre
Rotterdam, Netherlands
(Meijer-Treschan, Pannen) Department of Anaesthesiology and Intensive
Care, University Hospital Dusseldorf, Germany
Title
Effect of remote ischemic conditioning on atrial fibrillation and outcome
after coronary artery bypass grafting (RICO-trial).
Source
BMC Anesthesiology. 11 , 2011. Article Number: 11. Date of
Publication: 23 May 2011.
Publisher
BioMed Central Ltd. (34 - 42 Cleveland Street, London W1T 4LB, United
Kingdom)
Abstract
Background: Pre- and postconditioning describe mechanisms whereby short
ischemic periods protect an organ against a longer period of ischemia.
Interestingly, short ischemic periods of a limb, in itself harmless, may
increase the ischemia tolerance of remote organs, e.g. the heart (remote
conditioning, RC). Although several studies have shown reduced biomarker
release by RC, a reduction of complications and improvement of patient
outcome still has to be demonstrated. Atrial fibrillation (AF) is one of
the most common complications after coronary artery bypass graft surgery
(CABG), affecting 27-46% of patients. It is associated with increased
mortality, adverse cardiovascular events, and prolonged in-hospital stay.
We hypothesize that remote ischemic pre- and/or post-conditioning reduce
the incidence of AF following CABG, and improve patient
outcome.Methods/design: This study is a randomized, controlled, patient
and investigator blinded multicenter trial. Elective CABG patients are
randomized to one of the following four groups: 1) control, 2) remote
ischemic preconditioning, 3) remote ischemic postconditioning, or 4)
remote ischemic pre- and postconditioning. Remote conditioning is applied
at the arm by 3 cycles of 5 minutes of ischemia and reperfusion. Primary
endpoint is the incidence AF in the first 72 hours after surgery, detected
using a Holter-monitor. Secondary endpoints include length-of-stay on the
intensive care unit and in-hospital, and the occurrence of major adverse
cardiovascular events at 30 days, 3 months and 1 year.Based on an expected
incidence in the control group of 27%, 195 patients per group are needed
to detect with 80% power a reduction by 45% following either pre- or
postconditioning, while allowing for a 10% dropout and at an alpha of
0.05. With the combined intervention expected to be stronger, we need 75
patients in this group to detect a reduction in incidence of AF of
60%.Discussion: The RICO-trial (the effect of Remote Ischemic Conditioning
on atrial fibrillation and Outcome) is a randomized controlled multicenter
trial, designed to investigate whether remote ischemic pre- and/or
post-conditioning of the arm reduce the incidence of AF following CABG
surgery.Trial registration: ClinicalTrials.gov under NCT01107184. 2011
Brevoord et al; licensee BioMed Central Ltd.

<6>
Accession Number
2011317579
Authors
Smith C.R. Leon M.B. Mack M.J. Miller D.C. Moses J.W. Svensson L.G. Tuzcu
E.M. Webb J.G. Fontana G.P. Makkar R.R. Williams M. Dewey T. Kapadia S.
Babaliaros V. Thourani V.H. Corso P. Pichard A.D. Bavaria J.E. Herrmann
H.C. Akin J.J. Anderson W.N. Wang D. Pocock S.J.
Institution
(Smith, Leon, Moses, Williams) Columbia University Medical Center-New York
Presbyterian Hospital, Milstein Bldg. 7-435, 177 Fort Washington Ave., New
York, NY 10032, United States
(Mack) Baylor Healthcare System, Dallas, TX, United States
(Dewey) Medical City Dallas, Dallas, TX, United States
(Miller) Stanford University Medical School, Palo Alto, CA, United States
(Akin, Anderson) Edwards Lifesciences, Irvine, CA, United States
(Svensson, Tuzcu, Kapadia) Cleveland Clinic Foundation, Cleveland, OH,
United States
(Webb) University of British Columbia-St. Paul's Hospital, Vancouver, BC,
Canada
(Fontana, Makkar) Cedars-Sinai Medical Center, Los Angeles, CA, United
States
(Babaliaros, Thourani) Emory University School of Medicine, Atlanta, GA,
United States
(Corso, Pichard) Washington Hospital Center, Washington, DC, United States
(Bavaria, Herrmann) Hospital of the University of Pennsylvania,
Philadelphia, PA, United States
(Wang, Pocock) London School of Hygiene and Tropical Medicine, London,
United Kingdom
Title
Transcatheter versus surgical aortic-valve replacement in high-risk
patients.
Source
New England Journal of Medicine. 364 (23) (pp 2187-2198), 2011. Date of
Publication: 09 Jun 2011.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
BACKGROUND: The use of transcatheter aortic-valve replacement has been
shown to reduce mortality among high-risk patients with aortic stenosis
who are not candidates for surgical replacement. However, the two
procedures have not been compared in a randomized trial involving
high-risk patients who are still candidates for surgical replacement.
METHODS: At 25 centers, we randomly assigned 699 high-risk patients with
severe aortic stenosis to undergo either transcatheter aortic-valve
replacement with a balloon-expandable bovine pericardial valve (either a
transfemoral or a transapical approach) or surgical replacement. The
primary end point was death from any cause at 1 year. The primary
hypothesis was that transcatheter replacement is not inferior to surgical
replacement. RESULTS: The rates of death from any cause were 3.4% in the
transcatheter group and 6.5% in the surgical group at 30 days (P = 0.07)
and 24.2% and 26.8%, respectively, at 1 year (P = 0.44), a reduction of
2.6 percentage points in the transcatheter group (upper limit of the 95%
confidence interval, 3.0 percentage points; predefined margin, 7.5
percentage points; P = 0.001 for noninferiority). The rates of major
stroke were 3.8% in the transcatheter group and 2.1% in the surgical group
at 30 days (P = 0.20) and 5.1% and 2.4%, respectively, at 1 year (P =
0.07). At 30 days, major vascular complications were significantly more
frequent with transcatheter replacement (11.0% vs. 3.2%, P<0.001); adverse
events that were more frequent after surgical replacement included major
bleeding (9.3% vs. 19.5%, P<0.001) and new-onset atrial fibrillation (8.6%
vs. 16.0%, P = 0.006). More patients undergoing transcatheter replacement
had an improvement in symptoms at 30 days, but by 1 year, there was not a
significant between-group difference. CONCLUSIONS: In high-risk patients
with severe aortic stenosis, transcatheter and surgical procedures for
aortic-valve replacement were associated with similar rates of survival at
1 year, although there were important differences in periprocedural risks.
(Funded by Edwards Lifesciences; Clinical Trials.gov number, NCT00530894.)
Copyright 2011 Massachusetts Medical Society.

<7>
Accession Number
2011327904
Authors
De Bie M.K. Van Rees J.B. Herzog C.A. Rabelink T.J. Schalij M.J. Jukema
J.W.
Institution
(De Bie, Van Rees, Schalij, Jukema) Department of Cardiology, Leiden
University Medical Center, PO box 9600, 2300 RC Leiden, Netherlands
(Herzog) Cardiovascular Special Studies Center, United States Renal Data
System, Minneapolis, MN, United States
(Herzog) Hennepin County Medical Center, University of Minnesota,
Minneapolis, MN, United States
(Rabelink) Department of Nephrology, Leiden University Medical Center,
Netherlands
Title
How to reduce the incidence of contrast induced acute kidney injury after
cardiac (invasive) procedures, a review and practical recommendations.
Source
Current Medical Research and Opinion. 27 (7) (pp 1347-1357), 2011. Date
of Publication: July 2011.
Publisher
Informa Healthcare (69-77 Paul Street, London EC2A 4LQ, United Kingdom)
Abstract
Background: Contrast induced acute kidney injury is an important
complication after cardiac (invasive) procedures and is associated with
substantial morbidity and mortality. The aim of the current article is to
provide a comprehensive overview of the current knowledge regarding
contrast induced acute kidney injury. Methods: Current literature was
reviewed and relevant articles were selected. Articles were identified
through MEDLINE and Pubmed selecting articles, limited between 1980 and
2010. Results: The pathophysiological process resulting in contrast
induced acute kidney injury is not completely understood, nevertheless
several mechanisms involved have been proposed. However, the risk factors
for contrast induced acute kidney injury and its timing are well known,
making it amenable for preventive strategies. In the past decade various
preventive strategies have been investigated with different results.
Conclusions: Currently, only adequate hydration, with saline, is uniformly
accepted as a beneficial prophylactic strategy. Furthermore promising
results have also been reported for several other prophylactic strategies.
These results, however, need to be confirmed in future trials. 2011
Informa UK Ltd.

<8>
Accession Number
2011337551
Authors
Takagi H. Manabe H. Umemoto T.
Institution
(Takagi, Manabe, Umemoto) Department of Cardiovascular Surgery, Shizuoka
Medical Center, Shizuoka, Japan
Title
The Gordian knot of revascularization for multivessel coronary artery
disease.
Source
Journal of Thoracic and Cardiovascular Surgery. 142 (1) (pp 241-242),
2011. Date of Publication: July 2011.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)

<9>
Accession Number
2011337536
Authors
Stocker C.F. Shekerdemian L.S. Horton S.B. Lee K.J. Eyres R. D'Udekem Y.
Brizard C.P.
Institution
(Stocker) Pediatric Intensive Care Unit, Mater Children's Hospital,
Brisbane, Australia
(Stocker, Shekerdemian, Brizard) Australia New Zealand Children's Heart
Research Center, Melbourne, Australia
(Shekerdemian) Departments of Pediatric Intensive Care, Royal Children's
Hospital, Melbourne, Australia
(Horton, D'Udekem, Brizard) Department of Cardiac Surgery, Royal
Children's Hospital, Melbourne, Australia
(Eyres) Department of Anaesthesiology, Royal Children's Hospital,
Melbourne, Australia
(Shekerdemian, Horton, D'Udekem, Brizard) University of Melbourne,
Melbourne, Australia
(Lee) Clinical Epidemiology and Biostatistics Unit, Murdoch Children's
Research Institute, Melbourne, Australia
(Brizard) Cardiac Surgery Department, Royal Children's Hospital,
Flemington Road, Parkville, VIC 3052, Australia
Title
The influence of bypass temperature on the systemic inflammatory response
and organ injury after pediatric open surgery: A randomized trial.
Source
Journal of Thoracic and Cardiovascular Surgery. 142 (1) (pp 174-180),
2011. Date of Publication: July 2011.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Objective: Systemic cooling for cardiopulmonary bypass is widely used to
attenuate the systemic inflammatory response syndrome and organ injury in
children after open surgery. We compared the effects of moderate
(24degreeC) and mild (34degreeC) hypothermia during bypass on markers of
the systemic inflammatory response syndrome and organ injury, and on
clinical outcome after corrective surgery for congenital heart disease.
Methods: Sixty-six children (mean age, 6.8 +/- 5.7 months; mean weight,
6.2 +/- 2.3 kg) were randomized to 24degreeC or 34degreeC bypass
temperature during cardiac surgery. Perfusion strategies were otherwise
strictly identical. Clinical data and blood samples were collected before
bypass, 5 minutes after aortic crossclamp release, and 4, 24, and 48 hours
after bypass. Patients were followed up until discharge from the hospital.
Results: In the 54 children with outcome data, bypass temperature did not
influence the duration of mechanical ventilation between the 24degreeC
group and the 34degreeC group (median [interquartile range] 22 [13-40]
hours vs 14 [8-40] hours, P = .14), intensive care unit stay (43 [24-49]
hours vs 29 [23-47] hours, P = .79), blood loss (29 [20-38] mL/kg vs 23
[13-38] mL/kg, P = .36), or incidence of postoperative infection (9% vs
11%, P = 1.0). There was no evidence of an influence of bypass temperature
on the markers of acute inflammation, innate immune response, organ
injury, coagulation, or hemodynamics. Conclusions: There is no evidence
that the systemic inflammatory response syndrome and organ injury after
pediatric open surgery are influenced by bypass temperature. The routine
use of hypothermic bypass may not be warranted in the pediatric
population. Copyright 2011 by The American Association for Thoracic
Surgery.

<10>
Accession Number
2011337529
Authors
Choi Y.S. Shim J.K. Kim J.C. Kang K.-S. Seo Y.H. Ahn K.-R. Kwak Y.L.
Institution
(Choi, Shim, Kim, Kwak) Department of Anesthesiology and Pain Medicine and
Anesthesia, College of Medicine, Yonsei University, 250 Seongsanno,
Seodaemun-Ku, Seoul 120-752, South Korea
(Kang, Seo, Ahn) Department of Anesthesiology and Pain Medicine,
University of Soonchunhyang Cheonan Hospital, Cheonan, South Korea
(Kwak) Severance Biomedical Science Institute, Seoul, South Korea
Title
Effect of remote ischemic preconditioning on renal dysfunction after
complex valvular heart surgery: A randomized controlled trial.
Source
Journal of Thoracic and Cardiovascular Surgery. 142 (1) (pp 148-154),
2011. Date of Publication: July 2011.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Objective: Acute kidney injury after cardiac surgery with cardiopulmonary
bypass is closely related to systemic inflammatory reactions and oxidative
stresses. Remote ischemic preconditioning is a systemic protective
strategy whereby brief limb ischemia confers systemic protection against
prolonged ischemia and inflammatory reactions in distant organs. This
study investigated whether remote ischemic preconditioning provides
systemic protective effect on kidneys that are not directly exposed to
ischemia-reperfusion injury during complex valvular heart surgery.
Methods: Seventy-six adult patients undergoing complex valvular heart
surgery were randomly assigned to either remote ischemic preconditioning
group (n = 38) or control group (n = 38). Remote ischemic preconditioning
consisted of 3 10-minute cycles of lower limb ischemia and reperfusion
with an automated cuff inflator. Primary end points were comparisons of
biomarkers of renal injury including serum creatinine, cystatin C and
neutrophil gelatinase-associated lipocalin, and incidence of acute kidney
injury. Secondary end points were comparisons of myocardial enzyme release
and pulmonary parameters. Results: There were no significant differences
in serum levels of biomarkers of renal injury between groups throughout
the study period. The incidence of acute kidney injury did not differ
between groups. Creatine kinase isoenzyme MB at 24 hours after surgery was
lower, and intensive care unit stay was shorter in the remote ischemic
preconditioning group than in the control group. Conclusions: In patients
undergoing complex valvular heart surgery, remote ischemic preconditioning
did not reduce degree of renal injury or incidence of acute kidney injury
whereas it did reduce myocardial injury and intensive care unit stay.
Copyright 2011 by The American Association for Thoracic Surgery.

<11>
Accession Number
2011337512
Authors
Speziale G. Nasso G. Esposito G. Conte M. Greco E. Fattouch K. Fiore F.
Del Giglio M. Coppola R. Tavazzi L.
Institution
(Speziale, Nasso, Fiore, Coppola) Division of Cardiac Surgery, Anthea
Hospital, GVM Hospitals of Care and Research, Bari, Italy
(Esposito, Conte) Division of Cardiac Surgery, Citt di Lecce Hospital, GVM
Hospitals of Care and Research, Lecce, Italy
(Greco) Division of Cardiac Surgery, Villa Maria Pia Hospital, GVM
Hospitals of Care and Research, Torino, Italy
(Fattouch) Division of Cardiac Surgery, University of Palermo, Palermo,
Italy
(Del Giglio, Tavazzi) Division of Cardiac Surgery, Villa Maria Cecilia
Hospital, GVM Hospitals of Care and Research, Cotignola, Italy
(Nasso) Department of Cardiac Surgery, Anthea Hospital-GVM Care and
Research, Via Camillo Rosalba 35-37, 70124 Bari, Italy
Title
Results of mitral valve repair for Barlow disease (bileaflet prolapse) via
right minithoracotomy versus conventional median sternotomy: A randomized
trial.
Source
Journal of Thoracic and Cardiovascular Surgery. 142 (1) (pp 77-83), 2011.
Date of Publication: July 2011.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Objective: The results of mitral repair for complex Barlow valves are
adequate and support earlier intervention. It is unknown whether these
results are reproducible in the context of minimally invasive surgery via
right minithoracotomy. Methods: We randomized patients with Barlow mitral
disease (bileaflet prolapse) to have conventional open repair via median
sternotomy (MS group) or minimally invasive (MI group) repair. Repair was
done using polytetrafluoroethylene chordal reimplantation for both
leaflets. In the MI group, we adopted right minithoracotomy, peripheral
cannulation, external aortic clamping, and surgery under direct vision.
Results: Both groups comprised 70 patients. The operative and the
cardiopulmonary bypass times were significantly longer in the MI group (P
= .003 and P = .012). Mitral repair was successful in 98.5% MI patients
and 100% MS patients. Operative mortality was comparable. The mean
mechanical ventilation time, intensive care unit stay, and hospital stay
were lower in the MI group (P = .014, P =.02, and P = .03,). Mean pain
score was lower in the MI group at postoperative days 2 and 4. At
follow-up, the freedom from moderate (2+) or severe (3+ or 4+) mitral
regurgitation was 98% versus 97% (P = .9). Two patients underwent
reoperation (1 in each group) for late failure of repair. The Kaplan-Meier
analysis confirmed these results. Conclusions: Our data indicate that the
optimal standard-of-care results of mitral repair for complex disease
(Barlow) are reproducible in the minimally invasive settings through right
minithoracotomy and direct vision. The minimally invasive technique can be
proposed for complex mitral disease and early referral of these patients
can be encouraged. Copyright 2011 by The American Association for
Thoracic Surgery.

<12>
Accession Number
2011337514
Authors
Smith P.K. Shernan S.K. Chen J.C. Carrier M. Verrier E.D. Adams P.X.
Todaro T.G. Muhlbaier L.H. Levy J.H.
Institution
(Smith, Muhlbaier) Division of Cardiovascular and Thoracic Surgery, Duke
University Medical Center, Box 3442, Durham, NC 27710, United States
(Shernan) Brigham and Women's Hospital, Harvard Medical School, Boston,
MA, United States
(Chen) Kaiser Permanente Medical Center, University of Hawaii, Honolulu,
HI, United States
(Carrier) Montreal Heart Institute, Montreal, ON, Canada
(Verrier) University of Washington, School of Medicine, Seattle, WA,
United States
(Adams) Alexion Pharmaceuticals, Cheshire, CT, United States
(Todaro) Procter and Gamble Pharmaceuticals, Cincinnati, OH, United States
(Levy) Emory University Hospital, Emory University, Atlanta, GA, United
States
Title
Effects of C5 complement inhibitor pexelizumab on outcome in high-risk
coronary artery bypass grafting: Combined results from the PRIMO-CABG i
and II trials.
Source
Journal of Thoracic and Cardiovascular Surgery. 142 (1) (pp 89-98), 2011.
Date of Publication: July 2011.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Objective: The previous Pexelizumab for Reduction of Infarction and
Mortality in Coronary Artery Bypass Graft Surgery I (PRIMO-CABG I) trial
(n = 3099) indicated that C5 complement inhibition with pexelizumab might
reduce myocardial infarction (MI) and postoperative mortality. PRIMO-CABG
II was designed to investigate the safety and efficacy of terminal
complement inhibition in reducing perioperative MI and mortality in
patients undergoing CABG surgery who have 2 or more predefined
preoperative risk factors. Methods: PRIMO-CABG II, a randomized,
double-blind, placebo-controlled trial, enrolled 4254 patients undergoing
CABG with or without valve surgery at 249 hospitals in North America and
Western Europe from June 2004 to July 2005. The patients were randomly
assigned to receive intravenous pexelizumab or placebo. The primary
composite endpoint was the incidence of death or MI within 30 days of
randomization. Results: The PRIMO-CABG II trial did not meet its
prespecified primary endpoint of death or MI at 30 days, the secondary
endpoints of death at 30 days, or the development of new or worsening
congestive heart failure (relative risk 0.91, 0.82, and 1.01,
respectively; P > .05). However, in a combined analysis of both pivotal
trials, PRIMO-CABG I and II (n = 7353), death at 30 days was significantly
reduced for the greatest risk subset (n = 2156, pexelizumab 5.7% vs
placebo 8.1%, P = .024). Furthermore, this mortality reduction persisted
throughout the 180-day follow-up period (pexelizumab 11.1% vs placebo
14.4%, P = .036). Conclusions: Pexelizumab was associated with a
nonsignificant 6.7% reduction in the primary composite endpoint of death
or MI at postoperative day 30 in CABG patients enrolled in the PRIMO-CABG
II trial, despite the suggestion of a more favorable treatment effect in
the previous PRIMO-CABG I trial. However, an exploratory analysis of the
combined PRIMO I and II data set using an established predictive risk
model showed a mortality benefit for high-risk surgical patients.
Copyright 2011 by The American Association for Thoracic Surgery.

<13>
Accession Number
2011331089
Authors
Laoutaris I.D. Dritsas A. Adamopoulos S. Manginas A. Gouziouta A.
Kallistratos M.S. Koulopoulou M. Voudris V. Cokkinos D.V. Sfirakis P.
Institution
(Laoutaris, Dritsas, Adamopoulos, Manginas, Gouziouta, Kallistratos,
Koulopoulou, Voudris, Cokkinos, Sfirakis) Stress Testing and Cardiac
Rehabilitation Laboratory, Onassis Cardiac Surgery Center, 356 Sygrou
Blv., 176 74, Athens, Greece
Title
Benefits of physical training on exercise capacity, inspiratory muscle
function, and quality of life in patients with ventricular assist devices
long-term postimplantation.
Source
European Journal of Cardiovascular Prevention and Rehabilitation. 18 (1)
(pp 33-40), 2011. Date of Publication: February 2011.
Publisher
SAGE Publications Inc. (2455 Teller Road, Thousand Oaks CA 91320, United
States)
Abstract
Background: Capacity to exercise may not be fully restored in patients
with heart failure even in the long term after ventricular assist device
(VAD) implantation. The benefits of exercise training in patients with VAD
are unknown. Design and methods: Fifteen patients, aged 38.3 +/- 15.9
years, bridged to heart transplantation with left ventricular assist
device or biventricular assist device were randomized at a ratio of 2:1 to
a training group (TG, n = 10) or a control group (n = 5), 6.3 +/- 4 months
after implantation. Both the groups were advised to walk 30-45 min/day. TG
also underwent moderate-intensity aerobic exercise using a bike or
treadmill for 45 min, three to five times a week, combined with
high-intensity inspiratory muscle training using a computer-designed
software to respiratory exhaustion, two to three times a week for 10
weeks. The patients were tested using cardiopulmonary exercise testing,
6-min walk test, spirometry and electronic pressure manometer for
inspiratory muscle strength (Pimax) and endurance (sustained Pimax)
measurement. Quality of life was assessed with the Minnesota Living with
Heart Failure questionnaire. Results: TG improved peak oxygen consumption
(19.3 +/- 4.5 vs. 16.8 +/- 3.7 ml/kg per min, P = 0.008) and
VO₂ at ventilatory threshold (15.1 +/- 4.2 vs. 12 +/- 5.6 ml/kg
per min, P = 0.01), whereas the ventilation/carbon dioxide slope decreased
(35.9 +/- 5.6 vs. 40 +/- 6.5, P = 0.009). The 6-min walk test distance
increased (527 +/- 76 vs. 462 +/- 88 m, P = 0.005) and quality of life was
improved (38.2 +/- 11.6 vs. 48.9 +/- 12.8, P = 0.005), as well as Pimax
(131.8 +/- 33 vs. 95.5 +/- 28cmH₂O, P = 0.005), sustained Pimax
(484 +/- 195 vs. 340 +/- 193cmH₂O/s/10³, P = 0.005),
and inspiratoty lung capacity (2.4 +/- 0.9 vs. 1.7 +/- 0.7 L, P = 0.008)
were improved. No significant changes were noted in the control group.
Conclusion: Our findings indicate that exercise training may improve the
functional status of VAD recipients even at a later period after
implantation and thus, may have additional importance in cases of
destination therapy. The European Society of Cardiology 2011.

<14>
Accession Number
70441495
Authors
Boergermann J. Gummert J. Legler T. Kuss O.
Institution
(Boergermann, Gummert) Heart Center NRW, Universtiy Clinic Ofthe Ruhr,
University Bochum, Bad Oeynhausen, Germany
(Legler, Kuss) Marthin-Luther-University of Halle-Wittenberg, Halle,
Germany
Title
Do treatment effects differ between randomized trials/propensity score
analyses? Evidence from meta-propensity score analysis: Off-pump versus
on-pump coronary artery bypass surgery.
Source
Innovations: Technology and Techniques in Cardiothoracic and Vascular
Surgery. Conference: 2011 International Society for Minimally Invasive
Cardiothoracic Surgery, ISMICS Annual Scientific Meeting Washington, DC
United States. Conference Start: 20110608 Conference End: 20110611.
Conference Publication: (var.pagings). 6 (3) (pp 190), 2011. Date of
Publication: May-June 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Objective: Analyses comparing randomized to non-randomized clinical trials
suffer from the fact that the study populations are usually different.
Therefore, differences in treatment effects are not necessarily due to the
different treatment modes but may result from differences between
populations. Methods: In a systematic review, we meta-matched randomized
clinical trials (RCT) and propensity score analyses (PS) that compared the
off- and the on-pump technique in coronary artery bypass grafting.
Meta-confound- ers were used for meta-matching and were summarized in a
meta- propensity score. We compared treatment effects between RCTs and PS
analyses for ten previously defined binary clinical outcomes in this meta-
matched population as differences in meta-odds ratios. Results: For all
clinical outcomes, the estimated differences in meta-odds ratios were
below an absolute value of 0.15, all confidence intervals included the
null. The overall difference was -0.03 [95% confidence interval: -0.12,
0.07], indicating a small, but precisely estimated difference between RCTs
and PS analyses in the meta-matched sample. Conclusions: In our example,
treatment effects of off-pump versus on-pump surgery from RCTs and PS
analyses were very similar in a meta-matched population of studies,
indicating a small effect of randomization itself.

<15>
Accession Number
70441488
Authors
Groh M. Groh B. Binns O. Burton H. Ely S. Johnson A. Champsaur G.
Institution
(Groh, Groh, Binns, Burton, Ely, Johnson) Asheville Heart, Asheville, NC,
United States
(Champsaur) Mission Hospital, Asheville, NC, United States
Title
Similar outcomes in patients with diastolic or systolic heart failure
treated for atrial fibrillation and structural heart disease.
Source
Innovations: Technology and Techniques in Cardiothoracic and Vascular
Surgery. Conference: 2011 International Society for Minimally Invasive
Cardiothoracic Surgery, ISMICS Annual Scientific Meeting Washington, DC
United States. Conference Start: 20110608 Conference End: 20110611.
Conference Publication: (var.pagings). 6 (3) (pp 188), 2011. Date of
Publication: May-June 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Objective: Recent meta-analysis suggests that the presence of AF is
associated with an adverse prognosis in HF patients. Our hypothesis was
that surgical ablation concomitant to structural heart repair would
improve long-term outcomes in patients with AF associated to either
systolic (SHF) or diastolic (DHF) HF. Methods: We reviewed a cohort of 273
consecutive patients (64% male, mean age 71.5 +/- 8.9 years) in HF
characterized by a NYHA Class >II (73% were in Class III or IV). Mean EF
was preserved (53.8%) in 148 patients with DHF and impaired (35%, p <
0.01) in 125 patients with SHF. All underwent corrective cardiac surgery
and combined ablation of the left atrium (LA). Ages of patients, duration
and distribution of types of AF, as well as proportions of concomitant
procedures (CABG only, valve only and combined valve and CABG) were
similar in both groups. Epicardial cardiac ablation was performed on the
beating heart to create a posterior box lesion and mitral line. Long-term
rhythm monitoring was based on 24-hour Holter, 7-day Holter or pacemaker
interrogation at 6 months and yearly thereafter. Results: Peri-operative
adverse events were balanced: mortality 1% in each group, pacemaker
implantation, 9% in DHF and 6% in SHF, re-exploration for bleeding, 2% in
each group, and permanent stroke, 1.4% in DHF and 0.8% in SHF, p = 0.81.
Over a mean follow-up of 33 months, there were 17 late deaths in the DHF
group and 19 in the SHF group. Actuarial survival for the whole group was
95.2% at 6-months, 93.3% at one year, 89% at 24-months and 87.9% at
36-months with no difference between SHF and DHF subgroups (Log-Rank test,
p = 0.23). Freedom from AF or atrial flutter was 78% and 80% at 6 months,
77% and 81% at one year, 68% and 77% at 2 years, and 66% and 75% at 36
months in DHF and SHF, respectively. Conclusions: Restoration of sinus
rhythm is achieved in over 70% of patients with HF undergoing structural
repair and concomitant AF ablation. The successful elimination of AF in HF
patients does not appear to be influenced by the type of HF, systolic or
diastolic.

<16>
Accession Number
70441404
Authors
Karmy-Jones R. Ferrigno L. Teso D. Shackford S.R.
Institution
(Karmy-Jones, Ferrigno, Teso, Shackford) Southwest Washington Medical
Center, Vancouver, WA, United States
Title
Traumatic aortic rupture: A non-systematic review of the literature and
plea for reporting standards.
Source
Innovations: Technology and Techniques in Cardiothoracic and Vascular
Surgery. Conference: 2011 International Society for Minimally Invasive
Cardiothoracic Surgery, ISMICS Annual Scientific Meeting Washington, DC
United States. Conference Start: 20110608 Conference End: 20110611.
Conference Publication: (var.pagings). 6 (3) (pp 148), 2011. Date of
Publication: May-June 2011.
Publisher
Lippincott Williams and Wilkins
Abstract
Objective: The enthusiasm for endovascular (TEVAR) as opposed to operative
(OR) repair of traumatic aortic injuries continues to increase based on
data that suggests that TEVAR is associated with lower mortality and
paraplegia risk. However, there remains concern regarding TEVAR specific
complications and follow-up data. A significant contributing factor may be
a lack of uniform reporting standards. Methods: A literature search of
papers published 2006 through 2010 which described management of traumatic
aortic rupture. Papers were categorized as concentrating on trauma (sole
trauma) or not (non-sole trauma). Papers were then further subcategorized
as TEVAR alone, TEVAR vs. OR, and OR alone. Papers were assessed for
whether or not they reported or defined stability, emergency procedures,
injury severity, Ishimaru classification, grade of injury, cross-clamp
time, bypass strategy and number of cases performed within 24 hours of
injury. Results: 7 meta-analyses and 88 review papers were identified, 58
sole trauma and 30 non-sole trauma. Both broad categories were deficient
in the trauma specific descriptions (% of papers reporting): Cross-clamp
time Bypass strategy Emergent defined Stability defined Ishimaru
classification Injury grade Number within 24 hours Non sole trauma 0 0 20%
7% 37% 10% 23% Sole trauma 36% 39% 19% 16% 7% 28% 60% A subset analysis of
sole trauma comparing TEVAR vs. OR in which injury severity and stability
were defined found 7 reports (813 OR, 177 TEVAR). No differences in injury
severity nor age were noted, although OR tended to be performed more
acutely (<24 hrs OR 46.8 + 18.5% vs. TEVAR 29.8 + 21.1%, p = 0.06).Average
reported mortality (OR 26 + 11% vs TEVAR 11.7 + 8.4%, p= 0.02) and
paraplegia (OR 3 + 2.5% vs TEVAR 0.2 + 0.6%, p= 0.03) while stroke was
greater but not significantly so in TEVAR (OR 0.37 +0.75% vs TEVAR 2 +
3.4%). Conclusions: Reporting standards are lacking in describing results
from series of traumatic rupture. Standards should include the following:
set definitions of stability, anatomic classifications, injury severity,
and timing of treatment. Subset analysis of cases in which the left
subclavian origin is crossed should be performed, and clinical outcomes
presented in terms of survivors who can be evaluated.

<17>
Accession Number
70444498
Authors
Bojan M. Gioanni S. Pouard P.
Institution
(Bojan, Gioanni, Pouard) France
Title
Renal failure after neonatal heart surgery, prevention and management.
Source
Applied Cardiopulmonary Pathophysiology. Conference: European Association
of Cardiothoracic Anaesthesiologists, EACTA 2010 Edinburgh United Kingdom.
Conference Start: 20100609 Conference End: 20100611. Conference
Publication: (var.pagings). 14 (1) (pp 98-100), 2010. Date of
Publication: 2010.
Publisher
Pabst Science Publishers
Abstract
As a result of advancement in surgical treatment, congenital heart disease
(CHD) became one of the leading causes of acute kidney injury (AKI) in
children in developed countries [1]. The incidence of AKI after CHD repair
was assessed to range between 2.7 and 9%, and survival rates between 21%
and 80% [2]. Previous research has focused mostly on the incidence and
risk factors of severe AKI requiring renal replacement therapy (RRT). But
recent studies in adult cardiac surgery showed the role of an even mild
post-operative serum creatinine (SCr) rise (0.3-0.5 mg/dl (26.5-44 ?mol/L)
within 48 h) as an independent predictor of 30-day mortality [3,4]. An
independent association was found between a small rise in SCr of 25% above
baseline and length of intensive care stay and mechanical ventilation in
children [5]. Neonates are at particularly high risk and young age is an
independent predictor for AKI after CHD repair [2,5]. When referring to a
Danish population, Pedersen et al found an adjusted OR of 4.34 for
neonates requiring RRT when compared to children [2]. However, the
incidence of neonatal AKI is likely to be higher than that reported, as
neonates commonly have non-oliguric renal failure. Preventive
interventions in AKI have been largely disappointing. One cannot
counteract all risk factors specific to CHD such as surgical complexity
and consequently long CPB and cross-clamp durations, the need for
hypothermic circulatory arrest (HCA), nor early age repair and
perioperative multi-organ failure due to haemodynamic deterioration.
Whatever has been tried, CPB flow remains non-pulsatile. Interventions
such as 'renaldose dopamine' and diuretic therapy have been shown not to
alter the course of AKI. NIRS monitoring of renal perfusion seems
promising but has not yet been shown to improve outcome. Early treatment
of the postoperative low cardiac output is nowadays probably the best
preventive intervention. The use of large-dose aprotinin during CPB has
been linked to postoperative AKI in adults. A very properly designed
retrospective analysis using a propensity score was conducted at the
Children's Hospital of Pittsburg and showed no association between the use
of aprotinin and AKI [6]. Similarly we found no association between the
need for RRT after CPB and the use of aprotinin in 116 neonates whether in
a univariate analysis (up to 13% with aprotinin vs. 9% without) or when
adjusting on weight, Aristotle score, length of CPB and the need for HCA.
The prognosis of severe AKI is highly dependent on the early start of RRT
in adults. There is no paediatric study comparing early and late use of
RRT but several publications pointed out the degree of fluid overload as a
determinant of outcome [7,8], suggesting necessarily early intervention.
When analysing 95 neonatal cases requiring RRT in our unit during the last
decade, we noted that mortality related neither to postoperative SCr rise
nor to postnatal age at operation, but to late onset of RRT, with a more
than 2-fold rise in the risk of death when RRT was started after the 48th
postoperative hour. Hence, our practice changed and nowadays we start RRT
if urine output remains below 2 ml kg^-1 h^-1 during
more than 4 h, when there is clinical evidence of fluid overload, when low
cardiac output or metabolic complications occur despite an optimal
preload, inotropic support and diuretics. Early management requires early
diagnosis. SCr is an unreliable marker for AKI and changes in SCr occur
late after the onset of AKI. When analysing the postoperative SCr of all
neonates we operated during two years and when considering the 28 patients
requiring RRT, less than one half of them fell into RIFLE F or into pRIFLE
F. Besides, in more than one half of them SCr rose after the 48th
postoperative hour. New markers of AKI are needed. More than 50 articles
on over 20 biomarkers of AKI were published in the last 7 years. The most
promising early non-invasive biomarkers are serum and urinary neutrophil
gelatinase-associate lipocalin (NGAL), urinary interleukin-18, kidney
injury molecule- 1 (KIM-1) and serum cystatin C. The most popular to date
is NGAL; current research on NGAL emerged from CHD repair populations [9].
The systematic review by Haase et al [10] concluded that urine and serum
NGAL are useful as early markers of AKI (2 h off-pump). However, the
reference standard used to define AKI was a 50% increase in SCr, the
number of patients was small, the measurement of NGAL was not standardized
and no specific analysis was conducted in neonates. We still need larger
studies based on harder outcomes, such as RRT requirement, cardiovascular
events and death, before providing NGAL for intervention. Data for RRT
modality choice in the treatment of paediatric AKI are limited. Walters et
al [11] recently overviewed the main modalities of RRT in paediatric
patients: peritoneal dialysis (PD), continuous RRT (CRRT) and intermittent
haemodialysis (IHD). The choice depends on the major goal of dialysis
therapy, the solute clearance or primarily haemofiltration, haemodynamic
stability, available resources and patient limiting factors. The only
study that compared PD to CRRT after CHD repair by Fleming et al [12] gave
advantage to CRRT over PD in terms of overall net urea or creatinine
removal, management of fluid overload and caloric intake. The recent
improvements in vascular access and control of the ultrafiltrate volume
allows CRRT to be performed in haemodynamically instable patients. Surveys
among US paediatric nephrologists demonstrate increased CRRT use over PD
in paediatric AKI [13]. Experience is still highly limited after cardiac
surgery in paediatrics. No ultrafiltration dose study has been performed
in paediatric AKI., and a rate of 2000 ml min-1 73m2-1 h-1, an
extrapolation based on IHD, was used for CRRT by many centres. Besides, a
recent Polish publication found a 76% mortality rate and a 68% rate of
complications in 25 patients aged 7 days to 11 yr managed with CRRT after
CHD repair [14]. In the smallest neonates vascular access may not be
achievable with double lumen catheters in the neck or groin and PD remains
the traditionally recommended RRT after CHD repair. It allows a fluid
depletion of 4ml kg-1 h-1 and a SCr clearance of 2 to 10ml min-1 1.73m2-1
in the neonate [15]. Pedersen et al [16] found it feasible and safe after
cardiac surgery in children, with a mortality rate of 20% and a
complication rate of 1 per 12 days of PD. Our experience in neonates was
similar during the last decade, with a 30-days mortality rate of about
30%. One complication occurred in every 12.8 days of PD, but when
considering peritonitis, haemoperitoneum or bowel perforation they only
occurred in every 45 days of PD. However, PD may be impossible in neonates
with automated machinery due to tubing dead space. Contraindications to PD
include diaphragmatic hernia and recent intra-abdominal surgery, sepsis or
malignancy. Conclusion There is clear association of early mortality and
morbidity following cardiac surgery with minimal changes of plasma
creatinine concentrations within 48 h and the clinician must avoid any
precipitating factors for further renal impairment. When AKI occurs, the
early onset of RRT is the only intervention that has been shown to improve
outcome. Therefore we need to develop new AKI definitions using early
biomarkers of renal injury in addition to functional markers which could
ultimately predict morbidity and mortality, and early intervention. The
choice between RRT methods is multifactorial, but experience with the
oldest one, PD, proves safety and effectiveness in the neonate after CHD
repair.

<18>
Accession Number
70444495
Authors
Filipovic M.
Institution
(Filipovic) Institute of Anaesthesiology, Kantonsspital, St. Gallen,
Switzerland
(Filipovic) Medical Faculty, University of Basel, Switzerland
Title
Preoperative risk assessment: Biomarkers versus exercise testing.
Source
Applied Cardiopulmonary Pathophysiology. Conference: European Association
of Cardiothoracic Anaesthesiologists, EACTA 2010 Edinburgh United Kingdom.
Conference Start: 20100609 Conference End: 20100611. Conference
Publication: (var.pagings). 14 (1) (pp 93-95), 2010. Date of
Publication: 2010.
Publisher
Pabst Science Publishers
Abstract
Preoperative cardiac risk assessment is traditionally based on three key
elements, the patient history, their functional capacity and the risk of
the surgical procedure. In case of poor functional capacity, the presence
of several clinical risk factors and high risk surgery, noninvasive
testing has to be considered [1]. Non-invasive testing for coronary artery
disease consists of physical exercise tests (treadmill or bicycle
ergometer) or pharmacological stress tests (nuclear perfusion imaging,
dobutamine or dipyridamol stress echocardiography). Non-invasive testing
for valvular heart disease consists of echocardiography as a first step.
All these examinations are expensive and time consuming and, if not
performed well in advance, call for postponing surgery. Recent data
suggest that biomarkers can play a substantial role in perioperative risk
evaluation. So far, the interest has focused on natriuretic peptides (NP)
and cardiac troponins (cTn). NP, primarily brain natriuretic peptide (BNP)
and the N-terminal fragments of its pro-hormone (NT-proBNP) are
neurohormones. They are released from the myocardium in response to
cardiac volume and pressure load [3]. Both are of high diagnostic value in
patients with congestive heart failure [4-6] or acute coronary syndromes
(ACS) [7,8]. The information derived from BNP or NT-proBNP measurements
seems to be similar. In surgical patients, available data consistently
show an association between elevated NP levels and adverse outcome after
non-cardiac [9-13] and cardiac surgery [14]. A recent meta-analysis on
30-day outcome reported on an odds ratio (OR) of 19.3 (95% CI: 8.5 to
43.7) for the association between an elevated pre-operative BNP level and
various cardiovascular outcomes (e.g. a composite of cardiac death and
nonfatal myocardial infarction and atrial fibrillation) [15]. We performed
a meta-analysis on the association between elevated NP levels and mid-term
outcome (6 months): the pooled OR for all-cause mortality was 4.97 (95%
CI: 3.06-8.07) [16]. Of even greater importance is the very high negative
predictive value (0.94. 95% CI: 0.88- 0.97) of a low NP level before
non-cardiac surgery [16]. This finding confirms the result of a smaller
study in vascular surgical patients that reported on a negative predictive
value for subsequent adverse cardiac events of 0.965 (95% CI: 0.879-0.996)
in case of a preoperative BNP value below 50 pg/L [17] and of two other
studies in patients undergoing non-vascular surgery [10] and vascular
surgery [18]. In the light of the recent data, NP analysis should be
considered in patients in whom the classic triad of risk assessment
(history, physical capacity and type of surgery) does not unambiguously
resolve the question of the necessity of further time consuming and
expensive testing. If NP levels are below a discrimination threshold and
the patient is clinically stable, the patient can proceed to surgery
without the need for further testing. If NP levels are above the
threshold, further testing, optimization of medical therapy and, rarely,
invasive therapy should be performed [19]. In the recently published
guidelines for the evaluation of patients at cardiac risk undergoing
non-cardiac surgery, NT-proBNP and BNP measurements should be considered
for obtaining independent prognostic information for perioperative and
late cardiac events in high-risk patients (Class IIa. level of evidence B)
[2]. The fact that NP are not mentioned in the AHA/ACC guidelines
published in 2007 [1] demonstrates the rapidly growing evidence in this
field of perioperative medicine. It has to be pointed out that, so far,
the optimal cut-off value of BNP or NT-proBNP has yet to be determined and
that the proposed approach is speculative and needs formal testing. cTn
are structural proteins of the contractile apparatus of skeletal and
myocardial myocytes. cTn are released into circulation only upon the
occurrence of cardiac cell death. This is typically the case in ACS
[20,21] but can also take place in other acute conditions [22] e.g. in
acute congestive heart failure [23] or in pulmonary embolism [24]. There
is growing evidence demonstrating the association between elevated
postoperative cTn levels and adverse short- and midterm outcomes after
major non-cardiac [25-30] and cardiac surgery [31,32]. Accordingly, cTn
analysis could be used for identification of patients whose risk was
preoperatively considered to be intermediate but whose postoperatively
elevated cTn levels, nevertheless, indicate a substantial risk for adverse
short- and long-term outcome. Such identification will be the basis for
future strategies of intensified observation and treatment. The
development and validation of those strategies needs further research.
Currently, a large number of studies have been published describing the
value of new biomarkers for risk assessment. In patients at high risk for
coronary events, for example, measurement of markers of plaque instability
(e.g. the pregnancy-associated plasma protein- A (PAPP-A) [33-35] or
measurement of markers of platelets reactivity (e.g.. the platelet
collagen receptor glycoprotein V1 [36- 37] could potentially prove to be
useful. However, even more important than studies of new biomarkers are
studies investigating how biomarker-guided management might enhance care
and outcome of this group of patients [38].

<19>
Accession Number
70440099
Authors
Abrishami A.
Institution
(Abrishami) Toronto Western Hospital, University Health Network,
University of Toronto, Canada
Title
Preoperative assessment of pain sensitivity and its correlation with
postoperative pain - A systematic review.
Source
Canadian Journal of Anesthesia. Conference: 2010 Annual Meeting of the
Canadian Anesthesiologists' Society, CAS Montreal, QC Canada. Conference
Start: 20100625 Conference End: 20100629. Conference Publication:
(var.pagings). 57 (pp S185), 2010. Date of Publication: June 2010.
Publisher
Springer New York
Abstract
Introduction: Identification of patients at risk of severe postoperative
pain will allow more effective pain management. Pain perception to minor
physical stimuli has been hypothesized to be related to the subsequent
pain ratings after surgery1. The objective of this systematic review is to
evaluate the correlation between preop pain sensitivity and postop pain
intensity. Methods: We searched MEDLINE, EMBASE, and the online format of
the international meeting abstracts to identify all correlational studies
on the topic. Studies with uni- and/or multivariate analysis were
included. All the included studies were independently reviewed, critically
appraised and data extracted by the authors. A p value <0.05 was
considered significant correlation. Results: Thirteen papers (n=817
patients) met the eligibility criteria. The median sample size was 54
patients (range: 20-165). The mean age of the patients ranged from 18 to
69 years. Each study was on one type of surgery; orthopedics, thoracic,
gynecologic, or lower abdominal surgery. Three types of pain stimuli were
applied; thermal, pressure, and electrical pain and four types of pain
measures were studied as follows: Pain threshold (detection of pain), Pain
tolerance (detection of intolerable pain), Supra-threshold pain intensity
(pain beyond patient threshold) and Temporal summation of pain
(sensitization caused by repetitive stimuli). Pain threshold and
supra-threshold pain were the most commonly studied variables. The pain
thresholds following heat, pressure or electrical stimuli were reported to
have reverse correlation with postop pain. The intensity of supra-
threshold heat pain was consistently shown to have direct correlation with
postop pain and only 13% of studies had no-correlation results (Figure 1).
In terms of methodological quality, the most common limitation of the
included studies was the method of statistical analysis and lack of
multivariate analysis. Discussion: The results of this systematic review
suggest that lower preop pain thresholds are associated with higher
postoperative pain intensity. Also, high levels of pain intensity evoked
by a supra-threshold heat stimulus were consistently associated with more
postoperative pain. More research is required to establish the correlation
of other pain sensitivity variables with postop pain outcomes.

<20>
Accession Number
70440026
Authors
Talab H.
Institution
(Talab) Ottawa Civc Hospital, Canada
Title
Association of postoperative myocardial ischemia identified by continuous
ECG monitoring with ischemic events.
Source
Canadian Journal of Anesthesia. Conference: 2010 Annual Meeting of the
Canadian Anesthesiologists' Society, CAS Montreal, QC Canada. Conference
Start: 20100625 Conference End: 20100629. Conference Publication:
(var.pagings). 57 (pp S82), 2010. Date of Publication: June 2010.
Publisher
Springer New York
Abstract
Introduction: Myocardial ischemia in the global perioperative period has
been studied (1,2). The relationship between postoperative myocardial
ischemia (POMI) and postoperative myocardial ischemic outcomes, however,
remains controversial. We present the results of a meta-analysis to
determine the relationship between the postoperative ST segment changes as
detected by continuous ECG monitoring, and clinically apparent cardiac
morbidity in patients undergoing non-cardiac surgery. Methods: Medline
database between 1950 and 2008 was searched, using the terms Anesthesia;
Anesthesia, general; Anesthesia, spinal; Anesthesiology, complications;
intraoperative complications; postoperative complications; postoperative
period; surgery; surgical; procedures; operative; electrocardiography;
electrocardiography; ambulatory; ischemia; myocardial ischemia; and
myocardial infarction. Studies with the following criteria were included:
cohort studies or RCTs; adult patients undergoing non-cardiac surgery;
ischemia monitoring by continuous electrocardiographic monitoring (minimum
2 lead) for at least 24 hours. Non-English publications were excluded.
Ischemic outcomes analysed included MI, unstable angina, ischemic
pulmonary edema, ischemic ventricular tachyarrhythmia and cardiac death.
Studies were evaluated independently by two researchers. Mantel-Haenszel
odds ratio and confidence interval were calculated using a random effects
model using Review Manager (version 5). Results: Twenty-six studies were
included, with a total of 3143 patients. Of these, 1113 patients
demonstrated postoperative ST segment changes on continuous Holter, while
2030 patients did not. The odds of having an ischemic event in the
presence of post-operative ischemia was 10.26 with a 95% confidence
interval of 6.38 - 16.49. Discussion: Previous studies examined the
occurrence of myocardial ischemia at various time points during the
perioperative continuum. The present meta-analysis shows that in patients
undergoing non-cardiac surgery, early postoperative myocardial ischemia
(ST segment changes) by itself is an important correlate of adverse
cardiac outcomes.

<21>
Accession Number
70440017
Authors
Denault A.
Institution
(Denault) Montreal Heart Institute, Universite de Montreal, Canada
Title
IV amiodarone and bi-ventricular echocardiographic function.
Source
Canadian Journal of Anesthesia. Conference: 2010 Annual Meeting of the
Canadian Anesthesiologists' Society, CAS Montreal, QC Canada. Conference
Start: 20100625 Conference End: 20100629. Conference Publication:
(var.pagings). 57 (pp S71), 2010. Date of Publication: June 2010.
Publisher
Springer New York
Abstract
Introduction: Atrial fibrillation is a common complication after cardiac
surgery. Postoperative atrial fibrillation is associated with increased
risks of morbidity and mortality, and preventive strategies using
amiodarone are commonly used during cardiac surgery. However the effect of
intravenous amiodarone administered intraoperatively on hemodynamic and
biventricular echocardiographic parameters assessed by transesophageal
echocardiography (TEE) has not been described in patients undergoing
valvular or complex surgery. Methods: The protocol was reviewed and
approved by the Research and Ethic Committees of our institution. Written
informed consent was obtained from all patients. Single-center
double-blind, double-dummy, randomized controlled trial in patients
undergoing valvular surgery. Patients received an intravenous (IV) loading
dose of 300 mg of either amiodarone or placebo in the operating room,
followed by a perfusion of 15 mg/kg per 24 hours for 2 days. A hemodynamic
profile and bi-ventricular comprehensive TEE exam were performed and
described before, after bolus and after cardiopulmonary bypass (CPB).
Postoperative complications and mortality at 6 years were also documented.
Results: One hundred and twenty patients (mean age 65+/-11 years) were
randomized to receive either amiodarone or placebo. The placebo group
included more patients with diabetes (p=0.0244) and showed a longer
duration of CPB (p=0.0426), while the patients in the amiodarone group had
more frequent isolated valvular procedures (p=0.0497). There was no
difference in the use of inotropic agents after CPB between the two groups
but the amiodarone group required temporary pacing for bradyarrhythmia for
up to 24 hours (p=0.0075) more frequently. After the bolus, the amiodarone
group showed an increase mean pulmonary artery pressure (p =0.0450) with
an associated reduction in S/D ratio of the hepatic venous velocity
(p=0.0457). A lower heart rate (p<0.0001) and lower cardiac index (p =
0.0157) were observed after CPB in the amiodarone group with higher
diastolic pulmonary venous flow velocities (p=0.0052). There were no
differences between groups in postoperative complications and survival at
6 years. Discussion: In patients undergoing cardiac valvular surgery,
intravenous amiodarone is well tolerated hemodynamically and not
associated after CPB with significant changes in systolic and diastolic
function and does not increase inotropic requirement when compared to
placebo despite a reduction in heart rate, cardiac index and increased
pacemaker requirement for 24 hours.