Results Generated From:
Embase <1980 to 2013 Week 16>
Embase (updates since 2013-04-12)
Embase <1980 to 2013 Week 16>
Embase (updates since 2013-04-12)
Embase <1980 to 2013 Week 16>
Embase (updates since 2013-04-12)
<1>
Accession Number
2013208623
Authors
Fowler Jr. V.G. Allen K.B. Moreira Jr. E.D. Moustafa M. Isgro F. Boucher
H.W. Corey G.R. Carmeli Y. Betts R. Hartzel J.S. Chan I.S.F. McNeely T.B.
Kartsonis N.A. Guris D. Onorato M.T. Smugar S.S. DiNubile M.J. Meulen
A.S.-T.
Institution
(Fowler Jr., Corey) Duke University Medical Center, Duke Clinical Research
Institute, Durham, NC, United States
(Allen) St. Luke's Mid-America Heart and Vascular Institute, Kansas City,
MO, United States
(Moreira Jr.) Division of Cancer Epidemiology, McGill University,
Montreal, QC, Canada
(Moreira Jr.) Associacao Obras Sociais Irma Dulce- Oswaldo Cruz
Foundation, Brazilian Ministry of Health, Salvador, Bahia, Brazil
(Moustafa) South Carolina Nephrology and Hypertension Center, Orangeburg,
SC, United States
(Isgro) Academic City Hospital Ludwigshafen, Ludwigshafen, Germany
(Boucher) Tufts Medical Center, Boston, MA, United States
(Carmeli) Beth Israel Deaconess Medical Center, Boston, MA, United States
(Betts) University of Rochester, School of Medicine, Rochester, NY, United
States
(Hartzel, Chan, McNeely, Kartsonis, Guris, Onorato, Smugar, DiNubile,
Meulen) Merck Sharp and Dohme, Whitehouse Station, NJ, United States
Title
Effect of an investigational vaccine for preventing Staphylococcus aureus
infections after cardiothoracic surgery: A randomized trial.
Source
JAMA - Journal of the American Medical Association. 309 (13) (pp
1368-1378), 2013. Date of Publication: 03 Apr 2013.
Publisher
American Medical Association (515 North State Street, Chicago IL 60654,
United States)
Abstract
Importance: Infections due to Staphylococcus aureus are serious
complications of cardiothoracic surgery. A novel vaccine candidate (V710)
containing the highly conserved S aureus iron surface determinant B is
immunogenic and generally well tolerated in volunteers. Objective: To
evaluate the efficacy and safety of preoperative vaccination in preventing
serious postoperative S aureus infection in patients undergoing
cardiothoracic surgery. Design, Setting, and Participants: Double-blind,
randomized, event-driven trial conducted between December 2007 and August
2011 among 8031 patients aged 18 years or older who were scheduled for
full median sternotomy within 14 to 60 days of vaccination at 165 sites in
26 countries. Intervention: Participants were randomly assigned to receive
a single 0.5-mL intramuscular injection of either V710 vaccine, 60 mug
(n=4015), or placebo (n=4016). Main Outcome Measures: The primary efficacy
end point was prevention of S aureus bacteremia and/or deep sternal wound
infection (including mediastinitis) through postoperative day 90.
Secondary end points included all S aureus surgical site and invasive
infections through postoperative day 90. Three interim analyses with
futility assessments were planned. Results: The independent data
monitoring committee recommended termination of the study after the second
interim analysis because of safety concerns and low efficacy. At the end
of the study, the V710 vaccine was not significantly more efficacious than
placebo in preventing either the primary end points (22/3528 V710 vaccine
recipients [2.6 per 100 person-years] vs 27/3517 placebo recipients [3.2
per 100 person-years]; relative risk, 0.81; 95% CI, 0.44-1.48; P = .58) or
secondary end points despite eliciting robust antibody responses. Compared
with placebo, the V710 vaccine was associated with more adverse
experiences during the first 14 days after vaccination (1219/3958 vaccine
recipients [30.8%; 95% CI, 29.4%-32.3%] and 866/3967 placebo recipients
[21.8%; 95% CI, 20.6%-23.1%], including 797 [20.1%; 95% CI, 18.9%-21.4%]
and 378 [9.5%; 95% CI, 8.6%-10.5%] with injection site reactions and 66
[1.7%; 95% CI, 1.3%-2.1%] and 51 [1.3%; 95% CI, 1.0%-1.7%] with serious
adverse events, respectively) and a significantly higher rate of
multiorgan failure during the entire study (31 vs 17 events; 0.9 [95% CI,
0.6-1.2] vs 0.5 [95% CI, 0.3-0.8] events per 100 person-years; P = .04).
Although the overall incidence of vaccine-related serious adverse events
(1 in each group) and the all-cause mortality rate (201/3958 vs 177/3967;
5.7 [95% CI, 4.9-6.5] vs 5.0 [95% CI, 4.3-5.7] deaths per 100
person-years; P = .20) were not statistically different between groups,
the mortality rate in patients with staphylococcal infections was
significantly higher among V710 vaccine than placebo recipients (15/73 vs
4/96; 23.0 [95% CI, 12.9-37.9] vs 4.2 [95% CI, 1.2-10.8] per 100
person-years; difference, 18.8 [95% CI, 8.0-34.1] per 100 person-years).
Conclusions and Relevance: Among patients undergoing cardiothoracic
surgery with median sternotomy, the use of a vaccine against S aureus
compared with placebo did not reduce the rate of serious postoperative S
aureus infections and was associated with increased mortality among
patients who developed S aureus infections. These findings do not support
the use of the V710 vaccine for patients undergoing surgical
interventions. Trial Registration: clinicaltrials.gov Identifier:
NCT00518687. 2013 American Medical Association. All rights reserved.
<2>
Accession Number
2013201372
Authors
Diegeler A. Borgermann J. Kappert U. Breuer M. Boning A. Ursulescu A.
Rastan A. Holzhey D. Treede H. Riess F.-C. Veeckmann P. Asfoor A. Reents
W. Zacher M. Hilker M.
Institution
(Diegeler, Reents, Zacher) Herz- und Gefas-Klinik Bad Neustadt, Bad
Neustadt, Germany
(Borgermann) Herz- und Diabeteszentrum Bad Oeynhausen, Bad Oeynhausen,
Germany
(Kappert) Herzzentrum Dresden, Dresden, Germany
(Breuer) Universitatsklinik Jena, Jena, Germany
(Boning) Universitatsklinik Giessen, Giessen, Germany
(Ursulescu) Robert Bosch Krankenhaus Stuttgart, Stuttgart, Germany
(Rastan, Holzhey) Herzzentrum Universitat Leipzig, Leipzig, Germany
(Treede) Universitatsklinik Hamburg-Eppendorf, Hamburg, Germany
(Ries) Albertinen-Krankenhaus Hamburg, Hamburg, Germany
(Veeckmann) Klinikum fur Herzchirurgie Karlsruhe, Karlsruhe, Germany
(Asfoor) Universitat Bochum, Bochum, Germany
(Hilker) Universitatsklinik Regensburg, Regensburg, Germany
Title
Off-pump versus on-pump coronary-artery bypass grafting in elderly
patients.
Source
New England Journal of Medicine. 368 (13) (pp 1189-1198), 2013. Date of
Publication: 28 Mar 2013.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
BACKGROUND: The benefits of coronary-artery bypass grafting (CABG) without
cardiopulmonary bypass in the elderly are still undetermined. METHODS: We
randomly assigned patients 75 years of age or older who were scheduled for
elective first-time CABG to undergo the procedure either without
cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The
primary end point was a composite of death, stroke, myocardial infarction,
repeat revascularization, or new renal-replacement therapy at 30 days and
at 12 months after surgery. RESULTS: A total of 2539 patients underwent
randomization. At 30 days after surgery, there was no significant
difference between patients who underwent off-pump surgery and those who
underwent on-pump surgery in terms of the composite outcome (7.8% vs.
8.2%; odds ratio, 0.95; 95% confidence interval [CI], 0.71 to 1.28; P =
0.74) or four of the components (death, stroke, myocardial infarction, or
new renal-replacement therapy). Repeat revascularization occurred more
frequently after off-pump CABG than after on-pump CABG (1.3% vs. 0.4%;
odds ratio, 2.42; 95% CI, 1.03 to 5.72; P = 0.04). At 12 months, there was
no significant between-group difference in the composite end point (13.1%
vs. 14.0%; hazard ratio, 0.93; 95% CI, 0.76 to 1.16; P = 0.48) or in any
of the individual components. Similar results were obtained in a
per-protocol analysis that excluded the 177 patients who crossed over from
the assigned treatment to the other treatment. CONCLUSIONS: In patients 75
years of age or older, there was no significant difference between on-pump
and off-pump CABG with regard to the composite outcome of death, stroke,
myocardial infarction, repeat revascularization, or new renal-replacement
therapy within 30 days and within 12 months after surgery. (Funded by
Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667). Copyright 2013
Massachusetts Medical Society.
<3>
Accession Number
2013201371
Authors
Lamy A. Devereaux P.J. Prabhakaran D. Taggart D.P. Hu S. Paolasso E.
Straka Z. Piegas L.S. Akar A.R. Jain A.R. Noiseux N. Padmanabhan C.
Bahamondes J.-C. Novick R.J. Vaijyanath P. Reddy S.K. Tao L.
Olavegogeascoechea P.A. Airan B. Sulling T.-A. Whitlock R.P. Ou Y. Pogue
J. Chrolavicius S. Yusuf S.
Institution
(Lamy, Devereaux, Whitlock, Ou, Pogue, Chrolavicius, Yusuf) Population
Health Research Institute, Hamilton Health Sciences, McMaster University,
Hamilton, ON L8L 2X2, Canada
(Noiseux) Centre Hospitalier de l'Universite de Montreal, Montreal, QC,
Canada
(Novick) London Health Sciences Centre, London, ON, Canada
(Prabhakaran) Centre for Chronic Disease Control, New Delhi, India
(Jain) SAL Hospital and Medical Institute, Ahmedabad, India
(Padmanabhan) G. Kuppuswamy Naidu Memorial Hospital, Coimbatore, India
(Vaijyanath) Frontier Lifeline, Dr. K M Cherian Heart Foundation, Chennai,
India
(Reddy) Mediciti Hospitals, Hyderabad, India
(Airan) All India Institute of Medical Sciences, New Delhi, India
(Taggart) University of Oxford, Oxford, United Kingdom
(Hu) Fu Wai Cardiovascular Hospital, Xicheng District, Beijing, China
(Paolasso) Instituto de Investigaciones Clinicas de Rosario, Rosario,
Argentina
(Olavegogeascoechea) Fundacion Medica de Rio Negro Y Neuguen, Rio Negro,
Argentina
(Straka) Third Faculty of Medicine, Charles University, Prague, Czech
Republic
(Piegas) Instituto Dante Pazzanese de Cardiologia, Sao Paulo, France
(Akar) Ankara University School of Medicine, Ankara, Turkey
(Bahamondes) Hospital Regional Temuco, Temuco, Chile
(Tao) Wuhan Asia Heart Hospital, Wuhan, Hubei, China
(Sulling) North Estonia Medical Center, Tallinn, Estonia
Title
Effects of off-pump and on-pump coronary-artery bypass grafting at 1 year.
Source
New England Journal of Medicine. 368 (13) (pp 1179-1188), 2013. Date of
Publication: 28 Mar 2013.
Publisher
Massachussetts Medical Society (860 Winter Street, Waltham MA 02451-1413,
United States)
Abstract
BACKGROUND: Previously, we reported that there was no significant
difference at 30 days in the rate of a primary composite outcome of death,
myocardial infarction, stroke, or new renal failure requiring dialysis
between patients who underwent coronary-artery bypass grafting (CABG)
performed with a beating-heart technique (off-pump) and those who
underwent CABG performed with cardiopulmonary bypass (on-pump). We now
report results on quality of life and cognitive function and on clinical
outcomes at 1 year. METHODS: We enrolled 4752 patients with coronary
artery disease who were scheduled to undergo CABG and randomly assigned
them to undergo the procedure off-pump or on-pump. Patients were enrolled
at 79 centers in 19 countries. We assessed quality of life and cognitive
function at discharge, at 30 days, and at 1 year and clinical outcomes at
1 year. RESULTS: At 1 year, there was no significant difference in the
rate of the primary composite outcome between off-pump and on-pump CABG
(12.1% and 13.3%, respectively; hazard ratio with off-pump CABG, 0.91; 95%
confidence interval [CI], 0.77 to 1.07; P=0.24). The rate of the primary
outcome was also similar in the two groups in the period between 31 days
and 1 year (hazard ratio, 0.79; 95% CI, 0.55 to 1.13; P=0.19). The rate of
repeat coronary revascularization at 1 year was 1.4% in the off-pump group
and 0.8% in the on-pump group (hazard ratio, 1.66; 95% CI, 0.95 to 2.89;
P=0.07). There were no significant differences between the two groups at 1
year in measures of quality of life or neurocognitive function.
CONCLUSIONS: At 1 year after CABG, there was no significant difference
between off-pump and on-pump CABG with respect to the primary composite
outcome, the rate of repeat coronary revascularization, quality of life,
or neurocognitive function. (Funded by the Canadian Institutes of Health
Research; CORONARY ClinicalTrials.gov number, NCT00463294). Copyright
2013 Massachusetts Medical Society.
<4>
[Use Link to view the full text]
Accession Number
2013222255
Authors
Mooney J.F. Ranasinghe I. Chow C.K. Perkovic V. Barzi F. Zoungas S.
Holzmann M.J. Welten G.M. Biancari F. Wu V.-C. Tan T.C. Cass A. Hillis
G.S.
Institution
(Mooney, Hillis) George Institute for Global Health, King George v
Building, Royal Prince Alfred Hospital, Missenden Road, Camperdown, NSW
2050, Australia
(Ranasinghe) George Institute for Global Health, Department of Cardiology,
Concord Repatriation General Hospital, Sydney, Australia
(Chow) George Institute for Global Health, Department of Cardiology,
Westmead Hospital, Australia
(Perkovic, Barzi) George Institute for Global Health, School of Public
Health and Preventive Medicine, Monash University, Melbourne, Australia
(Zoungas) Department of Emergency Medicine, Karolinska University
Hospital, Department of Internal Medicine, Stockholm, Sweden
(Holzmann) Department of Vascular Surgery, Erasmus Medical Centre,
Rotterdam, Netherlands
(Welten) Division of Cardiothoracic and Vascular Surgery, Oulu University
Hospital, Oulu, Finland
(Biancari) Division of Nephrology, Department of Internal Medicine,
National Taiwan University Hospital, Taipei, Taiwan (Republic of China)
(Wu) Department of Cardiology, Westmead Hospital, Australia
(Tan) George Institute for Global Health, United States
(Cass) George Institute for Global Health, Department of Cardiology,
Concord Repatriation General Hospital, United States
Title
Preoperative estimates of glomerular filtration rate as predictors of
outcome after surgery: A systematic review and meta-analysis.
Source
Anesthesiology. 118 (4) (pp 809-824), 2013. Date of Publication: April
2013.
Publisher
Lippincott Williams and Wilkins (530 Walnut Street,P O Box 327,
Philadelphia PA 19106-3621, United States)
Abstract
Background: Kidney dysfunction is a strong determinant of prognosis in
many settings. Methods: A systematic review and meta-analysis was
undertaken to explore the relationship between estimated glomerular
filtration rate (eGFR) and adverse outcomes after surgery. Cohort studies
reporting the relationship between eGFR and major outcomes, including
all-cause mortality, major adverse cardiovascular events, and acute kidney
injury after cardiac or noncardiac surgery, were included. Results:
Forty-six studies were included, of which 44 focused exclusively on
cardiac and vascular surgery. Within 30 days of surgery, eGFR less than 60
mlmin1.73 m was associated with a threefold increased risk of death
(multivariable adjusted relative risk [RR] 2.98; 95% confidence interval
[CI] 1.95-4.96) and acute kidney injury (adjusted RR 3.13; 95% CI
2.22-4.41). An eGFR less than 60 mlmin1.73 m was associated with an
increased risk of all-cause mortality (adjusted RR 1.61; 95% CI 1.38-1.87)
and major adverse cardiovascular events (adjusted RR 1.49; 95% CI
1.32-1.67) during long-term follow-up. There was a nonlinear association
between eGFR and the risk of early mortality such that, compared with
patients having an eGFR more than 90 mlmin1.73 m the pooled RR for death
at 30 days in those with an eGFR between 30 and 60 mlmin1.73 m was 1.62
(95% CI 1.43-1.80), rising to 2.85 (95% CI 2.49-3.27) in patients with an
eGFR less than 30 mlmin1.73 m and 3.75 (95% CI 3.44-4.08) in those with an
eGFR less than 15 mlmin1.73 m. CONCLUSION:: There is a powerful
relationship between eGFR, and both short-and long-term prognosis after,
predominantly cardiac and vascular, surgery. 2013, the American Society
of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
<5>
[Use Link to view the full text]
Accession Number
2013222259
Authors
Grassin-Delyle S. Couturier R. Abe E. Alvarez J.C. Devillier P. Urien S.
Institution
(Grassin-Delyle) Laboratoire de Pharmacologie, UPRES EA220, Hopital Foch,
11 rue Guillaume Lenoir, 92150 Suresnes, France
(Grassin-Delyle, Abe, Alvarez) Laboratoire de Pharmacologie-Toxicologie,
Hopital Raymond Poincare, Garches, France
(Grassin-Delyle, Abe, Alvarez) Universite Versailles Saint Quentin en
Yvelines, UFR Sciences de la Sante, Versailles, France
(Couturier) Departement d'Anesthesie, Centre Chirurgical Marie
Lannelongue, Le-Plessis-Robinson, France
(Devillier) CIC-0901 Inserm Necker-Cochin, URC Paris Centre, Paris, France
(Urien) Universite Paris Descartes, Sorbonne Paris Cite, France
Title
A practical tranexamic acid dosing scheme based on population
pharmacokinetics in children undergoing cardiac surgery.
Source
Anesthesiology. 118 (4) (pp 853-862), 2013. Date of Publication: April
2013.
Publisher
Lippincott Williams and Wilkins (530 Walnut Street,P O Box 327,
Philadelphia PA 19106-3621, United States)
Abstract
Background: Pediatric cardiac surgery patients are at high risk for
bleeding, and the antifibrinolytic drug tranexamic acid (TA) is often used
to reduce blood loss. However, dosing schemes remain empirical as a
consequence of the absence of pharmacokinetic study in this population.
The authors' objectives were thus to investigate the population
pharmacokinetics of TA in pediatric cardiac surgery patients during
cardiopulmonary bypass (CPB). Methods: Twenty-one patients were randomized
to receive TA either continuously (10 mg/kg followed by an infusion of 1
mgkgh throughout the operation, and 10 mg/kg into the CPB) or
discontinuously (10 mg/kg, then 10 mg/kg into the CPB and 10 mgkgh at the
end of CPB). Serum concentrations were measured at eight time points with
chromatography-mass spectrometry and the data were modeled using Monolix
(Lixoft, Orsay, France). Results: Tranexamic acid pharmacokinetics was
ascribed to a two-compartment open model. The main covariate effects were
body weight and CPB. Representative pharmacokinetic parameters adjusted to
a 70-kg body weight were as follows: systemic clearance, 2.45 l/h; volume
of distribution in the central compartment, 14.1 l; intercompartmental
clearance, 5.74 l/h; and peripheral volume, 32.8 l. In accordance with
this model, the authors proposed a weight-adjusted dosing scheme to
maintain effective TA concentrations in children during surgery,
consisting of one loading dose followed by a continuous infusion.
Conclusions: The authors report for the first time the pharmacokinetics of
TA in children undergoing cardiac surgery with CPB, and propose a dosing
scheme for optimized TA administration in those children. 2013, the
American Society of Anesthesiologists, Inc. Lippincott Williams & Wilkins.
<6>
Accession Number
2013210150
Authors
Tully P.J.
Institution
(Tully) Department of Surgery, Flinders Medical Centre, Flinders
University of South Australia, Bedford Park, SA, Australia
(Tully) The School of Psychology, The University of Adelaide, Adelaide,
SA, Australia
(Tully) The Discipline of Psychiatry, The University of Adelaide,
Adelaide, SA, Australia
(Tully) The Heart Failure Self Management Program, Ambulatory and Primary
Healthcare Directorate, Hampstead Rehabilitation Centre, Northfield,
Australia
Title
Psychological depression and cardiac surgery: A comprehensive review.
Source
Journal of Extra-Corporeal Technology. 44 (4) (pp 224-232), 2012. Date of
Publication: December 2012.
Publisher
American Society of Extra-Corporeal Technology (P.O. Box 11086, Richmond
VA 23230, United States)
Abstract
The psychological and neurological impact of cardiac surgery has been of
keen empirical interest for more than two decades although reports showing
the prognostic influence of depression on adverse outcomes lag behind the
evidence documented in heart failure, myocardial infarction, and unstable
angina. The paucity of research to date is surprising considering that
some pathophysiological mechanisms through which depression is
hypothesized to affect coronary heart disease (e.g., platelet activation,
the inflammatory system, dysrhythmias) are known to be substantially
influenced by the use of cardiopulmonary bypass. As such, cardiac surgery
may provide a suitable exemplar to better understand the psychiatric
mechanisms of cardiopathogenesis. The extant literature is comprehensively
reviewed with respect to the deleterious impact of depression on cardiac
and neuropsychological morbidity and mortality. Research to date indicates
that depression and major depressive episodes increase major
cardiovascular morbidity risk after cardiac surgery. The association
between depressive disorders and incident delirium is of particular
relevance to cardiac surgery staff. Contemporary treatment intervention
studies are also described along with suggestions for future cardiac
surgery research.
<7>
Accession Number
2013210149
Authors
Sistino J.J. Bonilha H.S.
Institution
(Sistino, Bonilha) College of Health Professions, Medical University of
South Carolina, Charleston, SC, United States
Title
Improvements in survival and neurodevelopmental outcomes in surgical
treatment of hypoplastic left heart syndrome: A meta-analytic review.
Source
Journal of Extra-Corporeal Technology. 44 (4) (pp 216-223), 2012. Date of
Publication: December 2012.
Publisher
American Society of Extra-Corporeal Technology (P.O. Box 11086, Richmond
VA 23230, United States)
Abstract
The purpose of this study was to analyze the changes over the past two
decades in hospital survival and neurodevelopmental outcomes after
surgical treatment for hypoplastic left heart syndrome. The hypothesis for
this study is that increasing hospital survival following the Stage I
Norwood (S1N) procedure is associated with improvements in
neurodevelopmental outcomes. Studies included in the meta-analysis were
identified by searching Ovid MEDLINE from January 1980 to October 2010. A
total of 72 articles were identified. Fifteen single-center study articles
were appropriate for obtaining survival data and 14 were used for
neurodevelopmental outcomes. Wechsler Intelligence Test IQ scores and the
Bayley II Mental Development (MDI) and Psychomotor Development Indices
(PDI) were the primary neurodevelopmental outcomes included in this
meta-analysis. Metaregression analysis using a mixed-effects model
compared the percent survival and neurodevelopmental scores with the year
of surgery. Hospital survival for the S1N operation increased
significantly from 1996 to 2007 (p < .05). The overall mean survival
during this time period was 80.05% (95% confidence interval [CI],
76.4-84.0%). Standardized Wechsler IQ scores increased significantly from
1989 to 1999 (p < .05) and the mean IQ was 85.09 (95% CI, 82.3-89.5). The
Bayley II MDI increased significantly from 1998 to 2005 (p < .05) with
amean MDI of 86.9 (95% CI, 84.9-88.9). The Bayley II PDI increased
significantly from 1998 to 2005 (p < .05) with a mean PDI of 73.4 (95% CI,
71.2-75.5). Increased survival has been associated with improved but below
normal neurodevelopmental outcomes.
<8>
Accession Number
2013209036
Authors
Aya H.D. Cecconi M. Hamilton M. Rhodes A. Mahajan R.P.
Institution
(Aya, Cecconi, Hamilton, Rhodes, Mahajan) St George's Hospital NHS Trust,
St George's University of London, London SW170QT, United Kingdom
Title
Goal-directed therapy in cardiac surgery: A systematic review and
meta-analysis.
Source
British Journal of Anaesthesia. 110 (4) (pp 510-517), 2013. Date of
Publication: April 2013.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
BackgroundPerioperative mortality after cardiac surgery has decreased in
recent years although postoperative morbidity is still significant.
Although there is evidence that perioperative goal-directed haemodynamic
therapy (GDT) may reduce surgical mortality and morbidity in non-cardiac
surgical patients, the data are less clear after cardiac surgery. The
objective of this review is to perform a meta-analysis on the effects of
perioperative GDT on mortality, morbidity, and length of hospital stay in
cardiac surgical patients.MethodsWe conducted a systematic review using
Medline, EMBASE, and the Cochrane Controlled Clinical Trials Register.
Additional sources were sought from experts. The inclusion criteria were
randomized controlled trials, mortality reported as an outcome,
pre-emptive haemodynamic intervention, and cardiac surgical population.
Included studies were examined in full and subjected to quantifiable
analysis, subgroup analysis, and sensitivity analysis where possible. Data
synthesis was obtained by using odds ratio (OR) and mean difference (MD)
for continuous data with 95% confidence interval (CI) utilizing a
random-effects model.ResultsFrom 4986 potential studies, 5 met all the
inclusion criteria (699 patients). The quantitative analysis showed that
the use of GDT reduced the postoperative complication rate (OR 0.33, 95%
CI 0.15-0.73; P=0,006) and hospital length of stay (MD -2.44, 95% CI -4.03
to -0.84; P=0,003). There was no significant reduction in
mortality.ConclusionThe use of pre-emptive GDT in cardiac surgery reduces
morbidity and hospital length of stay. 2013 The Author [2013]. Published
by Oxford University Press on behalf of the British Journal of
Anaesthesia. All rights reserved. For Permissions, please email:
journals.permissions@oup.com.
<9>
Accession Number
2013195895
Authors
Jilaihawi H. Doctor N. Kashif M. Chakravarty T. Rafique A. Makar M.
Furugen A. Nakamura M. Mirocha J. Gheorghiu M. Stegic J. Okuyama K.
Sullivan D.J. Siegel R. Min J.K. Gurudevan S.V. Fontana G.P. Cheng W.
Friede G. Shiota T. Makkar R.R.
Institution
(Jilaihawi, Doctor, Kashif, Chakravarty, Rafique, Makar, Furugen,
Nakamura, Mirocha, Gheorghiu, Stegic, Okuyama, Sullivan, Siegel, Min,
Gurudevan, Fontana, Cheng, Friede, Shiota, Makkar) Cedars-Sinai Heart
Institute, Cardiovascular Intervention Center, 8631 West Third Street, Los
Angeles, CA 90048, United States
Title
Aortic annular sizing for transcatheter aortic valve replacement using
cross-sectional 3-dimensional transesophageal echocardiography.
Source
Journal of the American College of Cardiology. 61 (9) (pp 908-916), 2013.
Date of Publication: 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Objectives: This study compared cross-sectional three-dimensional (3D)
transesophageal echocardiography (TEE) to two-dimensional (2D) TEE as
methods for predicting aortic regurgitation after transcatheter aortic
valve replacement (TAVR). Background: Data have shown that TAVR sizing
using cross-sectional contrast computed tomography (CT) parameters is
superior to 2D-TEE for the prediction of paravalvular aortic regurgitation
(AR). Three-dimensional TEE can offer cross-sectional assessment of the
aortic annulus but its role for TAVR sizing has been poorly elucidated.
Methods: All patients had severe symptomatic aortic stenosis and were
treated with balloon-expandable TAVR in a single center. Patients studied
had both 2D-TEE and 3D imaging (contrast CT and/or 3D-TEE) of the aortic
annulus at baseline. Receiver-operating characteristic curves were
generated for each measurement parameter using post-TAVR paravalvular AR
moderate or greater as the state variable. Results: For the 256 patients
studied, paravalvular AR moderate or greater occurred in 26 of 256 (10.2%)
of patients. Prospectively recorded 2D-TEE measurements had a low
discriminatory value (area under the curve = 0.52, 95% confidence
interval: 0.40 to 0.63, p = 0.75). Average cross-sectional diameter by CT
offered a high degree of discrimination (area under the curve = 0.82, 95%
confidence interval: 0.73 to 0.90, p < 0.0001) and mean cross-sectional
diameter by 3D-TEE was of intermediate value (area under the curve = 0.68,
95% confidence interval: 0.54 to 0.81, p = 0.036). Conclusions:
Cross-sectional 3D echocardiographic sizing of the aortic annulus
dimension offers discrimination of post-TAVR paravalvular AR that is
significantly superior to that of 2D-TEE. Cross-sectional data should be
sought from 3D-TEE if good CT data are unavailable for TAVR sizing. 2013
American College of Cardiology Foundation.
<10>
Accession Number
2013196368
Authors
Balaguer J.M. Yu C. Byrne J.G. Ball S.K. Petracek M.R. Brown N.J.
Pretorius M.
Institution
(Balaguer, Yu, Byrne, Ball, Petracek) Department of Cardiac Surgery,
Vanderbilt University Medical School, Nashville, TN, United States
(Balaguer) Department of Cardiac Surgery, TN Valley Healthcare System,
Nashville, TN, United States
(Brown) Department of Biostatistics, Vanderbilt University Medical School,
Nashville, TN, United States
(Brown, Pretorius) Division of Clinical Pharmacology, Department of
Medicine, Vanderbilt University Medical School, Nashville, TN, United
States
(Pretorius) Department of Anesthesiology, Vanderbilt University Medical
School, Nashville, TN, United States
Title
Contribution of endogenous bradykinin to fibrinolysis, inflammation, and
blood product transfusion following cardiac surgery: A randomized clinical
trial.
Source
Clinical Pharmacology and Therapeutics. 93 (4) (pp 326-334), 2013. Date of
Publication: April 2013.
Publisher
Nature Publishing Group (Houndmills, Basingstoke, Hampshire RG21 6XS,
United Kingdom)
Abstract
Bradykinin increases during cardiopulmonary bypass (CPB) and stimulates
the release of nitric oxide, inflammatory cytokines, and tissue-type
plasminogen activator (t-PA), acting through its B 2 receptor. This study
tested the hypothesis that endogenous bradykinin contributes to the
fibrinolytic and inflammatory response to CPB and that bradykinin B 2
receptor antagonism reduces fibrinolysis, inflammation, and subsequent
transfusion requirements. Patients (N = 115) were prospectively randomized
to placebo, -aminocaproic acid (EACA), or HOE 140, a bradykinin B 2
receptor antagonist. Bradykinin B 2 receptor antagonism decreased
intraoperative fibrinolytic capacity as much as EACA, but only EACA
decreased D-dimer formation and tended to decrease postoperative bleeding.
Although EACA and HOE 140 decreased fibrinolysis and EACA attenuated blood
loss, these treatments did not reduce the proportion of patients
transfused. These data suggest that endogenous bradykinin contributes to
t-PA generation in patients undergoing CPB, but that additional effects on
plasmin generation contribute to decreased D-dimer concentrations during
EACA treatment.
<11>
Accession Number
2013196878
Authors
Graham E.M. Taylor S.N. Zyblewski S.C. Wolf B. Bradley S.M. Hollis B.W.
McGowan Jr. F.X. Atz A.M.
Institution
(Graham, Zyblewski, Atz) Division of Cardiology, Department of Pediatrics,
Medical University of South Carolina, 165 Ashley Avenue, MSC 915,
Charleston, SC 29425, United States
(Taylor, Hollis) Division of Neonatology, Department of Pediatrics,
Medical University of South Carolina, Charleston, SC, United States
(Wolf) Division of Biostatistics and Epidemiology, Department of Medicine,
Medical University of South Carolina, Charleston, SC, United States
(Bradley) Division of Cardiothoracic Surgery, Department of Surgery,
Medical University of South Carolina, Charleston, SC, United States
(McGowan Jr.) Department of Anesthesiology and Perioperative Medicine,
Medical University of South Carolina, Charleston, SC, United States
Title
Vitamin D status in neonates undergoing cardiac operations: Relationship
to cardiopulmonary bypass and association with outcomes.
Source
Journal of Pediatrics. 162 (4) (pp 823-826), 2013. Date of Publication:
April 2013.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Objectives: To determine the incidence of vitamin D deficiency in neonates
with congenital heart disease and whether differences exist by race. In
addition, we determined the effect of cardiopulmonary bypass on vitamin D
levels and explored associations between 25-hydroxyvitamin D [25(OH)D]
levels and postoperative outcomes. Study design: We performed a secondary
analysis of a prospective randomized controlled trial in 70 neonates
undergoing cardiac surgery. The neonates' 25(OH)D levels were measured in
the operating room before skin incision (baseline), at the cessation of
cardiopulmonary bypass, and at 24 hours postoperatively. Associations
between these levels and clinical outcomes were explored. Vitamin D
deficiency was defined as a 25(OH)D level <20 ng/mL. Results: Vitamin D
deficiency was present in 84% (59/70); concentrations in African Americans
(n = 20) were significantly lower than those of Caucasian/other
race/ethnicity (n = 50) (10.2 +/- 4.2 vs 16.0 +/- 5.6 ng/mL, P < .0001).
The 24-hour postoperative 25(OH)D levels were not different from baseline
and correlated with a reduced postoperative inotropic requirement (r =
-0.316, P = .008). Conclusions: Vitamin D deficiency is prevalent in
neonates with congenital cardiac defects, and lower postoperative 25(OH)D
levels are associated with the need for increased inotropic support in
neonates undergoing cardiac operations. These findings support that
vitamin D deficiency may play a role in myocardial injury and
postoperative recovery and warrants further investigation. 2013 Mosby
Inc.
<12>
Accession Number
2013177937
Authors
Gelvez-Zapata S.M. Gaffney D. Scarci M. Coonar A.S.
Institution
(Gelvez-Zapata, Scarci, Coonar) Department of Thoracic Surgery, Papworth
Hospital NHS Foundation Trust, Papworth Everard, Cambridge CB23 3RE,
United Kingdom
(Gaffney) Department of Bioinformatics, Wellcome Trust Sanger Institute,
Hinxton, Cambridge, United Kingdom
Title
What is the survival after surgery for localized malignant pleural
mesothelioma?.
Source
Interactive Cardiovascular and Thoracic Surgery. 16 (4) (pp 533-537),
2013. Date of Publication: April 2013.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
A best evidence topic in thoracic surgery was written according to a
structured protocol. This was with the purpose of assisting our management
of patients with localized malignant mesothelioma of the pleura (LMM).
Although the terminology is used inconsistently, this variant has been
formally defined by the WHO as a distinct entity defined as localized
disease histologically identical to the diffuse form but without any
evidence of pleural spread. Treatments for LMM include different
combinations of surgery, chemotherapy and radiotherapy. There is an
impression that LMM may have a better outcome than the commoner diffuse
form of malignant mesothelioma that has been reported to have a survival
between 8 and 14 months. In order to advise our patients on prognosis, we
studied the duration of survival after surgical resection of LMM. A total
of 150 papers were found, of which 16 represented the best evidence to
answer the question. The authors, journal, date, country of publication,
study type, relevant outcomes and results of these papers are tabulated.
It is difficult to combine the results of these 16 papers because both
treatments and results are reported differently. Some report median
survival (range: 11.6-36 months) and others disease-free survival (range:
0 months to 11 years). Median survival to the longest follow-up was 29
months when calculated by pooling data from informative papers using the
Kaplan-Meier method. Our review suggests that survival in LMM is longer
than that generally quoted for the more common diffuse form of malignant
mesothelioma. Hence, aggressive treatment of LMM may be reasonable in
appropriate patients. The Author 2013. Published by Oxford University
Press on behalf of the European Association for Cardio-Thoracic Surgery.
All rights reserved.
<13>
Accession Number
2013177936
Authors
Khorsandi M. Skouras C. Shah R.
Institution
(Khorsandi, Shah) Department of Cardiothoracic Surgery, University
Hospital of South Manchester, Wythenshawe Hospital, Southmoor Road,
Wythenshawe, Manchester M23 9LT, United Kingdom
(Skouras) Department of Surgery, Royal Infirmary of Edinburgh, Edinburgh,
United Kingdom
Title
Is there any role for resuscitative emergency department thoracotomy in
blunt trauma?.
Source
Interactive Cardiovascular and Thoracic Surgery. 16 (4) (pp 509-516),
2013. Date of Publication: April 2013.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
A best evidence topic in cardiothoracic surgery was written according to a
structured protocol. The question addressed was whether there is any role
for resuscitative emergency department thoracotomy in severe blunt trauma.
Emergency thoracotomy is an accepted intervention for patients with
penetrating cardiothoracic trauma. However, its role in blunt trauma has
been challenged and has been a subject of considerable debate. Altogether,
186 relevant papers were identified, of which 14 represented the best
evidence to answer the question. The author, journal, date, country of
publication and relevant outcomes are tabulated. The 14 studies comprised
2 systematic reviews and 12 retrospective studies. The systematic review
performed by the Trauma Committee of the American College of Surgeons
included 42 studies and a cumulative total of 2193 blunt trauma patients
who underwent an emergency department thoracotomy, reporting a survival
rate of 1.6. According to this review, 15 of the survivors suffered from
neurological sequelae, but survivors from both penetrating and blunt
trauma were included. A systematic review comprising 24 studies reported a
survival rate of 1.4 among 1047 blunt trauma patients. Of the
retrospective studies, 11 report poor survival rates, ranging from 0 to 6.
Only one study reports a higher survival rate (12.2). Five of the studies
reported on the neurological outcome of survivors. The majority of the
studies suffered from limitations due to the small number of included
cases. The reported survival after an emergency department thoracotomy for
blunt trauma is very low in the vast majority of available studies.
Furthermore, the neurological sequelae in the few survivors are frequent
and severe. Interestingly, some author groups recommend that emergency
department thoracotomy should be contraindicated in cases of blunt trauma
with no signs of life at the scene of trauma or on arrival at the
emergency department. Larger, well-designed series will be required to
reach a consensus on valid prognostic factors and specific subgroups of
blunt trauma patients with substantial chances of survival. The Author
2012. Published by Oxford University Press on behalf of the European
Association for Cardio-Thoracic Surgery. All rights reserved.
<14>
Accession Number
2013177913
Authors
Dall K. Ford C. Fisher R. Dunning J.
Institution
(Dall, Fisher) Department of Cardiothoracic Surgery, Royal Infirmary of
Edinburgh, Edinburgh, United Kingdom
(Ford) Department of Emergency Medicine, Royal Infirmary of Edinburgh,
Edinburgh, United Kingdom
(Dunning) Department of Cardiothoracic Surgery, James Cook University
Hospital, Middlesbrough, United Kingdom
Title
Is there a survival advantage of incomplete resection of non-small-cell
lung cancer that is found to be unresectable at thoracotomy?.
Source
Interactive Cardiovascular and Thoracic Surgery. 16 (4) (pp 529-532),
2013. Date of Publication: April 2013.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
A best evidence topic in thoracic surgery was written according to a
structured protocol. The question addressed was: in patients with
non-small-cell lung cancer that is found to be unresectable at
thoracotomy, is incomplete resection superior for achieving survival
advantage? Altogether more than 400 papers were found using the reported
search, of which nine represented the best evidence to answer the clinical
question. The authors, journal, date and country of publication, patient
group studied, study type, relevant outcomes and results of these papers
were tabulated. In total, data from an estimated 1083 patients were
analysed. Three-year survival rates varied from 0 to 22 in incomplete
resection and from 0 to 10 in exploratory thoracotomy. Median survival
ranged from 6.5 to 19.1 months in incomplete resection and from 5.3 to 17
months in exploratory thoracotomy. The majority of studies (8/9) found
survival in incomplete resection to be superior. However, only 3/9 studies
presented statistical analysis of results. The largest of these found
superior postoperative survival in incomplete resection (including
residual nodal disease), one study showed a significant survival
difference for R1 but not R2 resection and another with small patient
numbers (n = 29) found no significant difference. We conclude that the
best evidence suggests that there may be a survival advantage from
incomplete resection of non-small-cell lung cancer when there is
microscopic (R1) or nodal residual disease, but not when macroscopic
residual (R2) disease remains. The Author 2013. Published by Oxford
University Press on behalf of the European Association for Cardio-Thoracic
Surgery. All rights reserved.
<15>
Accession Number
2013201891
Authors
Tinahones F.J. Queipo-Ortuno M.I. Clemente-Postigo M. Fernnadez-Garcia D.
Mingrone G. Cardona F.
Institution
(Tinahones, Fernnadez-Garcia) Endocrinology and Nutrition Service,
Hospital Virgen de la Victoria, Malaga, Spain
(Tinahones, Queipo-Ortuno, Fernnadez-Garcia, Cardona) CIBER Fisiopatologia
de la Obesidad y Nutricion (06/03), Instituto de Salud Carlos III, Malaga,
Spain
(Queipo-Ortuno, Clemente-Postigo, Cardona) Laboratorio Investigacion
Biomedica 1a Planta, Hospital Clinico Universitario Virgen de la Victoria,
Campus de Teatinos, Malaga 29010, Spain
(Mingrone) Department of Internal Medicine, Catholic University, Rome,
Italy
Title
Postprandial hypertriglyceridemia predicts improvement in insulin
resistance in obese patients after bariatric surgery.
Source
Surgery for Obesity and Related Diseases. 9 (2) (pp 213-218), 2013. Date
of Publication: March-April 2013.
Publisher
Elsevier Inc. (360 Park Avenue South, New York NY 10010, United States)
Abstract
Background: Morbidly obese patients have associated diseases, such as
diabetes, hypertension, hyperlipidemia, and cardiovascular disease.
Bariatric surgery improves these obesity-related co-morbidities, including
insulin resistance. Evidence has shown that patients with morbid obesity
have postprandial hypertriglyceridemia (HTG) and that this type of HTG is
related to the degree of insulin resistance. Also, bariatric surgery
produces a dramatic reduction in triglyceride levels. However, it is
unknown whether patients with postprandial HTG have a different clinical
evolution after bariatric surgery. The setting of our study was a
university hospital. Methods: We studied 57 morbidly obese patients who
had mild or severe postprandial HTG after fat overload (<30 mg/dL or >90
mg/dL increase in triglycerides, respectively). All the patients underwent
bariatric surgery. After surgery, the anthropometric and biochemical
variables and the Homeostasis Model Assessment of Insulin Resistance were
measured for 1 year at 0, 15, 30, 45, 90, 180, and 365 days after surgery.
Results: The patients with more severe postprandial HTG had a greater
percentage of change in the Homeostasis Model Assessment of Insulin
Resistance at 30, 90, and 180 days after surgery than the patients with
less severe postprandial HTG. Multiple regression analysis showed that the
postprandial triglyceride levels predict the variation in the Homeostasis
Model Assessment of Insulin Resistance index, more so than did traditional
variables, such as anthropometric, inflammatory, or hormonal data.
Conclusion: The postprandial HTG level might be the best predictor of
improved insulin resistance in morbidly obese patients after bariatric
surgery. 2013 American Society for Metabolic and Bariatric Surgery.
<16>
Accession Number
71030708
Authors
Haase-Fielitz A. Haase M. Plass M. Murray P. Bailey M. Bellomo R. Bagshaw
S.
Institution
(Haase-Fielitz, Haase) Otto Von-Guericke University, Magdeburg, Germany
(Plass) German Heart Center, Berlin, Germany
(Murray) University College Dublin, Ireland
(Bailey) ANZIC, Melbourne, Australia
(Bellomo) Austin Hospital, Melbourne, Australia
(Bagshaw) University of Alberta, Canada
Title
Perioperative sodium bicarbonate to prevent acute kidney injury after
cardiac surgery: A multicenter double-blind randomized controlled trial.
Source
Critical Care. Conference: 33rd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20130319
Conference End: 20130322. Conference Publication: (var.pagings). 17 (pp
S154-S155), 2013. Date of Publication: 19 Mar 2013.
Publisher
BioMed Central Ltd.
Abstract
Introduction Evidence suggests a nephroprotective effect of urinary
alkalinization in patients at risk of acute kidney injury (AKI). Methods
In a multicenter, double-blind, RCT we enrolled 350 adult cardiac surgery
patients. At induction of anesthesia, patients received either 24 hours of
intravenous infusion of sodium bicarbonate (5.1 mmol/kg) or sodium
chloride (5.1 mmol/kg). The primary endpoint was the proportion of
patients developing AKI. Results Sodium bicarbonate increased urinary pH
(from 6.0 to 7.5, P <0.001). More patients in the bicarbonate group
(83/174 (47.7%)) developed AKI compared with control (64/176 (36.4%), OR =
1.60 (95% CI, 1.04 to 2.45); unadjusted P = 0.032). A greater
postoperative (Graph Presented) increase in urinary NGAL in patients
receiving bicarbonate infusion was observed compared with control (P =
0.011). The incidence of postoperative RRT was similar but hospital
mortality was increased in patients treated with bicarbonate compared with
chloride (11/174 (6.3%) vs. 3/176 (1.7%), OR 3.89 (1.07 to 14.2), P =
0.031). See Figure 1. Conclusion On this basis of our findings we do not
recommend the use of perioperative infusions of sodium bicarbonate to
reduce the incidence or severity of AKI in this patient group.
<17>
Accession Number
71030520
Authors
Hajjar L. Vincent J.L. Rhodes A. Annane D. Galas F. Almeida J. Zeferino S.
Camara L. Santos V. Pereira J. Osawa E. MacIel E. Rodrigues A. Jardim J.
Blini D. Araujo E. Bergamin F. Kalil Filho R. Auler J.
Institution
(Hajjar, Galas, Almeida, Zeferino, Camara, Santos, Pereira, Osawa, MacIel,
Rodrigues, Jardim, Blini, Araujo, Kalil Filho, Auler) Heart Institute, Sao
Paulo, Brazil
(Vincent) Universite Libre de Bruxelles, Brussels, Belgium
(Rhodes) University of London, United Kingdom
(Annane) Faculte Medicine Paris, France
(Bergamin) Cancer Institute, Sao Paulo, Brazil
Title
Vasopressin Versus Norepinephrine for the Management of Shock after
Cardiac Surgery (VaNCS study): A randomized controlled trial.
Source
Critical Care. Conference: 33rd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20130319
Conference End: 20130322. Conference Publication: (var.pagings). 17 (pp
S83), 2013. Date of Publication: 19 Mar 2013.
Publisher
BioMed Central Ltd.
Abstract
Introduction Vasoplegic syndrome is a common complication after cardiac
surgery, with negative impact on patient outcomes and hospital costs.
Pathogenesis of vasodilatory phenomenon after cardiac surgery remains a
matter of controversy. Loss of vascular tone can be partly explained by
the depletion of neurohypophyseal arginine vasopressin stores. Vasopressin
is commonly used as an adjunct to catecholamines to support blood pressure
in refractory septic shock, but its effect on vasoplegic shock is unknown.
We hypothesized that the use of vasopressin would be more effective on
treatment of shock after cardiac surgery than norepinephrine, decreasing
the composite endpoint of mortality and severe morbidity. Methods In this
prospective and randomized, double-blind trial, we assigned patients who
had vasoplegic shock to receive either vasopressin (0.01 to 0.06 U/minute)
or norepinephrine (0.01 to 1 mug/kg/minute) in addition to open-label
vasopressors. All vasopressor infusions were titrated and tapered
according to protocols to maintain a target blood pressure. The primary
endpoint was major morbidity according to STS (30-day mortality,
mechanical ventilation >48 hours, mediastinitis, surgical re-exploration,
stroke, acute renal failure). Secondary outcomes were time on mechanical
ventilation, ICU and hospital stay, new infection, the time to attainment
of hemodynamic stability, occurrence of adverse events and safety. Results
A total of 300 patients underwent randomization, were infused with the
study drug (148 patients received vasopressin, and 152 norepinephrine),
and were included in the analysis. Patients who received vasopressin had a
lower rate of morbidity (23.5% vs. 34%, P = 0.001) as compared with the
norepinephrine group. The 30-day mortality rate was 6.1% in the
norepinephrine group and 4.6% in the vasopressin group (P = 0.570). There
were no significant differences in the overall rates of serious adverse
events (7.4% and 6.6%, respectively; P = 0.772). Conclusion Vasopressin
reduces major morbidity after cardiac surgery as compared with
norepinephrine among patients with cardiac surgery with vasoplegic shock.
Acknowledgement Clinical Trials number NCT01505231.
<18>
Accession Number
71030493
Authors
Arulkumaran N. Corredor C. Hamilton M. Grounds M. Ball J. Rhodes A.
Cecconi M.
Institution
(Arulkumaran, Corredor, Hamilton, Grounds, Ball, Rhodes, Cecconi) St
George's Hospital, London, United Kingdom
Title
Treatment-related cardiac complications associated with goal-directed
therapy in high-risk surgical patients: A meta-analysis.
Source
Critical Care. Conference: 33rd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20130319
Conference End: 20130322. Conference Publication: (var.pagings). 17 (pp
S73), 2013. Date of Publication: 19 Mar 2013.
Publisher
BioMed Central Ltd.
Abstract
Introduction We hypothesized that goal-directed therapy (GDT) is not
associated with an increased risk of cardiac complications in high-risk,
noncardiac surgical patients. Patients with limited cardiopulmonary
reserve are at risk of mortality and morbidity after major surgery [1].
Augmentation of the oxygen delivery index (DO<sub>2</sub>I) with a
combination of intravenous fluids and inotropes (GDT) has been shown to
reduce the postoperative mortality and morbidity in high-risk patients
[2]. However, concerns regarding cardiac complications associated with
fluid challenges and inotropes used to augment cardiac output may deter
clinicians from instituting early GDT in the very patients who are more
likely to benefit. Methods Systematic search of MEDLINE, Embase and
CENTRAL databases for randomized controlled trials of GDT in high-risk
surgical patients. Studies including cardiac surgery, trauma, and
pediatric surgery were excluded to minimize heterogeneity. We reviewed the
rates of all cardiac complications, arrhythmias, acute myocardial
ischemia, and acute pulmonary edema. Meta-analyses were performed and
forest plots drawn using RevMan software. Data are presented as odd ratios
(ORs) (95% CIs), and P values. Results We identif ed 23 randomized
controlled trials including 2,219 patients, who reported cardiac
complications. GDT was associated with a reduction in total cardiovascular
complications (OR = 0.55 (0.39 to 0.78), P = 0.0007), and with a
significantly reduced incidence of arrhythmias (OR = 0.59 (0.38 to 0.91),
P = 0.02). GDT was not associated with an increase in acute pulmonary
edema (OR = 0.68 (0.42 to 1.10), P = 0.11) or acute myocardial ischemia
(OR = 0.70 (0.38 to 1.27), P = 0.23). Subgroup analysis of overall
cardiovascular complications revealed that the benefit is most pronounced
in patients receiving fluid and inotrope therapy (OR = 0.55 (0.34 to
0.89), P = 0.01) to achieve a supranormal oxygen delivery target (OR =
0.50 (0.32 to 0.79), P = 0.003), guided by the use of minimally invasive
cardiac outmonitoring (OR = 0.50 (0.33 to 0.77), P = 0.002). Conclusion
Perioperative, physiologically guided, GDT in high-risk surgical patients
is not associated and actually reduces postoperative cardiovascular
complications.
<19>
Accession Number
71030491
Authors
Osawa E. Rhodes A. Vincent J. Almeida J. Fukushima J. Pileggi B. Park C.
Camara L. Auler Jr J. Chan R. Piccioni M. Lima M. Galas F. Hajjar L.
Institution
(Osawa, Almeida, Fukushima, Pileggi, Park, Camara, Auler Jr, Chan,
Piccioni, Lima, Galas, Hajjar) Heart Institute, Sao Paulo, Brazil
(Rhodes) St George's Healthcare NHS Trust, St George's University of
London, United Kingdom
(Vincent) Universite Libre de Bruxelles, Brussels, Belgium
Title
Goal-directed resuscitation therapy in high-risk patients undergoing
cardiac surgery (GRICS study): A randomized controlled trial -preliminary
results.
Source
Critical Care. Conference: 33rd International Symposium on Intensive Care
and Emergency Medicine Brussels Belgium. Conference Start: 20130319
Conference End: 20130322. Conference Publication: (var.pagings). 17 (pp
S72-S73), 2013. Date of Publication: 19 Mar 2013.
Publisher
BioMed Central Ltd.
Abstract
Introduction A goal-directed resuscitation therapy (GDT) through
optimization of cardiac output reduces complications in noncardiac
surgeries. We investigated whether the implementation of a GDT protocol in
high-risk cardiac surgery with the use of LiDCO Rapid reduces
postoperative complications as compared with the standard of care. Methods
We performed a prospective and randomized study whereby consecutive
patients fulf lling one high-risk criteria (EuroSCORE >5, ejection
fraction <50%, recent myocardial infarction, unstable angina or
extracardiac arteriopathy) were allocated to GDT or conventional
hemodynamic therapy. We excluded patients with endocarditis, previous use
of dobutamine, need for IABP, high dose of vasopressors and emergency
surgery. The GDT protocol involved hemodynamic resuscitation aimed at a
target of a cardiac index >3 l/minute/m<sup>2</sup> through a three-step
approach: fluid therapy of 250 ml lactated Ringer's solution, dobutamine
infusion up to a dose of 20 mug/kg/minute, and red blood cell transfusion
to reach a hematocrit level above 28%. Results Twenty patients from the
GDT group were compared with 20 control patients. Both groups were
comparable concerning baseline characteristics and severity scores, except
for a higher prevalence of hypertension and heart failure in the GDT
group. Intraoperative data showed no difference regarding length of
extracorporeal circulation, fluid balance, transfusion or inotropic
requirement. Patients from the GDT group were given more fluids within the
first 8 hours as compared with the conventional group (1,250 ml vs. 500
ml, P <0.001). GDT patients showed a median ICU stay of 3 days (95% CI: 3
to 4) compared with 5 days in control patients (95% CI: 4 to 7). Moreover,
hospital stay was less prolonged in GDT patients (10 days vs. 14 days, P =
0.043). Inotropic dependence was lower in the GDT group (29 hours vs. 55
hours, P = 0.003) as well as the cumulative dobutamine dosage (8 vs. 19
mug/kg/day, P = 0.025). Also, GDT group presented a lower incidence of
infections, tachyarrithmias and acute renal failure (RIFLE R) when
compared with the control group. Conclusion A hemodynamic therapy tailored
to an optimized cardiac output reduced the length of ICU stay, vasoactive
drug requirement and postoperative complications. Acknowledgement Grants
received from FAPESP 2011/19987-5.
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