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<1>
Accession Number
2013407702
Authors
Guo M. Xie B. Sun X. Hu M. Yang Q. Lei Y.
Institution
(Guo, Xie, Sun, Hu, Yang, Lei) Department of Cardiothoracic Surgery,
Chenggong Hospital of Xiamen University, Xiamen 361003, China
Title
A comparative study of the therapeutic effect in two protocols:
Video-assisted thoracic surgery combined with laparoscopy versus right
open transthoracic esophagectomy for esophageal cancer management.
Source
Chinese-German Journal of Clinical Oncology. 12 (2) (pp P68-P71), 2013.
Date of Publication: February 2013.
Publisher
Springer Verlag (Tiergartenstrasse 17, Heidelberg D-69121, Germany)
Abstract
Objective: The aim was to evaluate the best intra-thoracoscopic surgery
technique between video-assisted thoracic surgery (VATS) combined with
laparoscopy and right open transthoracic esophagectomy, in patients with
esophageal cancer. Methods: From November 2006 to May 2008, 221 patients
with esophageal cancer were enrolled in this study, prospective randomized
in two groups. 111 patients were performed the VATS technique
(Experimental group), whereas in the other 110 patients esophagectomy was
adopted by thoracotomy (Control group). Results: The time consuming of
Experimental group was 272.3 min in average with a standard deviation(std)
of 57.9, and it was 218.7 min in average with std of 91.0 in the control
group (P = 0.000). The operative blood loss was 219.7 +/- 194.4 mL in the
Experimental group, compared with 590.0 +/- 324.4 mL in the control group,
with significant difference (P = 0.000). Postoperative hospital stay of
Experimental group was 9.6 +/- 1.7 d, and it was 11.4 +/- 2.3 d in the
control group (P = 0.000). There was no-delayed union of incision in the
Experimental group, but 6.36% in the control group (P = 0.007). The
disorder of gastric emptying occurred 0.9% in the Experimental group,
whereas 6.4% in the Control group. There was no significant difference in
survival curves and rates (P = 0.555). Conclusion: There were several
advantages of VATS technique, such as reduced hemorrhage, better recovery,
few complications, and great number of lymph node dissection, although
there was no significant difference in long-term survival rate. Thus the
VATS combined with laparoscopy technique was worthy of generalization in
esophageal surgery with good prospects. 2013 Springer-Verlag Berlin
Heidelberg.

<2>
Accession Number
23235596
Authors
Wasiak J. Law J. Watson P. Spinks A.
Institution
(Wasiak) Victorian Adult Burns Service and School of Public Health and
Preventative Medicine, Monash University, The Alfred Hospital,Melbourne,
Australia.
Title
Percutaneous transluminal rotational atherectomy for coronary artery
disease.
Source
Cochrane database of systematic reviews (Online). 12 (pp CD003334), 2012.
Date of Publication: 2012.
Abstract
This is an update of the review on 'Percutaneous transluminal rotational
atherectomy for coronary artery disease' first published in The Cochrane
Library Issue 4, 2003. Percutaneous transluminal coronary rotational
atherectomy (PTCRA) debulks atherosclerotic plaque from coronary arteries
using an abrasive burr. On rotation, the burr selectively removes hard
tissue. PTCRA has been used both as an alternative to and in conjunction
with balloon angioplasty to open up blocked coronary arteries. Its ongoing
effectiveness and safety compared with other modes of removing
atherosclerotic plaques is reviewed. To assess the effects of PTCRA for
coronary artery disease in patients with non-complex and complex lesions
(e.g. ostial, long or diffuse lesions or those arising from in-stent
re-stenosis) of the coronary arteries. For the original review, we
searched the Heart Group Specialised Register; The Cochrane Library to
Issue 2, 2001; and MEDLINE, CINAHL, EMBASE and Current Contents to
December 2002 and reviewed reference lists for relevant articles. For the
current review, we searched the same registries from 2002 to 2012 and
reviewed reference lists for relevant articles. We included randomised and
quasi-randomised controlled trials of PTCRA compared with placebo, no
treatment or another intervention and excluded cross-over trials. Two
review authors independently extracted data and assessed the risk of bias
of the studies identified. Data were extracted independently by two review
authors. We asked authors of trials to provide information when missing
data were encountered. Statistical summaries used risk ratios (RR) and
weighted mean differences. We included 12 trials enrolling 3474 patients.
The overall risk of bias was unclear for the majority of articles due to a
lack of reported data; however, the authors determined that this would be
unlikely to impact negatively as most data outcomes were objective (e.g.
death vs. no death). There was no evidence of the effectiveness in
improving patient outcomes of PTCRA in non-complex lesions. In complex
lesions, there were no statistically significant differences in
re-stenosis rates at six months (RR 1.05; 95% confidence interval (CI)
0.83 to 1.33) and at one year (RR 1.21; 95% CI 0.95 to 1.55) in those
receiving PTCRA with adjunctive balloon angioplasty (PTCA) (PTCRA/PTCA)
compared to those receiving PTCA alone. Morphological characteristics
distinguishing complex lesions have not been examined in parallel-arm
randomised controlled trials. The evidence for the effectiveness of PTCRA
in in-stent re-stenosis is unclearCompared to angioplasty alone,
PTCRA/PTCA did not result in a statistically significant increase in the
risk of major adverse cardiac events (myocardial infarction (MI),
emergency cardiac surgery or death) during the in-hospital period (RR
1.27; 95% CI 0.86 to 1.90). Compared to angioplasty, PTCRA was associated
with nine times the risk of an angiographically detectable vascular spasm
(RR 9.23; 95% CI 4.61 to 18.47), four times the risk of perforation (RR
4.28; 95% CI 0.92 to 19.83) and about twice the risk of transient vessel
occlusions (RR 2.49; 95% CI 1.25 to 4.99) while angiographic dissections
(RR 0.48; 95% CI 0.34 to 0.68) and stents used as a bailout procedure (RR
0.29; 95% CI 0.09 to 0.87) were less common. When conventional PTCA is
feasible, PTCRA appears to confer no additional benefits. There is limited
published evidence and no long-term data to support the routine use of
PTCRA in in-stent re-stenosis. Compared to angioplasty alone, PTCRA/PTCA
did not result in a higher incidence of major adverse cardiac events, but
patients were more likely to experience vascular spasm, perforation and
transient vessel occlusion. In certain circumstances (e.g. patients
ineligible for cardiac surgery, those with architecturally complex
lesions, or those with lesions that fail PTCA), PTCRA may achieve
satisfactory re-vascularisation in subsequent procedures.

<3>
Accession Number
23258136
Authors
Sakaguchi M. Sasaki Y. Hirai H. Hosono M. Nakahira A. Seo H. Suehiro S.
Institution
(Sakaguchi) Department of Cardiovascular Surgery, Osaka City University
Graduate School of Medicine, Osaka, Japan.
Title
Efficacy of landiolol hydrochloride for prevention of atrial fibrillation
after heart valve surgery.
Source
International heart journal. 53 (6) (pp 359-363), 2012. Date of
Publication: 2012.
Abstract
The goal of this prospective study was to examine the effects of landiolol
hydrochloride on prevention of atrial fibrillation and on hemodynamics in
the acute postoperative phase after heart valve surgery. The subjects were
60 patients who underwent valve surgery at our hospital from April 2008 to
July 2010. The patients were randomly divided into two groups: the
landiolol group (30 patients) and the control (no landiolol) group (30
patients). In the landiolol group, continuous intravenous landiolol was
initiated immediately on admission to the intensive care unit at a dose of
10 mug/kg/ minute. Occurrence of atrial fibrillation was compared between
the groups over an observation period of 72 hours after surgery. Atrial
fibrillation occurred in 6 patients (20%) in the landiolol group and 16
(53.3%) in the control group during the observation period. Landiolol
hydrochloride significantly reduced the occurrence of atrial fibrillation
in the acute postoperative phase after heart valve surgery. Heart rate was
significantly decreased by landiolol, but aggravation of hemodynamics was
not observed. These results suggest that landiolol is a useful drug for
prevention of atrial fibrillation after valve surgery.

<4>
Accession Number
2013416665
Authors
Sezai A. Nakata K.-I. Iida M. Yoshitake I. Wakui S. Hata H. Shiono M.
Institution
(Sezai, Nakata, Iida, Yoshitake, Wakui, Hata, Shiono) Department of
Cardiovascular Surgery, Ninon University School of Medicine, 30-1
Oyaguchi-kamimachi, Itabashi-ku, Tokyo 173-8610, Japan
Title
Results of low-dose carperitide infusion in high-risk patients undergoing
coronary artery bypass grafting.
Source
Annals of Thoracic Surgery. 96 (1) (pp 119-126), 2013. Date of
Publication: July 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Background: This study investigated the efficacy of human atrial
natriuretic peptide (hANP, carperitide) for high-risk patients undergoing
coronary artery bypass grafting (CABG). Methods: This was a randomized
controlled trial of 367 high-risk patients (European System for Cardiac
Operative Risk Evaluation above 6) undergoing CABG. The primary endpoint
was major adverse cardiovascular and cerebrovascular events (MACCE).
Secondary endpoints were (1) postoperative death, (2) MACCE +
hemodialysis, and (3) serum creatinine and brain natriuretic peptide (BNP)
levels. Logistic regression analysis was conducted to identify
preoperative and perioperative factors related to early death and MACCE.
Results: There was no significant difference of survival between the hANP
and placebo groups (p = 0.1651), but the MACCE-free rate was significantly
higher in the hANP group than in the placebo group (p < 0.0001). No
patient from the hANP group started hemodialysis after operation, but 7
patients did in the placebo group, and the dialysis rate was significantly
lower in the hANP group (p = 0.0147). Serum creatinine and BNP were also
significantly lower in the hANP group at 1 year postoperatively. MACCE
were strongly associated with age 75 years or older, chronic kidney
disease, hemodialysis, left ventricular dysfunction, and nonuse of
carperitide. Conclusions: In the early postoperative period, carperitide
has a cardiorenal protective effect that prevents postoperative MACCE and
hemodialysis. Perioperative low-dose carperitide infusion may be useful in
high-risk patients undergoing on-pump CABG. 2013 The Society of Thoracic
Surgeons.

<5>
Accession Number
2013416700
Authors
Kandler K. H. Moller C. Hassager C. S. Olsen P. Lilleor N. Steinbruchel
D.A.
Institution
(Kandler, H. Moller, S. Olsen, Lilleor, Steinbruchel) Department of
Cardiothoracic Surgery, Rigshospitalet, Copenhagen University Hospital,
Blegdamsvej 9, 2100 Copenhagen, Denmark
(Hassager) Department of Cardiology, Rigshospitalet, Copenhagen University
Hospital, Denmark
Title
Patient-prosthesis mismatch and reduction in left ventricular mass after
aortic valve replacement.
Source
Annals of Thoracic Surgery. 96 (1) (pp 66-71), 2013. Date of Publication:
July 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Background: The presence of patient-prosthesis mismatch (PPM) after aortic
valve replacement may influence patient survival. We examined the
relationship between PPM and changes in left ventricular mass index at 3
months follow-up and also overall survival. Methods: From patients
included in the Mosaic trial, we studied data from 266 patients who
underwent aortic valve replacement with the Medtronic Mosaic porcine
bioprosthesis and had an echocardiography performed 3 months
postoperatively. Complete echocardiographic data, to calculate left
ventricular mass index, was available in 78% of the patients. The primary
outcome for this substudy was prevalence and severity of PPM. Secondary
outcomes were reduction in left ventricular mass index at 3 months
follow-up and medium-term survival. Patients without PPM were defined as
having an indexed effective orifice area greater than 0.85
cm²/m², and those with moderate and severe PPM as
having an indexed effective orifice area between 0.65
cm²/m² and 0.85 cm²/m² or
below 0.65 cm²/m², respectively. Results: PPM was
found in 217 (82%) patients. No difference in overall survival was found
between patients with PPM and those without PPM. The change in left
ventricular mass index was significantly different between groups (no PPM
-31.4 +/- 28.0 g/m², moderate PPM 1.1 +/- 34.4 g/m²,
and severe PPM -5.9 +/- 29.7 g/m², respectively (p = 0.01).
Conclusions: The presence of PPM did not influence medium-term survival.
However, patients without PPM showed a marked reduction in left
ventricular mass index as soon as 3 months postoperatively. 2013 The
Society of Thoracic Surgeons.

<6>
Accession Number
2013416711
Authors
Dreifaldt M. Mannion J.D. Bodin L. Olsson H. Zagozdzon L. Souza D.
Institution
(Dreifaldt, Souza) Department of Cardiovascular Surgery, University
Hospital, 701 85 Orebro, Sweden
(Mannion) Department of Surgery, Bayhealth Medical Center, Dover, DE,
United States
(Bodin) Institute of Environmental Medicine, Unit of Intervention and
Implementation Research, Karolinska Institute, Stockholm, Sweden
(Olsson) Svensk PCI AB, Central Hospital, Karlstad, Sweden
(Zagozdzon) Department of Cardiology, University Hospital, Orebro, Sweden
Title
The no-touch saphenous vein as the preferred second conduit for coronary
artery bypass grafting.
Source
Annals of Thoracic Surgery. 96 (1) (pp 105-111), 2013. Date of
Publication: July 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Background: Injury incurred while saphenous veins are being obtained
results in poor graft patency and impairs the results of coronary artery
bypass grafting. A novel method of obtaining veins, the no-touch
technique, has shown improved long-term saphenous vein graft patency.
Methods: This randomized trial included 108 patients undergoing coronary
artery bypass grafting and compared the patency of no-touch saphenous vein
with that of radial artery grafts. Each patient was assigned to receive
one no-touch saphenous vein and one radial artery graft to either the left
or the right coronary territory to complement the left internal thoracic
artery. Results: Angiography was performed in 99 patients (92%) at a mean
of 36 months postoperatively. Graft and grafted coronary artery patency
was evaluated. The patency of grafts for no-touch saphenous vein and
radial artery was 94% versus 82% (p = 0.01), respectively. The patency of
coronary arteries grafted with no-touch saphenous vein and radial artery
grafts was 95% versus 84% (p = 0.005), respectively. Eighty-nine of 96
(93%) left internal thoracic artery grafts were patent. Conclusions:
No-touch saphenous vein grafts showed a significantly higher patency rate
than the radial artery grafts and the patency was comparable to the
patency for left internal thoracic artery grafts. This highlights the
improvement in saphenous vein graft quality with the no-touch technique
and increases the number of situations in which saphenous veins may be
preferable to radial artery grafts as conduits in coronary artery bypass
grafting. 2013 The Society of Thoracic Surgeons.

<7>
Accession Number
2013424445
Authors
Patti G. Pasceri V. Mangiacapra F. Colonna G. Vizzi V. Ricottini E.
Montinaro A. D'Ambrosio A. Wijns W. Barbato E. Di Sciascio G.
Institution
(Patti, Mangiacapra, Vizzi, Ricottini, D'Ambrosio, Di Sciascio) Department
of Cardiovascular Sciences, Campus Bio-Medico University of Rome, Rome,
Italy
(Pasceri) Interventional Cardiology Unit, San Filippo Neri Hospital, Rome,
Italy
(Colonna, Montinaro) Interventional Cardiology Unit, Vito Fazzi Hospital,
Lecce, Italy
(Wijns, Barbato) Cardiovascular Center, OLV Hospital, Aalst, Belgium
Title
Efficacy of clopidogrel reloading in patients with acute coronary syndrome
undergoing percutaneous coronary intervention during chronic clopidogrel
therapy (from the Antiplatelet therapy for reduction of myocardial damage
during angioplasty [ARMYDA-8 RELOAD-ACS] trial).
Source
American Journal of Cardiology. 112 (2) (pp 162-168), 2013. Date of
Publication: 15 Jul 2013.
Publisher
Elsevier Inc. (360 Park Avenue South, New York NY 10010, United States)
Abstract
Whether an additional clopidogrel load in patients receiving chronic
clopidogrel therapy and undergoing percutaneous coronary intervention
(PCI) for acute coronary syndrome (ACS) is associated with clinical
benefit has not been well characterized. The aim of the present study was
to evaluate, in a randomized protocol, the safety and effectiveness of
clopidogrel reload for patients with ACS undergoing PCI in the background
of chronic clopidogrel therapy. A total of 242 patients with
non-ST-segment elevation ACS with >10 days of clopidogrel therapy randomly
received a 600-mg loading dose of clopidogrel 4 to 8 hours before PCI (n =
122) or placebo (n = 120). The primary end point was the 30-day incidence
of major adverse cardiac events (death, myocardial infarction, target
vessel revascularization). The primary end point occurred in 4.1% of
patients in the reload arm versus 14.1% in the placebo arm (odds ratio
0.26, 95% confidence interval 0.10 to 0.73, p = 0.013). This benefit in
the reload arm was mainly from the prevention of periprocedural myocardial
infarction (4.1% vs 13%, p = 0.02) and was paralleled by lower
periprocedural platelet reactivity. The aggregometry data were consistent
with the clinical outcome. No difference was found in the bleeding
outcomes between the 2 groups. In conclusion, the results from the
Antiplatelet therapy for Reduction of MYocardial Damage during Angioplasty
(ARMYDA-8 RELOAD-ACS) trial have shown a significant clinical benefit from
reloading patients with ACS receiving chronic clopidogrel therapy before
PCI. These data might be relevant in clinical practice, given the large
number of patients with ACS who are still currently treated with
clopidogrel during PCI. 2013 Elsevier Inc. All rights reserved.

<8>
Accession Number
23207562
Authors
Zheng S.Y. Wu M. Huang J.S. Mai M.J. Chen T.B. He G.W.
Institution
(Zheng) Department of Cardiovascular Surgery, Guangdong Cardiovascular
Institute, Guangdong General Hospital, Guangdong, China.
Title
Use of antispastic nicardipine and nitroglycerin (NG) cocktail solution
increases graft flow during off-pump coronary artery bypass grafting.
Source
The Journal of cardiovascular surgery. 53 (6) (pp 783-788), 2012. Date of
Publication: Dec 2012.
Abstract
NG solution composed of nicardipine and nitroglycerin is a new
anti-spastic solution for arterial grafts. We investigated its efficacy on
the left internal thoracic artery (LITA) during off-pump coronary artery
bypass grafting (OPCAB). The free flow of LITA in 41 OPCAB patients was
measured. The patients were divided to four groups: LITA pedicle wrapped
with normal saline (Group I, N.=10) or NG (Group II, N.=11); or in
addition to wrapping, 2 cc NG (Group III, N.=10) or normal saline (Group
IV, N.=10) injected into LITA. After 30 min, the distal end free flow and
the graft flow by an ultrasound probe were measured. The free flow
significantly increased in Group II (30.0+/-4.7 vs. 21.6+/-4.5 cc/min,
P=0.007) and III (70.0+/-11.5 vs. 24.5+/-6 cc/min, P=0.001) but not in
Group I (20.8+/-4.7 vs. 19.4+/-4.1 cc/min, P=0.33) or IV (35.8+/-7.5 vs.
29+/-9.2 cc/min, P=0.06) with significant differences between the Group
III to all other groups (P=0.016-0.001). The graft flow by ultrasound
probe was significantly higher in Group III (41.2+/-6.2 cc/min) than that
in Group IV (24.1+/-3.1 cc/min, P=0.028). Use of NG solution for LITA
graft preparation is a choice of antispastic protocol. NG solution used
either topically or intraluminally significantly increases the blood flow
of IMA grafts with the best effect obtained by intraluminal injection. The
present study provides an additional anti-spastic method by using second
generation of calcium antagonists and nitric oxide donor in coronary
artery bypass surgery.

<9>
Accession Number
22972072
Authors
Freitas E.R. Soares B.G. Cardoso J.R. Atallah A.N.
Institution
(Freitas) Physical Therapy Department, UNOPAR / Centro Cochrane do Brasil,
Londrina, Brazil.
Title
Incentive spirometry for preventing pulmonary complications after coronary
artery bypass graft.
Source
Cochrane database of systematic reviews (Online). 9 (pp CD004466), 2012.
Date of Publication: 2012.
Abstract
Incentive spirometry (IS) is a treatment technique that uses a mechanical
device to reduce pulmonary complications during postoperative care. This
is an update of a Cochrane review first published in 2007. Update the
previously published systematic review to compare the effects of IS for
preventing postoperative pulmonary complications in adults undergoing
coronary artery bypass graft (CABG). We searched CENTRAL and DARE on The
Cochrane Library (Issue 2 of 4 2011), MEDLINE OVID (1948 to May 2011),
EMBASE (1980 to Week 20 2011), LILACS (1982 to July 2011) , the
Physiotherapy Evidence Database (PEDro) (1980 to July 2011), Allied &
Complementary Medicine (AMED) (1985 to May 2011), CINAHL (1982 to May
2011). Randomised controlled trials comparing IS with any type of
prophylactic physiotherapy for prevention of postoperative pulmonary
complications in adults undergoing CABG. Two reviewers independently
evaluated trial quality using the guidelines of the Cochrane Handbook for
Systematic Reviews and extracted data from included trials. For continuous
outcomes, we used the generic inverse variance method for meta-analysis
and for dichotomous data we used the Peto Odds Ratio. This update included
592 participants from seven studies (two new and one that had been
excluded in the previous review in 2007. There was no evidence of a
difference between groups in the incidence of any pulmonary complications
and functional capacity between treatment with IS and treatment with
physical therapy, positive pressure breathing techniques (including
continuous positive airway pressure (CPAP), bilevel positive airway
pressure (BiPAP) and intermittent positive pressure breathing (IPPB),
active cycle of breathing techniques (ACBT) or preoperative patient
education. Patients treated with IS had worse pulmonary function and
arterial oxygenation compared with positive pressure breathing. Based on
these studies there was no improvement in the muscle strength between
groups who received IS demonstrated by maximal inspiratory pressure and
maximal expiratory pressure . Our update review suggests there is no
evidence of benefit from IS in reducing pulmonary complications and in
decreasing the negative effects on pulmonary function in patients
undergoing CABG. In view of the modest number of patients studied,
methodological shortcomings and poor reporting of the included trials,
these results should still be interpreted cautiously. An appropriately
powered trial of high methodological rigour is needed to determine if
there are patients who may derive benefit from IS following CABG.

<10>
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Accession Number
20551371
Authors
Reed S.D. Whellan D.J. Li Y. Friedman J.Y. Ellis S.J. Pina I.L. Settles
S.J. Davidson-Ray L. Johnson J.L. Cooper L.S. O'Connor C.M. Schulman K.A.
HF-ACTION Investigators
Institution
(Reed) Duke Clinical Research Institute, Duke University School of
Medicine, Durham, NC 27715, USA.
Title
Economic evaluation of the HF-ACTION (Heart Failure: A Controlled Trial
Investigating Outcomes of Exercise Training) randomized controlled trial:
an exercise training study of patients with chronic heart failure.
Source
Circulation. Cardiovascular quality and outcomes. 3 (4) (pp 374-381),
2010. Date of Publication: Jul 2010.
Abstract
Heart Failure: A Controlled Trial Investigating Outcomes of Exercise
Training (HF-ACTION) assigned 2331 outpatients with medically stable heart
failure to exercise training or usual care. We compared medical resource
use and costs incurred by these patients during follow-up. Extensive data
on medical resource use and hospital bills were collected throughout the
trial for estimates of direct medical costs. Intervention costs were
estimated using patient-level trial data, administrative records, and
published unit costs. Mean follow-up was 2.5 years. There were 2297
hospitalizations in the exercise group and 2332 in the usual care group
(P=0.92). The mean number of inpatient days was 13.6 (standard deviation
[SD], 27.0) in the exercise group and 15.0 (SD, 31.4) in the usual care
group (P=0.23). Other measures of resource use were similar between
groups, except for trends indicating that fewer patients in the exercise
group underwent high-cost inpatient procedures. Total direct medical costs
per participant were an estimated $50,857 (SD, $81,488) in the exercise
group and $56,177 (SD, $92,749) in the usual care group (95% confidence
interval for the difference, $-12,755 to $1547; P=0.10). The direct cost
of exercise training was an estimated $1006 (SD, $337). Patient time costs
were an estimated $5018 (SD, $4600). The cost of exercise training was
relatively low for the health care system, but patients incurred
significant time costs. In this economic evaluation, there was little
systematic benefit in terms of overall medical resource use with this
intervention. URL: http://www.clinicaltrials.gov. Unique identifier:
NCT00047437.

<11>
Accession Number
2013421311
Authors
Wojakowski W. Pyrlik A. Krol M. Buszman P. Ochala A. Milewski K. Smolka G.
Kawecki D. Rudnik A. Pawlowski T. Jadczyk T. Wyderka R. Cybulski W.
Dworowy S. Tendera M.
Institution
(Wojakowski, Pyrlik, Ochala, Smolka, Pawlowski, Jadczyk, Wyderka,
Cybulski, Dworowy, Tendera) Third Division of Cardiology, Medical
University of Silesia, Ziolowa 45-47, 40-635 Katowice, Poland
(Krol, Buszman, Milewski, Rudnik) American Heart of Poland, Ustron, Poland
(Kawecki) Division of Cardiology, Medical University of Silesia, Zabrze,
Poland
Title
Circulating endothelial progenitor cells are inversely correlated with
in-stent restenosis in patients with non-ST-segment elevation acute
coronary syndromes treated with EPC-capture stents (JACK-EPC trial).
Source
Minerva Cardioangiologica. 61 (3) (pp 301-311), 2013. Date of Publication:
June 2013.
Publisher
Edizioni Minerva Medica (Corso Bramante 83-85, Torino 10126, Italy)
Abstract
Aim. Aim of the study was to evaluate the association between circulating
endothelial progenitor cells (EPCs) and angiographic outcomes after
implantation of Genous stent in patients with non-ST-segment elevation
acute coronary syndromes (ACS) (NSTE-ACS) undergoing urgent percutaneous
coronary intervention (PCI). Methods. Sixty patients treated with
EPC-capture stent (N.=30) or bare metal stents (BMS) (N.=30) receiving 80
mg atorvastatin and dual antiplatelet therapy (DAT) for 12 months.
Restenosis was assessed after 6 months by quantitative coronary
angiography (QCA) and major acute coronary events (MACE) evaluated after 6
and 12 months. Inclusion criteria: de novo lesion >70% in native vessel,
diameter 2.5-4 mm, lesion length <30 mm. Exclusion criteria: diabetes,
previous revascularization, significant left main stenosis, chronic total
occlusions (CTO) and multivessel disease. Results. Majority of patients in
EPC-capture stent and BMS groups presented with NSTE-MI (73.3% and 70%,
respectively). Mean stent length was 20.1+/-8 and 19.9+/-10 mm, diameter
3+/-0.97 and 3.1+/-0.88 mm in respective groups. The binary restenosis was
significantly lower in Genous (13 vs. 26.6%, P=0.04). Risk of MACE after 6
and 12 months were comparable in both groups. There was no stent
thrombosis. Numbers of circulating EPCs were significantly approximately
2-fold higher during the ACS than after 6 months. Mobilization of EPCs
during acute ischemia was significantly lower in patients who developed
restenosis after 6 months (3 vs. 4.5 cells/muL, P=0.002) and it was
negatively correlated with late-loss after 6 months (R=-0.42; P<0.03).
Conclusion. Use of Genous stents in NSTE-ACS is associated with lower
restenosis rate than BMS at 6 months. There was no ST through 1 year. The
number of circulating EPCs is inversely correlated with in-stent late loss
(LL).

<12>
Accession Number
2013416262
Authors
Ngai K.M.G.
Institution
(Ngai) Department of Emergency Medicine, Mount Sinai School of Medicine,
New York, NY, United States
Title
Prehospital fibrinolysis as an alternative to primary percutaneous
coronary intervention in ST-segment elevation myocardial infarction when
resources are limited.
Source
Journal of Clinical Outcomes Management. 20 (6) (pp 250-253), 2013. Date
of Publication: June 2013.
Publisher
Turner White Communications Inc. (125 Strafford Avenue, Suite 220, Wayne
PA 19087-3391, United States)

<13>
Accession Number
2013404938
Authors
Moss E. Miller C.S. Jensen H. Basmadjian A. Bouchard D. Carrier M.
Perrault L.P. Cartier R. Pellerin M. Demers P.
Institution
(Moss, Jensen, Bouchard, Carrier, Perrault, Cartier, Pellerin, Demers)
Department of Cardiac Surgery, Montreal Heart Institute, Universite de
Montreal, 5000 Belanger Street, Montreal, QC H1T 1C8, Canada
(Miller) Faculty of Medicine, McGill University, Montreal, QC, Canada
(Basmadjian) Department of Medicine, Montreal Heart Institute/Universite
de Montreal, Montreal, QC, Canada
Title
A randomized trial of early versus delayed mediastinal drain removal after
cardiac surgery using silastic and conventional tubes.
Source
Interactive Cardiovascular and Thoracic Surgery. 17 (1) (pp 110-115),
2013. Date of Publication: July 2013.
Publisher
Oxford University Press (Great Clarendon Street, Oxford OX2 6DP, United
Kingdom)
Abstract
OBJECTIVESMediastinal drainage following cardiac surgery with traditional
large-bore plastic tubes can be painful and cumbersome. This study was
designed to determine whether prolonged drainage (5 days) with a silastic
tube decreased the incidence of significant pericardial effusion and
tamponade following aortic or valvular surgery.METHODSOne hundred and
fifty patients undergoing valvular or aortic surgery in a tertiary cardiac
surgery institution were randomized to receive a conventional mediastinal
tube plus a silastic Blake drain (n = 75), or two conventional tubes (n =
75). Conventional drains were removed on postoperative day (POD) 1, while
Blake drains were removed on POD 5. The primary end-point was the combined
incidence of significant pericardial effusion (>=15 mm) or tamponade
through POD 5. Secondary end-points included total mediastinal drainage,
postoperative atrial fibrillation (AF) and pain.RESULTSAnalysis was
performed for 67 patients in the Blake group and 73 in the conventional
group. There was no difference between the two groups in the combined
end-point of significant effusion or tamponade (7.4 vs 8.3%, P = 0.74), or
in the incidence of AF (47 vs 46%, P = 0.89). Mean 24-h drainage was
greater in the Blake group than in the conventional group (749 +/- 444 ml
vs 645 +/- 618 ml, P < 0.01). Overall incidence of significant pericardial
effusion at 30 days was 12.1% (n = 17), with 5% (n = 7) requiring
drainage. The Blake group had a numerically lower incidence of effusion
requiring drainage at POD 30 (3.0 vs 6.8%, P = 0.44). Postoperative pain
was similar between groups.CONCLUSIONSIn patients undergoing ascending
aortic or valvular surgery, prolonged drainage with silastic tubes is safe
and does not increase postoperative pain. There was no difference between
the Blake and conventional drains with regard to significant pericardial
effusion or tamponade in this cohort; however, this conclusion is limited
by the low overall incidence of the primary outcome in this cohort. 2013
The Author. Published by Oxford University Press on behalf of the European
Association for Cardio-Thoracic Surgery. All rights reserved.

<14>
Accession Number
22248761
Authors
de Oliveira R.M. Tenorio S.B. Tanaka P.P. Precoma D.
Institution
(de Oliveira) Universidade Federal do Parana (UFPR), Brazil.
Title
Control of pain through epidural block and incidence of cardiac
dysrhythmias in postoperative period of thoracic and major abdominal
surgical procedures: a comparative study.
Source
Revista brasileira de anestesiologia. 62 (1) (pp 10-18), 2012. Date of
Publication: 2012 Jan-Feb.
Abstract
Upper abdomen and thorax surgeries cause intense pain. Some of
postoperative pain main complications are cardiocirculatory complications.
The objective of this study was to test the hypothesis that postoperative
analgesia with employment of local anesthetics plus spinal opioids may
reduce the incidence of cardiovascular complications in postoperative
period of patients in these conditions, comparing with classical methods
of postoperative analgesia, opioids and NSAIDs, administered upon
patient's demand. Eighty adult patients, ASA I and II, without ECG
alterations, were allocated into two groups of 40: Group A, patients under
general anesthesia with propofol, cisatracurium and isoflurane, associated
with epidural anesthesia with catheter and control of postoperative
analgesia with bupivacaine and epidural morphine; and Group B, patients
under general anesthesia with the same drugs and doses of A, plus
postoperative analgesia carried out with NSAIDs and intravenous morphine
at the end of surgery and in regular intervals. In both groups Holter was
applied for 24 hours. Pain evaluation was carried out through visual
analog scale. In pain evaluation, an evident predominance of 0 score
(p<0.001) was observed in Group A and there was also reduction of blood
pressure levels in postoperative period in a more accentuated way.
Ventricular and supraventricular dysrhythmias were five times more
frequent in Group B (p=0.00001), in which a tendency to a higher frequency
of ventricular extrasystoles in age>50 years (22.2% versus 0.0%. p=0.26)
was also detected. No significative difference of heart rate among groups
(p>0.05) was observed. The best quality of analgesia in postoperative
period, carried out in Group A, reduced the incidence of cardiovascular
complications. Copyright 2012 Elsevier Editora Ltda. All rights reserved.

<15>
Accession Number
21226918
Authors
Biere S.S. Maas K.W. Bonavina L. Garcia J.R. van Berge Henegouwen M.I.
Rosman C. Sosef M.N. de Lange E.S. Bonjer H.J. Cuesta M.A. van der Peet
D.L.
Institution
(Biere) Department of Surgery, VU university medical center, Amsterdam,
the Netherlands.
Title
Traditional invasive vs. minimally invasive esophagectomy: a multi-center,
randomized trial (TIME-trial).
Source
BMC surgery. 11 (pp 2), 2011. Date of Publication: 2011.
Abstract
There is a rise in incidence of esophageal carcinoma due to increasing
incidence of adenocarcinoma. Probably the only curative option to date is
the use of neoadjuvant therapy followed by surgical resection. Traditional
open esophageal resection is associated with a high morbidity and
mortality rate. Furthermore, this approach involves long intensive care
unit stay, in-hospital stay and long recovery period. Minimally invasive
esophagectomy could reduce the morbidity and accelerate the post-operative
recovery. Comparison between traditional open and minimally invasive
esophagectomy in a multi-center, randomized trial. Patients with a
resectable intrathoracic esophageal carcinoma, including the
gastro-esophageal junction tumors (Siewert I) are eligible for inclusion.
Prior thoracic surgery and cervical esophageal carcinoma are indications
for exclusion. The surgical technique involves a right thoracotomy with
lung blockade and laparotomy either with a cervical or thoracic
anastomosis for the traditional group. The minimally invasive procedure
involves a right thoracoscopy in prone position with a single lumen tube
and laparoscopy either with a cervical or thoracic anastomosis. All
patients in both groups will undergo identical pre-operative and
post-operative protocol. Primary endpoint of this study are post-operative
respiratory complications within the first two post-operative weeks
confirmed by clinical, radiological and sputum culture data. Secondary
endpoints are the operative data, the post-operative data and oncological
data such as quality of the specimen and survival. Operative data include
duration of the operation, blood loss and conversion to open procedure.
Post-operative data include morbidity (major and minor), quality of life
tests and hospital stay.Based on current literature and the experience of
all participating centers, an incidence of pulmonary complications for 57%
in the traditional arm and 29% in the minimally invasive arm, it is
estimated that per arm 48 patients are needed. This is based on a
two-sided significance level (alpha) of 0.05 and a power of 0.80. Knowing
that approximately 20% of the patients will be excluded, we will randomize
60 patients per arm. The TIME-trial is a prospective, multi-center,
randomized study to define the role of minimally invasive esophageal
resection in patients with resectable intrathoracic and junction
esophageal cancer. TRIAL REGISTRATION (NETHERLANDS TRIAL REGISTER):
NTR2452.

<16>
Accession Number
22066355
Authors
Azarnoush K. Camilleri L. Aublet-Cuvelier B. Geoffroy E. Dauphin C. Dubray
C. De Riberolles C.
Institution
(Azarnoush) Heart Surgery Department, Hopital Gabriel Montpied CHU
Clermont-Ferrand, France.
Title
Results of the first randomized French study evaluating self-testing of
the International Normalized Ratio.
Source
The Journal of heart valve disease. 20 (5) (pp 518-525), 2011. Date of
Publication: Sep 2011.
Abstract
In this single-center French study, the conventional management of
patients receiving vitamin K antagonists (VKAs) was compared with an
International Normalized Ratio (INR) self-testing program. The aim was to
determine the reliability of self-testing devices, and to estimate the
variability of the self-measured INR within the therapeutic and target
range. A total of 206 patients who had undergone valve replacement with a
mechanical prosthesis, with or without myocardial revascularization,
between May 2004 and September 2007 was randomized into two groups. Group
1 patients (n = 103) underwent INR monitoring at a laboratory, while Group
2 patients (n = 103) underwent self-testing INR using either the CoaguChek
(Roche) (Group 2A; n = 55) or INRatio (Hemosense) (Group 2B; n = 48)
system. Patients in Group 1 underwent at least once-monthly INR
measurement, while those in Group 2 carried out once-weekly self-testing,
and also underwent once-monthly INR measurement at the laboratory. The
large majority of patients (97.9%) were treated with fluindione. The mean
follow up period was 49.0 +/- 10.3 weeks. Self-testing was reliable, with
a correlation coefficient between device- and laboratory-measured INRs of
0.80 [CI: 0.78, 0.82] (p < 0.0001). The proportion of time spent within
the INR target range was significantly higher for Group 2 (61.5 +/- 19.3%
versus 55.5 +/- 19.9%; p < 0.05), while the absolute mean deviation of INR
from the target range was higher in Group 1 (60.1 +/- 70.2% versus 47.4
+/- 51.5%). Adverse events were reported by seven patients in Group 1, but
by no patients in Group 2 (p < 0.01). INR self-testing devices are
reliable and beneficial. Moreover, INR self-monitoring allows an enhanced
stability within a target range, and also helps to prevent serious
postoperative complications.

<17>
Accession Number
20923922
Authors
Mitchell A.J. Lord O.
Institution
(Mitchell) Department of Liaison Psychiatry, Leicester General Hospital,
Leicester, UK.
Title
Do deficits in cardiac care influence high mortality rates in
schizophrenia? A systematic review and pooled analysis.
Source
Journal of psychopharmacology (Oxford, England). 24 (4 Suppl) (pp 69-80),
2010. Date of Publication: Nov 2010.
Abstract
We have previously documented inequalities in the quality of medical care
provided to those with mental ill health but the implications for
mortality are unclear. We aimed to test whether disparities in medical
treatment of cardiovascular conditions, specifically receipt of medical
procedures and receipt of prescribed medication, are linked with elevated
rates of mortality in people with schizophrenia and severe mental illness.
We undertook a systematic review of studies that examined medical
procedures and a pooled analysis of prescribed medication in those with
and without comorbid mental illness, focusing on those which recruited
individuals with schizophrenia and measured mortality as an outcome. From
17 studies of treatment adequacy in cardiovascular conditions, eight
examined cardiac procedures and nine examined adequacy of prescribed
cardiac medication. Six of eight studies examining the adequacy of cardiac
procedures found lower than average provision of medical care and two
studies found no difference. Meta-analytic pooling of nine medication
studies showed lower than average rates of prescribing evident for the
following individual classes of medication; angiotensin converting enzyme
inhibitors (n = 6, aOR = 0.779, 95% CI = 0.638-0.950, p = 0.0137),
beta-blockers (n = 9, aOR = 0.844, 95% CI = 0.690-1.03, p = 0.1036) and
statins (n = 5, aOR = 0.604, 95% CI = 0.408-0.89, p = 0.0117). No
inequality was evident for aspirin (n = 7, aOR = 0.986, 95% CI =
0.7955-1.02, p = 0.382). Interestingly higher than expected prescribing
was found for older non-statin cholesterol-lowering agents (n = 4, aOR =
1.55, 95% CI = 1.04-2.32, p = 0.0312). A search for outcomes in this
sample revealed ten studies linking poor quality of care and possible
effects on mortality in specialist settings. In half of the studies there
was significantly higher mortality in those with mental ill health
compared with controls but there was inadequate data to confirm a
causative link. Nevertheless, indirect evidence supports the observation
that deficits in quality of care are contributing to higher than expected
mortality in those with severe mental illness (SMI) and schizophrenia. The
quality of medical treatment provided to those with cardiac conditions and
comorbid schizophrenia is often suboptimal and may be linked with
avoidable excess mortality. Every effort should be made to deliver
high-quality medical care to people with severe mental illness.

<18>
Accession Number
20940567
Authors
Mo J. Oh H. Ahn Y. Seo W.
Institution
(Mo) Department of Rehabilitation Standard & Policy, National
Rehabilitation Center Research Institute, Seoul, Republic of Korea.
Title
Implementation of a clinical pathway in primary spontaneous pneumothorax
patients treated by wedge resection surgery.
Source
Clinical nurse specialist CNS. 24 (6) (pp 295-303), 2010. Date of
Publication: 2010 Nov-Dec.
Abstract
This study was conducted to develop a clinical pathway for primary
spontaneous pneumothorax (PSP) patients treated by wedge resection
surgery. The authors also aimed to evaluate the effects of the
implementation of the PSP clinical pathway on (1) complication occurrence
rates, (2) self-efficacy with respect to PSP recurrence prevention, (3)
patient-perceived quality of life, and (4) patient treatment satisfaction.
This study was conducted using a quasi-experimental, nonequivalent study
design. The study subjects were 60 PSP patients admitted to the thoracic
surgery departments at 2 university hospitals located in Seoul, South
Korea. A retrospective medical record review was conducted to develop a
PSP clinical pathway, and the developed clinical pathway was then applied
to the treatment group (n = 30). Complication occurrence rates,
self-efficacy with respect to PSP recurrence prevention, perceived quality
of life, and patient treatment satisfaction were measured. The developed
PSP clinical pathway is comprehensive and includes self-care and
recurrence prevention education in addition to common protocols, such as
medication and diagnostic tests. The pathway significantly improved
self-efficacy with respect to preventing PSP recurrence, health-related
quality of life, and patient treatment satisfaction, but did not reduce
complication rates. The present study offers a new comprehensive clinical
pathway for PSP patients who have undergone wedge resection surgery. This
study may be useful in the clinical nursing field by providing guiding
standards for PSP-related education with respect to diet, exercise,
self-supervision, complication, stress control, and recurrence prevention.

<19>
Accession Number
20884442
Authors
Testa L. Agostoni P. Vermeersch P. Biondi-Zoccai G. Van Gaal W. Bhindi R.
Brilakis E. Latini R.A. Laudisa M.L. Pizzocri S. Lanotte S. Brambilla N.
Banning A. Bedogni F.
Institution
(Testa) Department of Interventional Cardiology, Istituto clinico S.
Ambrogio, Milan, Italy.
Title
Drug eluting stents versus bare metal stents in the treatment of saphenous
vein graft disease: a systematic review and meta-analysis.
Source
EuroIntervention : journal of EuroPCR in collaboration with the Working
Group on Interventional Cardiology of the European Society of Cardiology.
6 (4) (pp 527-536), 2010. Date of Publication: Sep 2010.
Abstract
Treatment of saphenous vein graft (SVG) disease is still a matter of
debate given the uncertainty of the available conflicting data. Our aim
was to assess, by means of a meta-analytic approach, the risk/benefit
profile of drug eluting stents (DES) versus bare metal stents (BMS) in the
treatment of SVG disease. A search of relevant studies in several
databases was performed. The endpoints of interest such as: major adverse
events (MAE) (the combination of overall death and non-fatal myocardial
infarction [AMI]), target vessel revascularisation (TVR), and target
lesion revascularisation (TLR) have been calculated in-hospital and at the
longest follow-up. Single endpoints and the rate of stent thrombosis (ST)
were also assessed. Three randomised controlled trials and 15 registry
studies were appraised, totalling 3,294 patients. During hospitalisation,
there was no difference in the risk of MAE, overall death, AMI and TVR. No
data were available to calculate the TLR rate. At a mean follow-up of 19.8
months, no significant differences were found in the risk of MAE and AMI.
BMS were associated with a trend towards a higher risk of overall death
(OR 1.32 [1,00-1.74], p=0.05, number needed to treat [NNT]=55). DES showed
superiority in terms of TVR (OR 1.86 [1.33-2.61], p=0.0003, NNT=16), and
TLR (OR 1.77 [1.27-2.48], p<0.0001, NNT=25). According to pre-specified
subgroup analyses, these effects seem less evident at the long-term
follow-up. DES were not associated with an increased risk of ST. Use of
DES in SVG substantially reduces both TVR and TLR. These data also
demonstrate that using DES in SVG is safe and contradict previous reports
of potential risks.

<20>
Accession Number
2013413358
Authors
Kenngott H.G. Clemens G. Gondan M. Senft J. Diener M.K. Rudofsky G.
Nawroth P.P. Buchler M.W. Fischer L. Muller-Stich B.P.
Institution
(Kenngott, Clemens, Senft, Diener, Buchler, Fischer, Muller-Stich)
Department of General, Visceral and Transplantation Surgery, University of
Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
(Gondan) Institute of Medical Biometry and Informatics, University of
Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
(Diener) Study Center of the German Surgical Society (SDGC), University of
Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg, Germany
(Rudofsky, Nawroth) Department of Medicine I and Clinical Chemistry,
University of Heidelberg, Im Neuenheimer Feld 110, 69120 Heidelberg,
Germany
Title
DiaSurg 2 trial - surgical vs. medical treatment of insulin-dependent type
2 diabetes mellitus in patients with a body mass index between 26 and 35
kg/m2: Study protocol of a randomized controlled multicenter trial -
DRKS00004550.
Source
Trials. 14 (1) , 2013. Article Number: 183. Date of Publication: 20 Jun
2013.
Publisher
BioMed Central Ltd. (Floor 6, 236 Gray's Inn Road, London WC1X 8HB, United
Kingdom)
Abstract
Background: Type 2 diabetes mellitus (T2DM) is a disease with high
prevalence, associated with severe co-morbidities as well as being a huge
burden on public health. It is known that glycemic control decreases
long-term morbidity and mortality. The current standard therapy for T2DM
is medical treatment. Several randomized controlled trials (RCTs)
performed in obese patients showed remission of T2DM after bariatric
surgery. Recent RCTs have shown bariatric procedures to produce a similar
effect in non-morbidly and non-severely obese, insulin-dependent T2DM
patients suggesting procedures currently used in bariatric surgery as new
therapeutical approach in patients with T2DM. This study aims at
investigating whether Roux-en-Y gastric bypass (RYGB) is an efficient
treatment for non-severely obese T2DM patients in terms of preventing
long-term complications and mortality.Methods: The DiaSurg 2 trial is a
multicenter, open randomized controlled trial comparing RYGB including
standardized medical treatment if needed to exclusive standardized medical
treatment of T2DM (control group). The primary endpoint is a composite
time-to-event endpoint (cardiovascular death, myocardial infarction,
coronary bypass, percutaneous coronary intervention, non-fatal stroke,
amputation, surgery for peripheral atherosclerotic artery disease), with a
follow-up period of 8 years. Insulin-dependent T2DM patients aged between
30 and 65 years will be included and randomly assigned to one of the two
groups. The experimental group will receive RYGB and, if needed,
standardized medical care, whereas the control group will receive
exclusive standardized medical care, both according to the national
treatment guidelines for T2DM. Statistical analysis is based on Cox
proportional hazards regression for the intention-to-treat population.
Assuming a loss to follow-up rate of 20%, 200 patients will be randomly
allocated to the comparison groups. A total sample size of n = 400 is
sufficient to ensure 80% power in a two-tailed significance test at alpha
= 5%.Discussion: The DiaSurg2 trial will yield long-term data (8 years) on
diabetes-associated morbidity and mortality in patients with
insulin-dependent T2DM receiving either RYGB or standardized medical
care.Trial registration: The trial protocol has been registered in the
German Clinical Trials Register DRKS00004550. 2013 Kenngott et al.;
licensee BioMed Central Ltd.

<21>
Accession Number
2013418147
Authors
Imazio M. Belli R. Brucato A. Ferrazzi P. Patrini D. Martinelli L. Polizzi
V. Cemin R. Leggieri A. Caforio A.L.P. Finkelstein Y. Hoit B. Maisch B.
Mayosi B.M. Oh J.K. Ristic A.D. Seferovic P. Spodick D.H. Adler Y.
Institution
(Imazio, Belli, Leggieri) Cardiology Department, Maria Vittoria Hospital,
Pharmacology Unit, Via Cibrario 72, 10141 Torino, Italy
(Brucato, Ferrazzi) Internal Medicine and Cardiac Surgery Departments,
Ospedali Riuniti, Bergamo, Italy
(Patrini) Humanitas Gavazzeni, Bergamo, Italy
(Martinelli) Ospedale Niguarda, Milano, Italy
(Polizzi) Ospedale San Camillo-Forlanini, Roma, Italy
(Cemin) Ospedale Regionale San Maurizio, Bolzano, Italy
(Caforio) Department of Cardiological Thoracic and Vascular Sciences,
Azienda Ospedaliera-Policlinico Universitario, Padova, Italy
(Finkelstein) Department of Pediatrics, Hospital for Sick Children,
University of Toronto, Toronto, ON, Canada
(Hoit) Harrington Heart and Vascular Institute, University Hospitals Case
Medical Center, Cleveland, OH, United States
(Maisch) Giessen and Marburg University, Marburg, Germany
(Mayosi) Department of Medicine, Groote Schuur Hospital, University of
Cape Town, Cape Town, South Africa
(Oh) Mayo Clinic, Division of Cardiovascular Diseases, Rochester, MN,
United States
(Ristic, Seferovic) Department of Cardiology, Clinical Centre of Serbia,
Belgrade University School of Medicine, Belgrade, Serbia
(Spodick) Internal Medicine Department, St Vincent Hospital, Worcester,
MA, United States
(Adler) Chaim Sheba Medical Center, Tel Hashomer and Sacker Faculty of
Medicine, Tel Aviv, Israel
Title
Rationale and design of the colchicine for prevention of the
post-pericardiotomy syndrome and post-operative atrial fibrillation
(COPPS-2 trial): A randomized, placebo-controlled, multicenter study on
the use of colchicine for the primary prevention of the postpericardiotomy
syndrome, postoperative effusions, and postoperative atrial fibrillation.
Source
American Heart Journal. 166 (1) (pp 13-19.e1), 2013. Date of Publication:
July 2013.
Publisher
Mosby Inc. (11830 Westline Industrial Drive, St. Louis MO 63146, United
States)
Abstract
Background The efficacy and safety of colchicine for the primary
prevention of the postpericardiotomy syndrome (PPS), postoperative
effusions, and postoperative atrial fibrillation (POAF) remain uncertain.
Although preliminary data from a single trial of colchicine given for 1
month postoperatively (COPPS trial) were promising, the results have not
been confirmed in a large, multicenter trial. Moreover, in the COPPS
trial, colchicine was given 3 days postoperatively. Methods The COPPS-2
study is a multicenter, double-blind, placebo-controlled randomized trial.
Forty-eight to 72 hours before planned cardiac surgery, 360 patients, 180
in each treatment arm, will be randomized to receive placebo or colchicine
without a loading dose (0.5 mg twice a day for 1 month in patients
weighing >=70 kg and 0.5 mg once for patients weighing <70 kg or
intolerant to the highest dose). The primary efficacy end point is the
incidence of PPS, postoperative effusions, and POAF at 3 months after
surgery. Secondary end points are the incidence of cardiac tamponade or
need for pericardiocentesis or thoracentesis, PPS recurrence,
disease-related admissions, stroke, and overall mortality. Conclusions The
COPPS-2 trial will evaluate the use of colchicine for the primary
prevention of PPS, postoperative effusions, and POAF, potentially
providing stronger evidence to support the use of preoperative colchicine
without a loading dose to prevent several postoperative complications.
ClinicalTrials.gov Identifier: NCT01552187. 2013 Mosby, Inc.

<22>
Accession Number
2013398785
Authors
Khan M.F. Wendel C.S. Thai H.M. Movahed M.R.
Institution
(Khan, Wendel, Thai, Movahed) Southern Arizona VA Health Care System,
Tucson, AZ, United States
(Khan, Thai, Movahed) University of Arizona, Tucson, AZ, United States
Title
Effects of percutaneous revascularization of chronic total occlusions on
clinical outcomes: A meta-analysis comparing successful versus failed
percutaneous intervention for chronic total occlusion.
Source
Catheterization and Cardiovascular Interventions. 82 (1) (pp 95-107),
2013. Date of Publication: 01 Jul 2013.
Publisher
Wiley-Liss Inc. (111 River Street, Hoboken NJ 07030-5774, United States)
Abstract
Background Chronic total occlusions (CTOs) represent the most complex and
challenging coronary lesions for percutaneous coronary intervention (PCI).
PCI for a CTO is a high-risk procedure and the long-term benefits of a
successful percutaneous CTO recanalization over the medical management (as
a result of failed PCI) are not clear, as the studies have shown
conflicting results in the past. The goal of this analysis was to clarify
this issue by performing a meta-analysis of the available literature.
Methods Using major electronic databases, we searched for studies
(randomized or observational) comparing death, major adverse
cardiovascular events (MACE), myocardial infarction (MI), and target
vessel revascularization (TVR) between patients who underwent PCI
recanalization of CTOs versus those treated with medical management as a
result of failed PCI attempts. Results We identified 23 observational
studies comparing the desired clinical parameters between patients with
successful CTO recanalization and those managed conservatively as a result
of attempted but failed PCI. The total number of patients observed in all
of the studies was 12,970 and the mean time of follow up was 3.7 +/- 2.1
years. Our results indicated that successful recanalization of a CTO
results in improved all-cause mortality (relative risk [RR] of 0.54, 95%
confidence interval [CI] (0.45-0.65), P-value < 0.001), lower rates of
MACE (RR of 0.70, 95% CI 0.60-0.83, P-value < 0.001) and reduced needs for
subsequent bypass surgery (RR of 0.25, 95% CI (0.21-0.30), P-value <
0.001). The difference in long-term mortality remained statistically
significant even after the adjustment for procedure related complications
and in-hospital deaths. Conclusion As compared to conservative management
(as a result of failed intervention), successful PCI recanalization of a
CTO appears to be associated with improved long-term clinical outcomes;
however, randomized controlled trials (RCTs) are needed to further confirm
these results. Copyright 2013 Wiley Periodicals, Inc.

<23>
Accession Number
2013412631
Authors
Rivera C. Falcoz P.-E. Rami-Porta R. Velly J.-F. Begueret H. Roques X.
Dahan M. Jougon J.
Institution
(Rivera, Velly, Jougon) Department of Thoracic Surgery, Haut Leveque
Hospital, University of Bordeaux, Bordeaux, France
(Falcoz) Department of Thoracic Surgery, Civil Hospital, University of
Strasbourg, Strasbourg, France
(Rami-Porta) Department of Thoracic Surgery, Mutua Terrassa University
Hospital, University of Barcelona, Barcelona, Spain
(Begueret) Department of Pathology, Haut Leveque Hospital, University of
Bordeaux, Bordeaux, France
(Roques) Department of Cardiac Surgery, Haut Leveque Hospital, University
of Bordeaux, Bordeaux, France
(Dahan) Department of Thoracic Surgery, Larrey Hospital, University of
Toulouse, Toulouse, France
Title
Mediastinal lymphadenectomy in elderly patients with non-small-cell lung
cancer.
Source
European Journal of Cardio-thoracic Surgery. 44 (1) (pp 88-92), 2013.
Article Number: ezs586. Date of Publication: July 2013.
Publisher
European Association for Cardio-Thoracis Surgery (3 Park Street, Windsor,
Berkshire SL4 1LU, United Kingdom)
Abstract
Objectives: The progressive ageing of the population is accompanied by an
increasing incidence of cancer. Our objective was to compare mediastinal
lymphadenectomy performed in the surgical treatment of non-small-cell lung
cancer (NSCLC) patients between >=70 and <70. Methods: We performed a
retrospective single-centre case-control study, including 80 patients >=70
years of age, surgically treated for NSCLC between January 2008 and
December 2010, matched 1:1 to 80 younger controls on gender, American
Society of Anesthesia score, performance status and histological subtype
of the tumour. The number and type of dissected hilar/intrapulmonary and
mediastinal lymph node stations as well as the number of resected lymph
nodes were compared between the two age groups. Results: The type of
pulmonary resection was significantly different between the two groups (P
= 0.03): pneumonectomy 6% (n = 5) for patients >=70 vs 12% (n = 10) for
patients <70, lobectomy 85 (n = 68) vs 65% (n = 52), bilobectomy 1 (n = 1)
vs 2% (n = 2) and sublobar resection 7 (n = 6) vs 20% (n = 16). There was
no significant difference in type of mediastinal lymphadenectomy (radical
vs sampling; P = 0.6). Elderly patients presented a more advanced N status
of lymph node invasion than younger controls (P = 0.02). The number and
type of dissected lymph node stations and the number of lymph nodes were
not significantly different between the two age groups (P = 0.66 and 0.25,
respectively). The mean number of metastatic lymph nodes was higher in
patients >=70 (2.3 vs 1.3 in patients <70; P = 0.002). Lymph node ratio
between metastatic and resected lymph nodes was higher in elderly patients
(0.11 vs 0.07 in younger controls; P = 0.009). Conclusions: Lymph node
involvement in surgically treated NSCLC was more significant in elderly
patients >=70 than in younger patients presenting comparable clinical and
histopathological characteristics, and undergoing a similar
lymphadenectomy. The Author 2012. Published by Oxford University Press on
behalf of the European Association for Cardio-Thoracic Surgery.

<24>
Accession Number
23152283
Authors
Hulzebos E.H. Smit Y. Helders P.P. van Meeteren N.L.
Institution
(Hulzebos) Department of Child Development and Exercise Center,University
Children's Hospital and Medical Center Utrecht, Utrecht, Netherlands. 2c/o
Cochrane Heart Group, London, UK.
Title
Preoperative physical therapy for elective cardiac surgery patients.
Source
Cochrane database of systematic reviews (Online). 11 (pp CD010118), 2012.
Date of Publication: 2012.
Abstract
After cardiac surgery, physical therapy is a routine procedure delivered
with the aim of preventing postoperative pulmonary complications. To
determine if preoperative physical therapy with an exercise component can
prevent postoperative pulmonary complications in cardiac surgery patients,
and to evaluate which type of patient benefits and which type of physical
therapy is most effective. Searches were run on the Cochrane Central
Register of Controlled Trials (CENTRAL) on the Cochrane Library (2011,
Issue 12 ); MEDLINE (1966 to 12 December 2011); EMBASE (1980 to week 49,
2011); the Physical Therapy Evidence Database (PEDro) (to 12 December
2011) and CINAHL (1982 to 12 December 2011). Randomised controlled trials
or quasi-randomised trials comparing preoperative physical therapy with no
preoperative physical therapy or sham therapy in adult patients undergoing
elective cardiac surgery. Data were collected on the type of study,
participants, treatments used, primary outcomes (postoperative pulmonary
complications grade 2 to 4: atelectasis, pneumonia, pneumothorax,
mechanical ventilation > 48 hours, all-cause death, adverse events) and
secondary outcomes (length of hospital stay, physical function measures,
health-related quality of life, respiratory death, costs). Data were
extracted by one review author and checked by a second review author.
Review Manager 5.1 software was used for the analysis. Eight randomised
controlled trials with 856 patients were included. Three studies used a
mixed intervention (including either aerobic exercises or breathing
exercises); five studies used inspiratory muscle training. Only one study
used sham training in the controls. Patients that received preoperative
physical therapy had a reduced risk of postoperative atelectasis (four
studies including 379 participants, relative risk (RR) 0.52; 95% CI 0.32
to 0.87; P = 0.01) and pneumonia (five studies including 448 participants,
RR 0.45; 95% CI 0.24 to 0.83; P = 0.01) but not of pneumothorax (one study
with 45 participants, RR 0.12; 95% CI 0.01 to 2.11; P = 0.15) or
mechanical ventilation for > 48 hours after surgery (two studies with 306
participants, RR 0.55; 95% CI 0.03 to 9.20; P = 0.68). Postoperative death
from all causes did not differ between groups (three studies with 552
participants, RR 0.66; 95% CI 0.02 to 18.48; P = 0.81). Adverse events
were not detected in the three studies that reported on them. The length
of postoperative hospital stay was significantly shorter in experimental
patients versus controls (three studies with 347 participants, mean
difference -3.21 days; 95% CI -5.73 to -0.69; P = 0.01). One study
reported a reduced physical function measure on the six-minute walking
test in experimental patients compared to controls. One other study
reported a better health-related quality of life in experimental patients
compared to controls. Postoperative death from respiratory causes did not
differ between groups (one study with 276 participants, RR 0.14; 95% CI
0.01 to 2.70; P = 0.19). Cost data were not reported on. Evidence derived
from small trials suggests that preoperative physical therapy reduces
postoperative pulmonary complications (atelectasis and pneumonia) and
length of hospital stay in patients undergoing elective cardiac surgery.
There is a lack of evidence that preoperative physical therapy reduces
postoperative pneumothorax, prolonged mechanical ventilation or all-cause
deaths.

<25>
Accession Number
22491665
Authors
Van't Westeinde S.C. Horeweg N. De Leyn P. Groen H.J. Lammers J.W. Weenink
C. Nackaerts K. van Klaveren R.J.
Institution
(Van't Westeinde) Department of Pulmonology, Erasmus MC Rotterdam,
Rotterdam, Netherlands.
Title
Complications following lung surgery in the Dutch-Belgian randomized lung
cancer screening trial.
Source
European journal of cardio-thoracic surgery : official journal of the
European Association for Cardio-thoracic Surgery. 42 (3) (pp 420-429),
2012. Date of Publication: Sep 2012.
Abstract
To assess the complication rate in participants of the screen arm of the
NELSON lung cancer screening trial who underwent surgical resection and to
investigate, based on a literature review, whether the complication rate,
length of hospital stay, re-thoracotomy and mortality rates after a
surgical procedure were different from those of the non-screening series,
taking co-morbidity into account. Between April 2004 and December 2008,
198 subjects underwent thoracic surgery. Co-morbid conditions were
retrieved from the medical records. Postoperative complications were
classified as minor and major. In total, 182 thoracotomies, 5
thoracotomies after video-assisted thoracoscopic surgery (VATS) and 11
VATS procedures were performed. In these patients, 36% had chronic
obstructive lung disease, 16% coronary artery disease, 14% diabetes
mellitus and 11% peripheral vascular disease. Following thoracotomy, 47%
(88/187) had >=1 minor (7-57% in literature) and 10% (18/187) >=1 major
complication (2-26% in literature); following VATS, 38% (6/16) had >=1
minor complication, but no major complications. Seventeen per cent (3/18)
of major complications and 21% (20/96) of minor complications were seen in
subjects operated for benign disease. The re-thoracotomy rate was 3% and
there was no 30-day mortality after thoracotomy or VATS (0-8.3% in
literature). The mortality rate of 0% after surgical procedures is low
when compared with the non-screening series (0-8.3%); the rate of
complications (53%) is within range when compared with the non-screening
series (8.5-58%). In conclusion, mortality rates after surgical procedures
are lower in the NELSON lung cancer screening trial than those in the
non-screening series. The rate of complications is within the same range
as in the non-screening series. Trial registration number: ISR CTN
63545820.

<26>
Accession Number
22422931
Authors
Fiorelli A. D'Aponte A. Canonico R. Palladino A. Vicidomini G. Limongelli
F. Santini M.
Institution
(Fiorelli) Thoracic Surgery Unit, Second University of Naples, Naples,
Italy.
Title
T2-T3 sympathectomy versus sympathicotomy for essential palmar
hyperhidrosis: comparison of effects on cardio-respiratory function.
Source
European journal of cardio-thoracic surgery : official journal of the
European Association for Cardio-thoracic Surgery. 42 (3) (pp 454-461),
2012. Date of Publication: Sep 2012.
Abstract
The aim of this study was to determine cardio-respiratory changes after
endothoracic sympathetic denervation and their correlation with the extent
of denervation. A total of 45 patients with essential palmar hyperhidrosis
were randomized into two groups: the conventional group (CG; 23 patients)
and the simplified group (SG; 22 patients). In the CG, excision of T2 and
T3 ganglia was performed, whereas in the SG only separation of the
sympathetic chain was performed at the same level. Patients underwent
respiratory and cardiovascular exercise tests before, at 2 weeks and again
at 6 months after the procedure. The postoperative values were then
compared with the preoperative values to assess the statistical
difference. Twenty-one patients in each group completed the study. In the
SG, forced expiratory volume in 1 s (FEV 1; P < 0.01) and forced vital
capacity (FVC; P < 0.01) were significantly reduced at 2 weeks, but
returned to similar baseline values 6 months after the procedure. No
significant cardiac changes were observed. In the CG, both FEV 1 and FVC
were significantly reduced at 2 weeks (P < 0.01) and at 6 months after
operation (P < 0.05). A significant reduction in forced expiratory flow
between 25 and 75% of vital capacity (P < 0.01) and a relevant increase in
airway resistance (P < 0.05) during the entire postoperative course were
also observed. Heart rates at rest and at peak exercise were significantly
reduced at 2 weeks (P < 0.01) and significantly decreased 6 months after
the procedure (P < 0.05). No other changes were registered. The
cardio-respiratory alterations remained at a sub-clinical level; all
patients completed the exercise test without symptoms. Sympathectomy may
result in a disturbance of bronchomotor tone and cardiac function. Such
changes remained at a sub-clinical level and seemed directly correlated
with the extension of denervation.

<27>
Accession Number
22939852
Authors
Hwang H.Y. Kim J.S. Oh S.J. Kim K.B.
Institution
(Hwang) Department of Thoracic and Cardiovascular Surgery, Seoul National
University Hospital, Seoul, Korea.
Title
A randomized comparison of the Saphenous Vein Versus Right Internal
Thoracic Artery as a Y-Composite Graft (SAVE RITA) trial: early results.
Source
The Journal of thoracic and cardiovascular surgery. 144 (5) (pp
1027-1033), 2012. Date of Publication: Nov 2012.
Abstract
The Saphenous Vein Versus Right Internal Thoracic Artery as a Y-Composite
Graft trial was designed to evaluate the saphenous vein compared with the
right internal thoracic artery as a Y-composite graft anastomosed to the
side of the left internal thoracic artery. In this early analysis, we
compared early angiographic patency rates and clinical outcomes. From
September 2008 to October 2011, 224 patients with multivessel coronary
artery disease were randomized prospectively to undergo off-pump
revascularization using the saphenous vein group (n = 112) or the right
internal thoracic artery group (n = 112) as Y-composite grafts. Early
postoperative (1.4 +/- 1.1 days) angiographic patency and clinical
outcomes were compared. There was 1 operative death in the right internal
thoracic artery group. No statistically significant differences in
postoperative morbidities, including atrial fibrillation and acute renal
failure, were observed between the groups. The number of distal
anastomoses using the side-arm Y-composite graft (saphenous vein vs right
internal thoracic artery) were 2.3 +/- 0.8 and 1.9 +/- 0.7 in the
saphenous vein and right internal thoracic artery groups, respectively (P
< .001). A third conduit was used in 44 patients (saphenous vein group vs
right internal thoracic artery group, 4/109 vs 40/110; P < .001) to extend
the side-arm Y-composite graft for complete revascularization. Early
angiography demonstrated an overall patency rate of 99.4% (771 of 776
distal anastomoses). Patency rates of the side-arm Y-composite graft
(saphenous vein vs right internal thoracic artery) were 98.8% (245 of 248)
and 99.5% (207 of 208) in the saphenous vein and right internal thoracic
artery groups, respectively (P = .629). A third conduit was needed to
extend the right internal thoracic artery composite graft and reach the
target vessels in 36.4% (40/110) of the patients. The saphenous vein
composite graft was comparable with the right internal thoracic artery
composite graft in terms of early angiographic patency and clinical
outcomes. Copyright 2012 The American Association for Thoracic Surgery.
Published by Mosby, Inc. All rights reserved.

<28>
Accession Number
22858430
Authors
Sezai A. Nakai T. Hata M. Yoshitake I. Shiono M. Kunimoto S. Hirayama A.
Institution
(Sezai) Department of Cardiovascular Surgery, Nihon University School of
Medicine, Tokyo, Japan.
Title
Feasibility of landiolol and bisoprolol for prevention of atrial
fibrillation after coronary artery bypass grafting: a pilot study.
Source
The Journal of thoracic and cardiovascular surgery. 144 (5) (pp
1241-1248), 2012. Date of Publication: Nov 2012.
Abstract
We previously performed a trial of intravenous landiolol hydrochloride
during and after cardiac surgery (the PASCAL trial) and demonstrated a
preventive effect on postoperative atrial fibrillation (AF). In the
present study, we investigated the efficacy of increasing the dose and
administration period of landiolol for prevention of postoperative AF, as
well as the effect of oral bisoprolol in the early postoperative period. A
total of 105 patients who underwent coronary artery bypass grafting were
randomized to 3 groups: a group receiving intravenous landiolol
perioperatively at 5 mug/kg/min for 3 days (group L), a group receiving
oral bisoprolol postoperatively together with landiolol (group LB), and a
control group without beta-blocker therapy (group C). The primary end
point was the presence/absence of postoperative AF. Secondary end points
were (1) the early clinical outcome, (2) hemodynamics, (3) cardiac enzymes
(creatine kinase isoenzyme MB, troponin-I, and human heart fatty
acid-binding protein), (4) high-sensitivity C-reactive protein (hs-CRP)
and pentraxin-3, (5) asymmetric dimethylarginine (ADMA), and (6) brain
natriuretic peptide. Postoperative AF occurred in 14.5% of group L, 9.1%
of group LB, and 35.3% of group C. A significant difference was observed
between groups LB and C. Significantly higher levels of troponin-I, human
heart fatty acid-binding protein, hs-CRP, pentraxin-3, and ADMA were noted
in group C than in groups L and LB. Landiolol and bisoprolol prevented
postoperative AF. The anti-ischemic, anti-inflammatory, and anti-oxidant
effects of these beta-blockers presumably inhibited the onset of AF.
Copyright 2012 The American Association for Thoracic Surgery. All rights
reserved.

<29>
Accession Number
22819366
Authors
Mavros M.N. Mitsikostas P.K. Alexiou V.G. Peppas G. Falagas M.E.
Institution
(Mavros) Alfa Institute of Biomedical Sciences, Athens, Greece.
Title
Gentamicin collagen sponges for the prevention of sternal wound infection:
a meta-analysis of randomized controlled trials.
Source
The Journal of thoracic and cardiovascular surgery. 144 (5) (pp
1235-1240), 2012. Date of Publication: Nov 2012.
Abstract
The study objective was to determine whether the application of gentamicin
collagen sponges reduces sternal wound infections in patients undergoing
cardiac surgery. A meta-analysis of randomized controlled trials was
performed. Four randomized controlled trials were eligible for inclusion.
By pooling data from 4 randomized controlled trials (4672 per-protocol
patients), gentamicin collagen sponges reduced deep sternal wound
infections (risk ratio, 0.62; 95% confidence interval, 0.39-0.97) and any
sternal wound infections (risk ratio, 0.61; confidence interval,
0.39-0.98). In contrast, no benefit was demonstrated regarding superficial
sternal wound infections (4 randomized controlled trials [4672 patients];
risk ratio, 0.65; 95% confidence interval, 0.34-1.25) and all-cause
mortality (3 randomized controlled trials [3994 patients]; risk ratio,
0.90; 95% confidence interval, 0.57-1.42). On the basis of data from 2
randomized controlled trials (3410 patients), gentamicin collagen sponges
also seemed to reduce surgically treated sternal wound infections (risk
ratio, 0.59; 95% confidence interval, 0.41-0.86). The most commonly
isolated pathogens were coagulase-negative Staphylococcus spp (43%) and
Staphylococcus aureus (28%). Gentamicin collagen sponges seem to reduce
the sternal wound infection rate in patients undergoing cardiac surgery.
The statistical heterogeneity among the existing trials underlines the
need for additional large, high-quality randomized controlled trials.
Copyright 2012 The American Association for Thoracic Surgery. Published
by Mosby, Inc. All rights reserved.

<30>
Accession Number
22770549
Authors
Mauermann W.J. Pulido J.N. Barbara D.W. Abel M.D. Li Z. Meade L.A. Schaff
H.V. White R.D.
Institution
(Mauermann) Department of Anesthesiology, Mayo Clinic, Rochester, MN, USA.
Title
Amiodarone versus lidocaine and placebo for the prevention of ventricular
fibrillation after aortic crossclamping: a randomized, double-blind,
placebo-controlled trial.
Source
The Journal of thoracic and cardiovascular surgery. 144 (5) (pp
1229-1234), 2012. Date of Publication: Nov 2012.
Abstract
Ventricular fibrillation occurs commonly after aortic crossclamping in
patients undergoing cardiac surgery. Ventricular fibrillation increases
myocardial oxygen consumption, and defibrillation may harm the myocardium.
Thus, a pharmacologic approach to decreasing the incidence of ventricular
fibrillation or the number of shocks required may be beneficial. The goal
of this study was to evaluate whether amiodarone or lidocaine was superior
to placebo for the prevention of ventricular fibrillation after aortic
crossclamping in patients undergoing a variety of cardiac surgical
procedures. Patients undergoing cardiac surgery requiring aortic
crossclamping were randomized to receive lidocaine 1.5 mg/kg, amiodarone
300 mg, or placebo before aortic crossclamp removal The primary outcomes
were the incidence of ventricular fibrillation and the number of shocks
required to terminate ventricular fibrillation. A total of 342 patients
completed the trial. On multivariate analysis, there was no difference in
the incidence of ventricular fibrillation among treatment groups. The
number of required shocks was categorized as 0, 1 to 3, and greater than
3. On multivariate analysis, patients receiving amiodarone required fewer
shocks to terminate ventricular fibrillation (odds ratio, 0.51; 95%
confidence interval, 0.31-0.83; P = .008 vs placebo). There was no
difference between lidocaine and placebo in the number of required shocks
(odds ratio, 0.86; 95% confidence interval, 0.52-1.41; P = .541). In
patients undergoing a variety of cardiac surgical procedures, neither
amiodarone nor lidocaine reduced the incidence of ventricular
fibrillation. Amiodarone decreased the number of shocks required to
terminate ventricular fibrillation. Copyright 2012 The American
Association for Thoracic Surgery. Published by Mosby, Inc. All rights
reserved.

<31>
Accession Number
20861205
Authors
Adluri R.K. Singh A.V. Skoyles J. Hitch T. Robins A. Baker M. Mitchell
I.M.
Institution
(Adluri) Department of Cardiac Surgery, Trent Cardiac Centre, Nottingham
City Hospital, Nottingham, UK.
Title
Effect of increased pump flow on hepatic blood flow and systemic
inflammatory response following on-pump coronary artery bypass grafting.
Source
Perfusion. 25 (5) (pp 293-303), 2010. Date of Publication: Sep 2010.
Abstract
Reduced organ perfusion during cardiopulmonary bypass (CPB) is responsible
for morbidity associated with cardiac surgery. Non-pulsatile flow and
hypothermia during CPB have been shown to cause reduced perfusion. During
CPB, cardiac output is directly proportional to the pump flow rate.
Therefore, we hypothesised that increasing pump flow during hypothermic
CPB would improve organ perfusion and reduce the inflammatory response in
the post-operative period. Ethics committee approval was obtained. Twelve
consecutive patients with good or moderate left ventricular function
undergoing elective or inpatient coronary artery bypass grafting were
included in the study after obtaining informed consent. Patients were
randomised to receive either normal flow or higher pump flow (20% more
than the usual flow during hypothermia). Hepatic blood flow, cytokines
such as interleukins 1beta, 6, 8, 10 and 12, tumour necrosis factor-alpha
and complements C3a, C4a and C5a were measured during the peri-operative
period. Data were analysed using SPSS (ver.15). Categorical data were
compared using the chi-square test and trends in cytokines were compared
using a repeated measures ANOVA test. Both the groups were similar in pre-
and peri-operative variables. Hepatic blood flow almost doubled in the
high-pump-flow group following an increase in the flow rate during
hypothermia(p=0.026). The release of serum complement IL-6 and 8 appeared
to be reduced in the high-flow group; however, the difference did not
reach statistical significance. Higher pump flows during hypothermic CPB
increase hepatic blood flow. There was a trend towards attenuation of
post-operative inflammatory response; however, larger studies will be
needed to confirm these findings.

<32>
Accession Number
20630920
Authors
Schramko A.A. Suojaranta-Ylinen R.T. Kuitunen A.H. Raivio P.M. Kukkonen
S.I. Niemi T.T.
Institution
(Schramko) Department of Anaesthesiology and Intensive Care Medicine,
Helsinki University Central Hospital, Meilahti Hospital, Helsinki,
Finland.
Title
Comparison of the effect of 6% hydroxyethyl starch and gelatine on cardiac
and stroke volume index: a randomized, controlled trial after cardiac
surgery.
Source
Perfusion. 25 (5) (pp 283-291), 2010. Date of Publication: Sep 2010.
Abstract
The objective of this study was to find out the effect of various doses of
hydroxyethyl starch (HES), gelatine or Ringer's acetate on cardiac and
stroke volume index after cardiac surgery. Three consecutive boluses (each
7 mLkg(-1)) of either 6% HES 130/0.4, 4% gelatine, or Ringer's acetate
solutions were administered to 45 patients postoperatively. The rate of
infusions was adjusted according to haemodynamic measurements. Thereafter,
infusion of the study solution (7 mLkg(-1)) was continued for the
following 12 hours. The total dose of study solution was 28 mLkg(-1). Mean
(SD) cardiac and stroke volume indices were greater in the HES group [2.8
Lmin(-1)m(-2) (0.7), 34.1 (6.7) mlm( -2)] than in the gelatine group [2.2
Lmin(-1)m( -2) (0.6), 25.8 (7.2) mlm(-2)] after completion of 7 mLkg(-1)
of study solution. At this stage, the effect of gelatine did not differ
from Ringer's acetate. After completion of 14 mLkg(-1) and 21 mLkg(-1) of
colloids, similar cardiac and stroke volume indices were observed and the
haemodynamic response was better in both colloid groups than in the
Ringer's acetate group. No differences between groups were detected on the
first postoperative morning. In the early postoperative phase after
cardiac surgery, the effect of a single dose of HES solution on the
haemodynamics was superior to the effect of gelatine or Ringer's acetate.
However, after repeated administration of the study solutions, the
haemodynamics in the two colloid groups appeared to be similar, but
superior to the Ringer's acetate group.

<33>
Accession Number
20627942
Authors
Lund P.E. Wassback G. Thomas O. Carlsson T. Schott U.
Institution
(Lund) Orebro University Hospital, Department of Cardiothoracic
Anaesthesiology and Intensive Care, Orebro, Sweden.
Title
Comparison of two infusion rates of antithrombin concentrate in
cardiopulmonary bypass surgery.
Source
Perfusion. 25 (5) (pp 305-312), 2010. Date of Publication: Sep 2010.
Abstract
Antithrombin concentrate (AT) is used to treat heparin resistance (HR) in
cardiac surgery. It is usually given slowly due to the fear of
anaphylaxis. This may delay cardiac catheterisation and the start of
cardiopulmonary bypass (CPB). HR is often defined as the failure to reach
or maintain a target activated clotting time (ACT) despite a standard dose
of heparin. It is not generally possible to predict which patients will
display HR, although there are known risk factors. Routine early
administration of AT before heparinisation is probably not cost-effective.
Infusing AT relatively quickly after demonstrating HR may be more
cost-effective, while not delaying surgery. The aim of this study is to
investigate the safety and side effects of a faster infusion of AT. Forty
patients undergoing elective heart surgery were included and randomised to
two groups in a double-blind fashion. Each group received 1000 IU of AT
intravenously (IV). One group received a slow infusion (100 IU/min) before
full-dose heparinisation. The other group received a fast infusion (250
IU/min). Haemodynamic and respiratory data were recorded. Any adverse
effects were noted. Thrombin-antithrombin, anti-Xa and antithrombin levels
in plasma were measured. No anaphylaxis occurred in either group. No
differences were found regarding haemodynamics, respiration or laboratory
results. Two patients experienced major haemorrhage and recovered; there
were two deaths, thought to be unrelated to the study drugs. AT can be
infused at a rate of 250 IU/min. This is faster than the current
recommendation of 100 IU/min. This rate of infusion allows restricting AT
infusion to those patients who display HR, without delaying surgery.
Optimal anticoagulant therapy for CPB probably includes point-of-care
measurement of ACT and plasma AT and small, but rapid, infusions of AT in
heparin-resistant patients.

<34>
Accession Number
2013405432
Authors
Van Der Heyden J. Van Werkum J. Hackeng C.M. Kelder J.C. Breet N.J. Deneer
V.H.M. Ackerstaff R.G.A. Tromp S.C. De Vries J.P.P.M. Vos J.A. Suttorp
M.J. Elsenberg E.H.A. Van Neerven D. Schonewille W.J. Wolters F. Ten Berg
J.M.
Institution
(Van Der Heyden, Van Werkum, Kelder, Breet, Suttorp, Elsenberg, Van
Neerven, Wolters, Ten Berg) Department of Interventional Cardiology, St.
Antonius Hospital Nieuwegein, Netherlands
(Van Werkum, Hackeng, Kelder, Breet, Deneer, Elsenberg, Van Neerven,
Wolters, Ten Berg) St. Antonius Centre for Platelet Function Research, St.
Antonius Hospital Nieuwegein, Netherlands
(Hackeng) Department of Biochemistry, St. Antonius Hospital Nieuwegein,
Netherlands
(Deneer) Department of Clinical Pharmacy, St. Antonius Hospital
Nieuwegein, Netherlands
(Ackerstaff, Tromp) Department of Clinical Neurophysiology, St. Antonius
Hospital Nieuwegein, Netherlands
(De Vries) Department of Vascular Surgery, St. Antonius Hospital
Nieuwegein, Netherlands
(Vos) Department of Interventional Radiology, St. Antonius Hospital
Nieuwegein, Netherlands
(Schonewille) Department of Neurology, St. Antonius Hospital Nieuwegein,
Netherlands
Title
High versus standard clopidogrel loading in patients undergoing carotid
artery stenting prior to cardiac surgery to assess the number of
microemboli detected with transcranial Doppler: Results of the randomized
IMPACT trial.
Source
Journal of Cardiovascular Surgery. 54 (3) (pp 337-347), 2013. Date of
Publication: June 2013.
Publisher
Edizioni Minerva Medica (Corso Bramante 83-85, Torino 10126, Italy)
Abstract
Aim. The aim of this study was to compare the effects of 300 mg or 600 mg
clopidogrel loading dose, prior to carotid artery stenting (CAS) on the
number of transcranial Doppler (TCD)-detected microembolic signals (MES)
and to investigate the relationship between the magnitude of platelet
reactivity and MES. Methods. In this prospective randomized, double-blind
study, 35 consecutive asymptomatic patients (17.1% females), scheduled for
CAS and cardiac surgery were included. The primary endpoint was the number
of TCD-detected MES. The secondary endpoints were the absolute magnitude
of on-treatment platelet reactivity and the adverse cerebral events.
Negative binomial regression to find predictors for sum of single emboli,
the student's t-test to assess the association between platelet function
tests and randomized dose of 300 mg or 600 mg clopidogrel, and the
R² calculation for the assessment of the association between
platelet function tests and embolic load, were used. Results. No
statistically significant difference in the number of TCD-detected MES, in
the sum of all the single emboli or showers and platelet aggregation
measurements between the two groups was observed (aggregometry:
21.7+/-18.3 versus 23+18%, P=0.8499 and 45.8+/-17.5 versus 46.5+/-14.5%,
P=0.9003) (verifyNow P2Y12 assay: 231+/-293 PRU versus 222+/-86 PRU,
P=0.7704). In one patient a transient ischemic attack occurred.
Conclusion. A loading dose of 300 mg of clopidogrel in combination with
aspirin is as effective as 600 mg of clopidogrel in achieving adequate
platelet inhibition and preventing periprocedural events in asymptomatic
patients undergoing CAS prior to cardiac surgery.

<35>
Accession Number
2013400258
Authors
Zomer A.C. Ionescu-Ittu R. Vaartjes I. Pilote L. Mackie A.S. Therrien J.
Langemeijer M.M. Grobbee D.E. Mulder B.J.M. Marelli A.J.
Institution
(Zomer) Department of Cardiology, Academic Medical Center, Amsterdam,
Netherlands
(Zomer, Vaartjes, Grobbee) Julius Center for Health Sciences and Primary
Care, University Medical Center Utrecht, Utrecht, Netherlands
(Zomer, Langemeijer, Mulder) Interuniversity Cardiology Institute of the
Netherlands, Utrecht, Netherlands
(Ionescu-Ittu, Therrien, Marelli) McGill Adult Unit for Congenital Heart
Disease Excellence, McGill University Health Center, 687 Pine Avenue,
Montreal, QC H3A 1A1, Canada
(Pilote) Division of Clinical Epidemiology, McGill University Research
Center, Montreal, QC, Canada
(Pilote) Division of Internal Medicine, McGill University Health Centre,
Montreal, QC, Canada
(Mackie) Division of Pediatric Cardiology, University of Alberta, AB,
Canada
Title
Sex differences in hospital mortality in adults with congenital heart
disease: The impact of reproductive health.
Source
Journal of the American College of Cardiology. 62 (1) (pp 58-67), 2013.
Date of Publication: 02 Jul 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Objectives The study objectives were to analyze sex differences in
hospital mortality of adult patients with congenital heart disease (CHD)
and to determine the impact of health services associated with pregnancy
on outcomes in women. Background The determinants of sex differences in
the demographic distribution of CHD are poorly understood. Methods The
Quebec CHD database and the Dutch CONCOR (CONgenital CORvitia) registry
were used to identify patients with CHD aged 18 to 65 years who were
hospitalized between 1996 and 2005. Regression analyses were used to
compare 30-day in-hospital mortality in men versus women and in women aged
18 to 45 years with versus without a pregnancy history, after adjustment
for age, CHD severity, comorbidities, and admission diagnosis. Results Of
39,776 patients followed for 259,741 patient years, 19,099 patients (48%)
had 54,195 admissions (62% among women). In those aged 18 to 45 years,
30-day in-hospital mortality was higher in men compared with women with
nonpregnancy admissions (adjusted rate ratio: 1.36; 95% confidence
interval: 1.02 to 1.81). The adjusted rate ratio for 30-day in-hospital
mortality in women with a pregnancy history compared with those without
was 0.49 (95% confidence interval: 0.24 to 0.99). A history of pregnancy
was not associated with an overall increase in medical encounters.
Conclusions We demonstrated a protective effect of sex on in-hospital
mortality in women with CHD of reproductive age that did not correlate
with increased medical surveillance. Future studies need to explore other
mechanisms to account for our observations. Understanding the determinants
of the sex distribution of adults with CHD is important for our ability to
predict demographic changes in the population with CHD. 2013 by the
American College of Cardiology Foundation.

<36>
Accession Number
2013400241
Authors
Maeng M. Holm N.R. Erglis A. Kumsars I. Niemela M. Kervinen K. Jensen J.S.
Galloe A. Steigen T.K. Wiseth R. Narbute I. Gunnes P. Mannsverk J.
Meyerdierks O. Rotevatn S. Nikus K. Vikman S. Ravkilde J. James S. Aaroe
J. Ylitalo A. Helqvist S. Sjogren I. Thayssen P. Virtanen K. Puhakka M.
Airaksinen J. Christiansen E.H. Lassen J.F. Thuesen L.
Institution
(Maeng, Holm, Christiansen, Lassen, Thuesen) Department of Cardiology,
Aarhus University Hospital, Brendstrupgaardsvej, Skejby, 8200 Aarhus N,
Denmark
(Erglis, Kumsars, Narbute) Department of Cardiology, Paul Stradins
Clinical Hospital, Riga, Latvia
(Niemela, Kervinen) Division of Cardiology, Oulu University Hospital,
Oulu, Finland
(Jensen, Galloe) Department of Cardiology, Gentofte University Hospital,
Gentofte, Denmark
(Steigen) Department of Cardiology, University Hospital of North Norway,
University of Tromso, Tromso, Norway
(Wiseth) Department of Cardiology, University Hospital of Tromso, Tromso,
Norway
(Gunnes) Department of Cardiology, St. Olav Hospital, Trondheim, Norway
(Mannsverk) Department of Cardiology, Feiring Clinic, Feiring, Norway
(Meyerdierks) Department of Cardiology, Ullevaal University Hospital,
Oslo, Norway
(Rotevatn) Department of Cardiology, Haukeland University Hospital,
Bergen, Norway
(Nikus, Vikman) Department of Cardiology, Tampere University Hospital,
Tampere, Finland
(Ravkilde, Aaroe) Department of Cardiology, Aalborg University Hospital,
Aalborg, Denmark
(James) Department of Cardiology, Uppsala University Hospital, Uppsala,
Sweden
(Ylitalo) Department of Cardiology, Satakunta Central Hospital, Pori,
Finland
(Helqvist) Department of Cardiology, Rigshospitalet, Copenhagen, Denmark
(Sjogren) Department of Cardiology, Falun Hospital, Falun, Sweden
(Thayssen) Department of Cardiology, Odense University Hospital, Odense,
Denmark
(Virtanen) Division of Cardiology, Helsinki University Central Hospital,
Helsinki, Finland
(Puhakka) Division of Cardiology, Kuopio University Central Hospital,
Kuopio, Finland
(Airaksinen) Division of Cardiology, Turku University Central Hospital,
Turku, Finland
Title
Long-term results after simple versus complex stenting of coronary artery
bifurcation lesions: Nordic bifurcation study 5-year follow-up results.
Source
Journal of the American College of Cardiology. 62 (1) (pp 30-34), 2013.
Date of Publication: 02 Jul 2013.
Publisher
Elsevier USA (6277 Sea Harbor Drive, Orlando FL 32862 8239, United States)
Abstract
Objectives This study sought to report the 5-year follow-up results of the
Nordic Bifurcation Study. Background Randomized clinical trials with
short-term follow-up have indicated that coronary bifurcation lesions may
be optimally treated using the optional side branch stenting strategy.
Methods A total of 413 patients with a coronary bifurcation lesion were
randomly assigned to a simple stenting strategy of main vessel (MV) and
optional stenting of side branch (SB) or to a complex stenting strategy,
namely, stenting of both MV and SB. Results Five-year clinical follow-up
data were available for 404 (98%) patients. The combined safety and
efficacy endpoint of cardiac death, non-procedure-related myocardial
infarction, and target vessel revascularization were seen in 15.8% in the
optional SB stenting group as compared to 21.8% in the MV and SB stenting
group (p = 0.15). All-cause death was seen in 5.9% versus 10.4% (p = 0.16)
and non-procedure-related myocardial infarction in 4% versus 7.9% (p =
0.09) in the optional SB stenting group versus the MV and SB stenting
group, respectively. The rates of target vessel revascularization were
13.4% versus 18.3% (p = 0.14) and the rates of definite stent thrombosis
were 3% versus 1.5% (p = 0.31) in the optional SB stenting group versus
the MV and SB stenting group, respectively. Conclusions At 5-year
follow-up in the Nordic Bifurcation Study, the clinical outcomes after
simple optional side branch stenting remained at least equal to the more
complex strategy of planned stenting of both the main vessel and the side
branch. 2013 by the American College of Cardiology Foundation.

<37>
Accession Number
2013410948
Authors
Fechner J. Ihmsen H. Schuttler J. Jeleazcov C.
Institution
(Fechner, Ihmsen, Schuttler, Jeleazcov) Department of Anaesthesiology,
University of Erlangen-Nurnberg, Erlangen, Germany
Title
The impact of intra-operative sufentanil dosing on post-operative pain,
hyperalgesia and morphine consumption after cardiac surgery.
Source
European Journal of Pain (United Kingdom). 17 (4) (pp 562-570), 2013. Date
of Publication: April 2013.
Publisher
Wiley-Blackwell Publishing Ltd (9600 Garsington Rd, Chiswell Green Ln,
Oxford OX4 2DQ, United Kingdom)
Abstract
Background: There is an ongoing debate whether opioids when used for
intra-operative analgesia may enhance post-operative pain. We studied the
effect of two different intra-operative dosings of sufentanil on
post-operative morphine consumption, pain and hyperalgesia after cardiac
anaesthesia. Methods: Forty-two male patients (age: 48-74 years)
undergoing first-time coronary artery bypass graft surgery were randomized
to one of two groups receiving total intravenous anaesthesia with propofol
and a target controlled infusion of sufentanil with a target of 0.4 ng/mL
(group SL, n = 20) or 0.8 ng/mL (group SH, n = 22) plasma concentration.
Post-operative morphine requirement in the first 48 h was assessed using
patient-controlled analgesia (PCA). Pain rating during deep inspiration,
and the extent of primary and secondary hyperalgesia near the sternotomy
wound were assessed. Results: The post-operative morphine requirements in
the first 48 h were 0.68 +/- 0.21 mg/kg in group SL and 0.96 +/- 0.44
mg/kg in group SH (p 0.05). In group SL, pain during deep inspiration was
significantly lower on the first post-operative day (p 0.05). Primary
hyperalgesia had its maximum on the second and third post-operative day,
without a difference between the two groups. The extent of secondary
mechanical pinprick hyperalgesia was not different between the groups.
Discussion: Intra-operative dosing of sufentanil significantly influenced
post-operative morphine consumption, pain and hyperalgesia. For cardiac
anaesthesia in combination with propofol, a sufentanil target
concentration of 0.4 ng/mL may be preferable. 2012 European Federation of
International Association.

<38>
Accession Number
2013403675
Authors
Woodruff D.Y. Van Veldhuizen P. Muehlebach G. Johnson P. Williamson T.
Holzbeierlein J.M.
Institution
(Woodruff, Holzbeierlein) Department of Urology, University of Kansas,
Kansas City, KS 66160, United States
(Van Veldhuizen) Department of Internal Medicine Division of
Hematology/Oncology, University of Kansas, Kansas City, KS 66160, United
States
(Muehlebach) Department of Thoracic and Cardiovascular Surgery, University
of Kansas, Kansas City, KS 66160, United States
(Johnson) Department of Radiology Section of Vascular and Interventional
Radiology, University of Kansas, Kansas City, KS 66160, United States
(Williamson) Division of Pulmonary/Critical Care, University of Kansas,
Kansas City, KS 66160, United States
Title
The perioperative management of an inferior vena caval tumor thrombus in
patients with renal cell carcinoma.
Source
Urologic Oncology: Seminars and Original Investigations. 31 (5) (pp
517-521), 2013. Date of Publication: July 2013.
Publisher
Elsevier Inc. (360 Park Avenue South, New York NY 10010, United States)
Abstract
Objectives: Inferior vena caval tumor thrombus (IVC-TT) occurs in 10% of
patients diagnosed with renal cell carcinoma (RCC). The perioperative
management of these patients remains challenging. Despite multiple
publications outlining surgical approaches and outcomes there have been
few studies detailing the best peri-operative management of patients with
IVC-TT. Our goal was to define the optimal management of patients with RCC
and IVC-TT. Materials and methods: A review of all published literature
regarding the management of RCC with IVC-TT was performed utilizing Pub
Med and the Cochrane Database. Reviews were also made of all relevant
literature regarding the need for cardiopulmonary bypass and
recommendations regarding thrombus in any location in patients with
malignancy. Specific items critically examined included: need for
preoperative heart catheterization, need for anticoagulation and type of
anticoagulation, need for additional studies such as lower extremity
duplex or venogram, and indications for vena caval filter placement. The
results were then presented to a multidisciplinary group made up of
experts in the fields of Urology, Hematology, Oncology, Cardiothoracic
Surgery, Interventional Radiology, and Pulmonary/Critical Care. Based on
the available literature a best practice guidelines regarding the
management of RCC with IVC-TT was established at our institution. Results:
Our institutional recommendations include (1) preoperative cardiac
catheterization in all patients believed to require cardiopulmonary bypass
for removal of the thrombus but only cardiac clearance for those who
bypass is unlikely, (2) preoperative anticoagulation using a low molecular
weight heparin such as enoxaparin unless contraindicated due to bleeding
from the tumor or other contraindication, (3) avoidance of vena caval
filters whenever possible is recommended due the potential for caval
thrombosis and the difficulties they present during surgical resection.
Conclusion: This study identified the available literature on the
management of IVC-TT in association with RCC and was carefully reviewed by
a multidisciplinary team. As a result, we have established a set of
practice guidelines at our institution to help optimally manage patients
with renal cell carcinoma and an inferior venal caval thrombus. 2013
Elsevier Inc.

<39>
Accession Number
23104947
Authors
Pilcher J.M. Young P. Weatherall M. Rahman I. Bonser R.S. Beasley R.W.
Institution
(Pilcher) Medical Research Institute of New Zealand, Wellington 6242, New
Zealand.
Title
A systematic review and meta-analysis of the cardioprotective effects of
remote ischaemic preconditioning in open cardiac surgery.
Source
Journal of the Royal Society of Medicine. 105 (10) (pp 436-445), 2012.
Date of Publication: Oct 2012.
Abstract
To investigate the cardioprotective efficacy of remote ischaemic
preconditioning (RIPC) in cardiac surgery. We have performed a systematic
search of MEDLINE, EMBASE and Cochrane Central Register of Controlled
Trials to identify randomized controlled trials involving RIPC. Randomized
controlled trials of RIPC in open cardiac surgery patients. Meta-analysis
was performed with the primary outcome the standardized mean difference
between intervention and control groups in 12 hour postoperative troponin
concentration. Heterogeneity was examined by fixed effects
meta-regression. Ten studies with a total of 693 participants were
included in the meta-analysis. RIPC reduced troponin levels 12 hours after
surgery compared with control. The fixed and random effects differences
were 0.35 (95% CI 0.19 to 0.51) and 0.53 (95% CI 0.18-0.88) respectively.
However, important heterogeneity was present. Fixed effects
meta-regression partially accounted for heterogeneity based on whether
studies had full blinding, comprising blinding of patients, surgeons,
anaesthetists and investigators. Studies with incomplete or no blinding
demonstrated a larger estimate of effect, 0.74 (95% CI 0.47 to 1.00)
compared to those with full blinding, 0.13 (95% CI - 0.07 to 0.33).
Although our analysis suggests RIPC may result in cardiac protection
during cardiac surgery, the effect was most marked in studies without full
blinding, with a smaller and statistically non-significant effect in fully
blinded studies. We propose that further double blind randomized
controlled trials investigating the cardioprotective effects of RIPC in
cardiac surgery are required to resolve the current clinical uncertainty.

<40>
Accession Number
23096672
Authors
Andres Jadue T. Roberto Gonzalez L. Manuel J. Irarrazaval L.L.
Institution
(Andres Jadue, Manuel J. Irarrazaval) Division de Enfermedades
Cardiovasculares, Facultad de Medicina, Pontificia Universidad Catolica de
Chile, Santiago, Chile
(Roberto Gonzalez) Equipo de Cirugia Cardiotoracica, Hospital 'Dr.
Guillermo Grant Benavente', Universidad de Concepcion, Concepcion, Chile
Title
Meta-analysis of coronary artery bypass surgery compared to percutaneous
transluminal angioplasty with stent in diabetic patients.
Source
Revista Medica de Chile. 140 (5) (pp 640-648), 2012. Date of Publication:
May 2012.
Publisher
Sociedad Medica de Santiago (Casilla 168, 9 Correo, 55, Santiago, Chile)
Abstract
Background: Diabetic patients are a group of primary interest in the study
of myocardial revascularization. Aim: To compare coronary artery bypass
grafting surgery (CABG) and percutaneous angioplasty with stents (PCI-S)
in diabetic patients with coronary three-vessel or left main coronary
artery disease. Material and Methods: Meta-analysis of MEDLINE randomized
controlled studies comparing CABG and PCI-S in diabetic patients. The
primary outcome measure was major adverse cardiovascular events (MACCE),
death, myocardial infarction, cerebrovascular accident (CVA) and coronary
re-intervention. Secondary outcomes were the individual components of
MACCE. Results: Three studies comparing CABG and PCI-S met the inclusion
criteria. One thousand sixty two patients were studied: 565 in the CABG
group and 597 in the PCI-S group. At one year follow up MACCE occurred in
24.9 and 12.7% of patients in PCI-S and CABG groups, respectively (Odds
ratio (OR) 2.27; 95% confidence intervals (CI) 1.66-3.09). There were no
differences in death or myocardial infarction. Strokes were less common in
the PCI-S group (OR 0.25, 95% CI 0.09-0.68) and coronary re-intervention
was required with higher frequency in the PCI-S group (OR 5.32, 95% CI
3.27-8.67). Conclusions: In diabetic patients with three-vessel coronary
disease or left main coronary artery, revascularization with CABG had
significantly less MACCE at one year than those treated with PCI-S. Stroke
frequency was higher in CABG, coronary re-intervention was higher in
PCI-S. These results must be interpreted cautiously.

<41>
Accession Number
22809563
Authors
Sorm Z. Vojacek J. Cermakova E. Pudil R. Stock U.A. Harrer J.
Institution
(Sorm) Department of Cardiac Surgery, Charles University in Prague,
Faculty of Medicine in Hradec Kralove, University Hospital Hradec Kralove,
Sokolska 581, 50005, Hradec Kralove, Czech Republic.
Title
Elective minimally invasive coronary artery bypass: shunt or tournique
occlusion? Assessment of a protective role of perioperative left anterior
descending shunting on myocardial damage. A prospective randomized study.
Source
Journal of cardiothoracic surgery. 7 (pp 69), 2012. Date of Publication:
2012.
Abstract
To determine impact of intraluminal-left anterior descending shunt to
prevent myocardial damage in minimally invasive coronary artery bypass. 38
patients were randomly assigned to external tournique occlusion (n = 19)
or intraluminal-left anterior descending shunt group (n= 19). Blood
samples for cardiac troponin T were collected at 30 minutes prior to, 6
and 24 hours after surgery. One patient in external tournique occlusion
and two patients in intraluminal-left anterior descending shunt group were
excluded from futher analysis due to preoperative cardiac troponin T level
above the 99th-percentile. Postoperatively, each six patients in external
tournique occlusion (33.3%) and intraluminal-left anterior descending
shunt (35.3%) group were above the 99th-percentile. Two patients from each
group (external tournique occlusion group 11.1% vs. intraluminal-left
anterior descending shunt group 11.8%) had peak values above 10-%
coeficient of variation cutoff (p = 1). There were no significant
differences in between both groups at all studied timepoints. There was no
protective effect of intraluminal shunting on myocardial damage compared
to short-term tournique occlusion. It is upon the surgeon's discretion
which method may preferrably be used to achieve a bloodless field in
grafting of the non-occluded left anterior descending in minimally
invasive coronary artery bypass.

<42>
Accession Number
21860192
Authors
Singh S.P. Kapoor P.M. Chowdhury U. Kiran U.
Institution
(Singh) Department of Cardiac Anaesthesia, CN Centre, All India Institute
of Medical Sciences, New Delhi, India.
Title
Comparison of S100beta levels, and their correlation with hemodynamic
indices in patients undergoing coronary artery bypass grafting with three
different anesthetic techniques.
Source
Annals of cardiac anaesthesia. 14 (3) (pp 197-202), 2011. Date of
Publication: 2011 Sep-Dec.
Abstract
Cardiac surgery with aid of cardiopulmonary bypass (CPB) is associated
with neurological dysfunction. The presence of cerebrospecific protein
S100beta in serum is an indicator of cerebral damage. This study was
designed to evaluate the influence of three different anesthesia
techniques, on S100beta levels, in patients undergoing coronary artery
bypass grafting on CPB. A total of 180 patients were divided into three
groups - each of who received sevoflurane, isoflurane and total
intravenous anesthesia as part of the anesthetic technique, respectively.
S100 were evaluated from venous sample at following time intervals - prior
to induction of anesthesia (T1), after coming off CPB (T2); 12 h after
aortic cross clamping (T3) and 24 h after aortic cross clamping (T4). In
all three groups, maximal rise in S100beta levels occurred after CPB which
gradually declined over next 24 h, the levels at 24 h post-AOXC being
significantly higher than baseline levels. Significantly low levels of
S100beta were noted at all postdose hours in the sevoflurane group, as
compared to the total intravenous anesthesia (TIVA) group, and at 12 and
24 h postaortic cross clamp, in comparison to the isoflurane group.
Comparing the isoflurane group with the TIVA group, the S100 levels were
lower in the isoflurane group only at 24 h postaortic cross clamp. It was
concluded that maximum rise in S100beta levels occurs immediately after
CPB with a gradual decline in next 24 h. The rise in S100beta levels is
significantly less in patients administered sevoflurane in comparison to
isoflurane or TIVA. Hemodynamic parameters had no influence on the
S100beta levels during the first 24 h after surgery.

<43>
Accession Number
20864904
Authors
Szczeklik W. Morawski W. Sanak M. Jakiela B. Bolkowski M. Cisowski M.
Szczeklik M. Bochenek A. Musial J.
Institution
(Szczeklik) 2nd Department of Medicine, Jagiellonian University Medical
Collage, Krakow, Poland.
Title
A single dose of aprotinin prevents platelet hyporeactivity after coronary
artery bypass graft surgery.
Source
Polskie Archiwum Medycyny Wewnetrznej. 120 (9) (pp 321-327), 2010. Date of
Publication: Sep 2010.
Abstract
Bleeding after coronary artery bypass graft (CABG) surgery is associated
with a significant increase in mortality. Even though aprotinin
significantly reduces bleeding in patients undergoing cardiac surgery, its
use has been recently substantially limited because of serious
cardiovascular complications. The exact mechanism of its action,
particularly its effect on platelet function, remains unclear. The aim of
the study was to assess the effect of aprotinin on platelet function in
patients undergoing CABG. In a randomized placebo-controlled double-blind
study, we investigated the effect of a single dose of aprotinin on
platelet function in 24 patients who underwent CABG between 2005 and 2006.
Before surgery and in the postoperative period, we measured platelet
activation markers (P-selectin and activated form of glycoprotein
IIb/IIIa) at baseline and following in vitro platelet activation with
adenosine diphosphate (ADP) or protease-activated receptor 1 (PAR-1)
agonist--thrombin receptor activator for peptide 6 (TRAP-6). Perioperative
bleeding and urinary metabolites of thromboxane A2 were also determined.
Aprotinin reduced perioperative bleeding by 26% (P <0.01) and prevented a
decrease in platelet sensitivity to ADP immediately after CABG. In vitro
platelet reactivity to TRAP-6 remained unchanged. Aprotinin did not affect
blood platelet count or urinary thromboxane A2 metabolite excretion after
CABG. Our results indicate that aprotinin may reduce perioperative
bleeding by its interference with ADP pathway of platelet activation,
thereby preventing postoperative hyporeactivity of platelets to ADP.
Platelet reactivity to PAR-1 receptor agonist was not affected by
aprotinin.

<44>
Accession Number
20453057
Authors
Zarani F. Besharat M.A. Sadeghian S. Sarami G.
Institution
(Zarani) Department of Psychology, University of Tehran, Iran.
Title
The effectiveness of the information-motivation-behavioral skills model in
promoting adherence in CABG patients.
Source
Journal of health psychology. 15 (6) (pp 828-837), 2010. Date of
Publication: Sep 2010.
Abstract
This study tested the efficacy of the Information-Motivation-Behavioral
(IMB) skills model-based intervention to promote adherence among patients
undergoing Coronary Artery Bypass Grafting (CABG) surgery, and evaluated
the relationship of psychological variables with adherence. A total of 152
CABG patients were randomly assigned to either an intervention group or to
a standard care control group. Participants completed pretest measures and
were reassessed one and three months later. Findings revealed that the
intervention group was significantly more adherent, which showed support
for the effectiveness of the IMB-based intervention. Furthermore,
psychological factors played an important role in patient adherence.

<45>
[Use Link to view the full text]
Accession Number
20588130
Authors
Stein T.R. Olivo E.L. Grand S.H. Namerow P.B. Costa J. Oz M.C.
Institution
(Stein) Division of Pain Medicine, Department of Anesthesiology, Columbia
University, New York, NY 10032, USA.
Title
A pilot study to assess the effects of a guided imagery audiotape
intervention on psychological outcomes in patients undergoing coronary
artery bypass graft surgery.
Source
Holistic nursing practice. 24 (4) (pp 213-222), 2010. Date of Publication:
2010 Jul-Aug.
Abstract
Depression and anxiety are associated with increased risk of postoperative
cardiac events and death in patients who have undergone coronary artery
bypass graft surgery. These risks persist even several months after the
procedure. Guided imagery has been used with cardiac surgery patients for
some time and with numerous anecdotal reports of considerable benefit. In
addition, this therapy is low-cost and easy to implement, and the
literature holds ample evidence for its efficacy in symptom reduction in
various patient populations. It was thus hypothesized that preoperative
use of guided imagery would reduce postoperative distress in patients
undergoing coronary artery bypass graft. Fifty-six patients scheduled to
undergo coronary artery bypass graft at Columbia University Medical Center
were randomized into 3 groups: guided imagery, music therapy, and standard
care control. Patients in the imagery and music groups listened to
audiotapes preoperatively and intraoperatively. All patients completed
psychological, complementary medicine therapies use, and other assessments
preoperatively and at 1 week and 6 months postoperatively. Only
preoperative distress was predictive of postoperative distress at
follow-up. Use of complementary medicine therapies was high in all groups
and this fact, in addition to the small sample size, may have accounted
for the lack of significant relationship between imagery and postoperative
distress. Regardless, this complementary and alternative medicine therapy
remains palatable to patients. Given its efficacy in other patient
populations, it is worth exploring its potential utility for this
population with a larger sample.

<46>
Accession Number
21044330
Authors
Montes F.R. Pardo D.F. Charris H. Tellez L.J. Garzon J.C. Osorio C.
Institution
(Montes) Department of Anesthesiology, Fundacion CardioInfantil-Instituto
de Cardiologia, Calle 163 A # 13B-60, Bogota, Colombia, South America.
Title
Comparison of two protective lung ventilatory regimes on oxygenation
during one-lung ventilation: a randomized controlled trial.
Source
Journal of cardiothoracic surgery. 5 (pp 99), 2010. Date of Publication:
2010.
Abstract
The efficacy of protective ventilation in acute lung injury has validated
its use in the operating room for patients undergoing thoracic surgery
with one-lung ventilation (OLV). The purpose of this study was to
investigate the effects of two different modes of ventilation using low
tidal volumes: pressure controlled ventilation (PCV) vs. volume controlled
ventilation (VCV) on oxygenation and airway pressures during OLV. We
studied 41 patients scheduled for thoracoscopy surgery. After initial
two-lung ventilation with VCV patients were randomly assigned to one of
two groups. In one group OLV was started with VCV (tidal volume 6 mL/kg,
PEEP 5) and after 30 minutes ventilation was switched to PCV (inspiratory
pressure to provide a tidal volume of 6 mL/kg, PEEP 5) for the same time
period. In the second group, ventilation modes were performed in reverse
order. Airway pressures and blood gases were obtained at the end of each
ventilatory mode. PaO2, PaCO2 and alveolar-arterial oxygen difference did
not differ between PCV and VCV. Peak airway pressure was significantly
lower in PCV compared with VCV (19.9 +/- 3.8 cmH2O vs 23.1 +/- 4.3 cmH2O;
p < 0.001) without any significant differences in mean and plateau
pressures. In patients with good preoperative pulmonary function
undergoing thoracoscopy surgery, the use of a protective lung ventilation
strategy with VCV or PCV does not affect the oxygenation. PCV was
associated with lower peak airway pressures.

<47>
Accession Number
20977758
Authors
Borges J.C. Lopes N. Soares P.R. Gois A.F. Stolf N.A. Oliveira S.A. Hueb
W.A. Ramires J.A.
Institution
(Borges) Heart Institute (InCor), University of Sao Paulo Medical of
School, Sao Paulo, Brazil.
Title
Five-year follow-up of angiographic disease progression after medicine,
angioplasty, or surgery.
Source
Journal of cardiothoracic surgery. 5 (pp 91), 2010. Date of Publication:
2010.
Abstract
Progression of atherosclerosis in coronary artery disease is observed
through consecutive angiograms. Prognosis of this progression in patients
randomized to different treatments has not been established. This study
compared progression of coronary artery disease in native coronary
arteries in patients undergoing surgery, angioplasty, or medical
treatment. Patients (611) with stable multivessel coronary artery disease
and preserved ventricular function were randomly assigned to CABG, PCI, or
medical treatment alone (MT). After 5-year follow-up, 392 patients (64%)
underwent new angiography. Progression was considered a new stenosis of >=
50% in an arterial segment previously considered normal or an increased
grade of previous stenosis > 20% in nontreated vessels. Of the 392
patients, 136 underwent CABG, 146 PCI, and 110 MT. Baseline
characteristics were similar among treatment groups, except for more
smokers and statin users in the MT group, more hypertensives and lower
LDL-cholesterol levels in the CABG group, and more angina in the PCI group
at study entry. Analysis showed greater progression in at least one native
vessel in PCI patients (84%) compared with CABG (57%) and MT (74%)
patients (p < 0.001). LAD coronary territory had higher progression
compared with LCX and RCA (P < 0.001). PCI treatment, hypertension, male
sex, and previous MI were independent risk factors for progression. No
statistical difference existed between coronary events and the development
of progression. The angioplasty treatment conferred greater progression in
native coronary arteries, especially in the left anterior descending
territories and treated vessels. The progression was independently
associated with hypertension, male sex, and previous myocardial
infarction.

<48>
Accession Number
71105173
Authors
Greco T. Bertini P. Greco M. Baldassarri R. Dossi R. Cariello C. Sassone
M.E. Di Prima A.L. Zangrillo A. Majure D.T.
Institution
(Greco, Greco, Dossi, Sassone, Di Prima, Zangrillo) Department of
Anaesthesia and Intensive Care, San Raffaele Scientific Institute, Milan,
Italy
(Bertini, Baldassarri, Cariello) Department of Anaesthesia and Critical
Care Medicine, Cardiothoracic Anaesthesia and Intensive Care, Azienda
Ospedaliero Universitaria Pisana, Pisa, Italy
(Majure) Department of Medicine, University of California, San Francisco,
United States
Title
The effect of milrinone on mortality in cardiac surgery: A meta-analysis
of randomised trials.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 226-227), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Introduction: Milrinone is associated with increased mortality in
long-term use in chronic heart failure. A recent meta-analysis suggested
that it might increase mortality in patients undergoing cardiac surgery
[1]. The authors conducted an updated meta-analysis of randomised trials
in patients undergoing cardiac surgery to determine if milrinone impacts
survival. Method: BioMedCentral, PubMed, EMBASE, the Cochrane central
register of clinical trials, and conference proceedings were searched for
randomised trials that compared milrinone versus placebo or any other
control in adult and paediatric patients undergoing cardiac surgery.
Authors of trials that did not include mortality data were contacted. Only
trials for which mortality was available were included. Results: Overall
analysis showed no difference in mortality between patients receiving
milrinone vs. control, (12/554 [2.2%] in the milrinone group vs. 10/483
[2.1%] in the control arm, RR = 1.15, 95% CI [0.55 to 2.43], P = 0.7) or
in analysis restricted to adults, (11/364 [3%] in the milrinone group vs.
9/371 [2.4%] in the control arm, RR = 1.17, 95% CI [0.54 to 2.53], P =
0.7). Sensitivity analyses performed in trials with low risk of bias
showed a trend towards an increase in mortality when using milrinone
versus any control, (8/153 [5.2%] in the milrinone arm versus 2/152 [1.3%]
in the control arm, RR = 2.71, 95% CI [0.82 to 9], P for effect = 0.10
with 7 studies included). Discussion: Despite theoretical concerns for
increased mortality with intravenous milrinone in patients undergoing
cardiac surgery, we were unable to confirm an adverse effect on survival.
However, we noted a trend towards an increased mortality in trials with
low risk of bias.

<49>
Accession Number
71105165
Authors
Zangrillo A. Cariello C. Dossi R. Bertini P. Sassone M.E. Baldassarri R.
Di Prima A.L. Taddeo D. Tarzia V. Pasin L.
Institution
(Zangrillo, Dossi, Sassone, Di Prima, Taddeo, Tarzia, Pasin) Department of
Anaesthesia and Intensive Care, San Raffaele Scientific Institute, Milan,
Italy
(Cariello, Bertini, Baldassarri) Department of Anaesthesia and Critical
Care Medicine, Cardiothoracic Anaesthesia and Intensive Care, Azienda
Ospedaliero Universitaria Pisana, Pisa, Italy
Title
A Bayesian network meta-analysis of randomised trials on anaesthetic drugs
and survival in cardiac surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 220), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Introduction: We performed direct and indirect comparisons among
desflurane, isoflurane, sevoflurane and total intravenous anaesthesia
(TIVA) to assess how anaesthetics influence patients' survival after
cardiac surgery. Methods: We performed standard pair-wise and Bayesian
network meta-analyses. Pertinent studies were independently searched in
BioMedCentral, MEDLINE/PubMed, Embase, and the Cochrane Library (last
updated in June 2012). Results: We identified 38 randomised trials with
survival data published between 1991 and 2012, with most studies (63%)
performed on coronary artery bypass grafting patients (CABG) with standard
cardiopulmonary bypass. The standard meta-analysis showed that the use of
a volatile agent was associated with a reduction in mortality when
compared to TIVA at the longest follow-up available (25/1994 [1.3%] in the
volatile group versus 43/1648 [2.6%] in the TIVA arm, odds ratio = 0.51,
95% confident interval 0.33 to 0.81, P for effect = 0.004, number needed
to treat = 74, I2 = 0%) with results confirmed in trials with low risk of
bias, in large trials and when including only CABG studies. Bayesian
network meta-analysis showed that sevoflurane (odds ratio = 0.31, 95%
credible interval 0.14 to 0.64) and desflurane (odds ratio = 0.43, 95%
credible interval 0.21 to 0.82) were individually associated with a
reduction in mortality when compared to TIVA (the results with isoflurane
went in the same direction but did not reach statistical significance).
Discussion: Anaesthesia with volatile agents appears to reduce mortality
after cardiac surgery when compared to TIVA, especially when sevoflurane
or desflurane is used. A large, multicentre trial to confirm that long
term survival is significantly influenced by the choice of the anaesthetic
is highly warranted.

<50>
Accession Number
71105111
Authors
Ochana A. Alexiev V. Carroll R. Kevin L. Harte B.
Institution
(Ochana, Carroll, Kevin, Harte) Galway University Hospitals, Galway,
Ireland
(Alexiev) National University of Ireland Galway, Galway, Ireland
Title
Comparison of the performance of standard double lumen tubes with
VivaSight-DLTM double lumen tubes for lung isolation during thoracic
surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 177-178), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Introduction: Double lumen tubes (DLT) are the preferred option for lung
isolation when selective lung ventilation is required. Ideally these tubes
are inserted with bronchoscopic guidance to ensure correct position. [1].
However, many centres still perform blind insertion due to resource
limitations or to lack of familiarity with bronchoscopic techniques. The
VivaSight-DL tube is a left-sided double lumen tube with an inbuilt
high-resolution camera just below the tracheal lumen which allows for
continuous display of tube position during and after the insertion process
on an external screen. Methods: Following ethics committee approval, we
compared the success of insertion of a Viva-Sight DL with a Mallincrodt
DLT inserted blindly with position immediately confirmed by bronchoscopic
guidance in a randomised controlled trial. After consent, 24 ASA 1-3
patients were randomly assigned to the 37F VivaSight (VS) or 37F left
doublelumen (DL) groups (12 per group). Exclusion criteria included
anticipated difficult laryngoscopy and BMI > 35. The following endpoints
were measured: 1. Ability to confirm correct tube position (sidedness and
depth). 2. Time to confirm tube position. 3. Incidence of view
obliteration by secretions. 4. Ability to detect malposition following
correct tube placement. 5. Quality of lung collapse. Results: Correct tube
position was confirmed in 9 of 12 patients (75%) in the VS group and 11 of
12 (91.5%) patients in the DL group. Failure in the VS group was due to
inability to clear secretions from the camera. Position was subsequently
confirmed by rescue with a bronchoscope. The failure in the DL group was
due to inability to pass the DLT through the vocal cords. This was rescued
with a single lumen ETT and bronchial blocker. Time to confirmation of
correct position was shorter in the VS group (106 vs. 178 seconds, P =
0.09, Student's t-test). The effects of learning did not influence
results. Satisfactory lung deflation was achieved in all patients.
Discussion: Although faster, the VivaSight- DL was inferior to
conventional DLT/bronchoscope for position confirmation. This was
primarily due to difficulty in clearing secretions from the camera despite
the integrated camera flushing system. Newer versions may provide
solutions for this problem. The Viva- Sight system shows promise as an
alternative to fibreoptic bronchoscopy for confirming DLT position, with
the potential for faster placement times and lower overall cost per
patient. Further studies are needed to verify our findings. We recommend
having a fibreoptic bronchoscope as backup while experience with this
system accumulates.

<51>
Accession Number
71105065
Authors
Kimenai D.M. Bastianen G. Daane C.R. Megens- Bastiaanse C.M. Van Der Meer
N.J.M. Scohy T.V. Gerritse B.M.
Institution
(Kimenai, Bastianen, Daane, Megens- Bastiaanse, Van Der Meer, Scohy,
Gerritse) Amphia Hospital, Breda, Netherlands
Title
Effect of colloids Gelatin and HES 130/0.4 on blood coagulation in cardiac
surgery patients: A randomised controlled trial.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 140-141), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Introduction: The choice of the prime solution for cardiopulmonary bypass
(CPB) can play an important role in limiting the effect on blood
coagulation, but it is still unclear what the effect of colloids on blood
coagulation is. The aim of this study was to investigate the effect of
synthetic colloids on blood coagulation in patients who underwent a CABG
(coronary artery bypass craft) procedure. Methods: Based on sample size
estimation (alpha = 0.05, power = 0.80) each treatment arm required 30
patients. Sixty elective CABG patients who underwent CPB were randomly
assigned to receive the prime solutions lactated Ringer's solution
combined with Hydroxyethyl Starch 130/0.4 (HES, 6% Volulyte, Fresenius
Kabi Nederland BV, The Netherlands) (HES group) or gelatin (Gelofusin ,
Braun Melsungen AG, Germany) (Gelo group). Blood loss was assessed using
chest tube drainage; secondary endpoints were amount of blood component
transfusion, routine coagulation tests values and rotation
thromboelastometry values (Rotem). Results: There was no significant
difference in chest tube drainage between the groups (total chest tube
drainage: HES group, 500 +/- 420 ml vs. Gelo group, 465 +/- 390 ml, P =
0.482). No significant differences were observed in any of the routine
coagulation tests, thromboelastometry parameters (table 1) and blood
component transfusion (Table Presented) between the groups. Independent
samples T-test; HES group vs. Gelo group. CT = clotting time; MCF =
maximum clot firmness Discussion: In this randomised controlled trial of
adults undergoing CABG procedure, there was no significant difference in
blood loss or blood coagulation between HES 130/0.4 and gelatin combined
with lactated Ringer's solution.

<52>
Accession Number
71105057
Authors
Bojan M.
Institution
(Bojan) Department of Anaesthesiology and Critical Care, Necker-Enfants
Malades Hospital, Paris, France
Title
Acute renal failure in paediatric cardiac surgery; recent developments.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 129-132), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Incidence, Pathophysiology The incidence of acute kidney injury (AKI)
following cardiac surgery in infants is estimated be up to 36%, and is
associated, depending on the severity of the injury, with a 5 to 9-fold
increase in the risk of death [1]. The pathogenesis of cardiac surgery
related AKI is complex, and it is largely assumed that the pathologic
lesion is acute tubular necrosis [2]. Unlike in adults, no scoring system
has been developed in infants to predict the risk of postoperative AKI,
but the length of the cardiopulmonary bypass (CPB) is the most important
risk factor identified. Of the several mechanisms which contribute to the
tubular injury during CPB, ischaemia and reperfusion, oxidative stress due
to the generation of free haemoglobin and iron through haemolysis [3], and
inflammation are thought to be the most prominent. Reduced renal
perfusion, as demonstrated by a renal oximetry beyond 50% which lasted for
more than 2 hours, was well correlated with postoperative renal
dysfunction in infants in a singlecentre study [4]. The autoregulation
threshold of the renal blood flow in children with CPB is not known to
date, but excursions of the mean arterial pressure below the lower limit
of the cerebral blood flow autoregulation have been shown to be associated
with the occurrence of AKI in adults with CPB [5]. It is now established
that normothermic and hypothermic CPB are associated with a similar risk
of renal impairment in children [6]. Both anaemia and transfusions have
been shown to favour injury to the kidney in adults undergoing cardiac
surgery. In neonates, the intra-operative haematocrit threshold was set at
30% to prevent neurologic injury [7]. No "renal" threshold has been
identified in children yet, but large transfusions have been associated
with a greater risk of AKI following cardiac surgery [8]. It is likely
that the use of miniaturized CPB circuits, resulting in fewer transfusions
and reduced systemic inflammatory reaction, be associated with a decrease
in the incidence of AKI, but unlike in adults, there is no such evidence
in children. Diagnosis Several reports highlight the lack of reliability
of early variations in serum creatinine to diagnose changes in kidney
function in adults, and a decrease in creatinine seems to be the normal
course following cardiac surgery [9, 10]. It is likely that the dilutional
effect of the bypass prime results in a further decrease in postoperative
creatinine in infants. An increase in creatinine is commonly seen beyond
48 h of surgery in patients with AKI. However, the development of acute
tubular necrosis is heralded by the appearance of sensitive urinary
biomarkers such as neutrophil gelatinase - associated lipocalin (NGAL),
interleukin(IL)-18, liver fatty acid-binding protein (L-FABP), kidney
injury molecule (KIM)-1 and cystatin C [11, 12] and such markers might
help with the early diagnosis of AKI. Several may even help distinguish
pre-renal from intrinsic AKI [13, 14], and predict recovery from AKI in
patients with renal support [15]. However, validation of the novel
biomarkers raises the question of the gold standard for the diagnosis of
AKI, still based on an increase in creatinine, and it has been suggested
using hard outcomes such as dialysis or death [16]. The most popular
biomarker to date is urine NGAL, but the best time for collection and the
most accurate threshold for the prediction of dialysis requirement appear
to be age dependent. In infants with CPB, Parikh et al. [11] found urine
NGAL concentrations beyond 72 ng/ mL within 6 h of CPB commencement was
significantly associated with at least 4-fold odds for severe AKI, as
defined by receipt of dialysis or a doubling in sCr from baseline, and
identified severe AKI with 42% sensitivity and 85% specificity. In a
meta-analysis pooling together over 2500 cases across several settings,
the threshold urine NGAL concentration of 278 ng/mL within 6 h of surgery
identified AKI requiring dialysis with 76% sensitivity and 80% specificity
[17]. Prevention and treatment No specific therapies have emerged that can
attenuate acute kidney injury or expedite recovery. One single-centre
study demonstrated that high-dose fenoldopam, a shortacting dopamine-1
agonist which has been shown to increase blood flow to both the cortex and
medulla, resulted in a decreased urine NGAL and cystatine C when infused
in infants on bypass [18]. To date, treatment remains supportive. In
adults with septic shock, there is evidence that increasing mean arterial
pressure from 65 to 75 mmHg increases urine output, no benefit being
observed beyond 75 mmHg [19]. The restoration of blood pressure is a
desirable therapeutic goal when the kidney appears to lose autoregulation,
particularly if a patients remains hypotensive and oliguric after adequate
fluid resuscitation. The initiation of dialysis remains somewhat
subjective, and the decision to start dialysis is strongly influenced by
individual physician practice. However, initiation of dialysis within 48 h
of CPB in infants with severe AKI has been shown to improve early and late
survival [20]. Studies examining NGAL, cystatin-C, NAG, and KIM-1 among
others have suggested these novel biomarkers have the potential to
distinguish patients in whom dialysis will be needed, implying that these
biomarkers may be integrated into clinical decision algorithms [21].
Prognosis Evidence suggests that adults who have had acute kidney injury
are at increased risk of subsequent chronic kidney disease [22]. No such
data is available in children. Dimopoulos et al [23] demonstrated that the
risk of death at long term was 5-fold higher in patients with grown-up
congenital heart disease in whom the glomerular filtration rate was
severely reduced, and 3-fold higher in those with a mild impairment.
However, associations between the occurrence of chronic kidney injury and
surgery have not been assessed, and to date, it is not known whether
cardiac surgery during childhood is a risk factor for subsequent kidney
injury. Conclusions AKI is a devastating complication following paediatric
cardiac surgery, and, albeit treatment remains supportive to date, it is
now admitted that early intervention improves survival. In keeping with
such a purpose, the most recent developments have focused on the
identification of new biomarkers enabling early diagnosis and accurate
prediction of the severity of AKI, and which are potentially useful tools
for clinical decision algorithms.

<53>
Accession Number
71105055
Authors
Murphy T.
Institution
(Murphy) Consultant Paediatric Cardiac Anaesthetist, Freeman Hospital,
Newcastle upon Tyne, United Kingdom
Title
Cerebral oximetry in paediatric cardiac surgery; tool or fashion?.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 125-127), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Tool - a device used to carry out a particular function Fashion - a
popular or the latest style of clothing, hair, decoration, or behaviour
Background Progress is continually being made in the field of treatment
for congenital cardiac defects. Surgical and anaesthetic techniques and
peri-operative management have been refined. Increasing emphasis is now
being placed not only on a satisfactory cardiological outcome after
surgery, but also on other markers of satisfactory outcome, including
neurological status. Although neurological injury is now less common than
in earlier eras, steps are still being taken to minimise peri-operative
neurological damage. It has been suggested that the use of NIRS may assist
in achieving that goal, although there are important differences of
opinion. This talk will attempt to address such differences and will
conclude that, currently, the use of cerebral oximetry in paediatric
cardiac surgery is still a little more fashion than tool. A NIRS monitor
might be defined as a 'tool' under the following circumstances: 1. The
theory behind near infrared spectroscopic examination of tissues is
robust, scientifically proven, acceptable and clinically relevant. 2. It
is utilised peri-operatively in order to secure better neurological
outcomes for our patients. 3. We can define, reliably, what a neurological
outcome is and how it may change or progress over time. 4. We presume that
we understand the timing and mechanism by which neurological injury occurs
(circulatory arrest, low cardiac output, embolic phenomena etc) and
therefore how it could be prevented. 5. There is a recognised, validated,
widely utilised algorithm that permits the team to make defined changes in
management strategy based on what information the NIRS monitor is
providing, with the aim of preventing brain injury. 6. There is clinically
convincing evidence that children managed with a NIRS monitor have
superior neurological outcomes compared to children managed
conventionally. 7. There is a relative absence of other, 'complicating'
factors that might make it difficult to understand the relationship
between NIRS use and neurological outcome. Examination of the evidence 1.
The theory behind NIRS monitoring is scientifically acceptable. 2. NIRS
can be used on its own or as part of a multimodal neuromonitoring set up
(together with EEG analysis and transcranial Doppler). Neuromonitoring is
used to try to secure better neurological outcomes and prevent damage. It
may be used as a surrogate for cardiac output/venous saturations; this is
a different use. 3. It is more difficult to define neurological outcome:
presence or absence of seizures during a defined period of time after
return from theatres? New lesions as detectable on an MRI scan? Any
abnormality of MRI (a significant proportion of CHD patients have abnormal
brains before they go to theatre)? Information from comprehensive
neurodevelopmental assessments at defined time points? There are other
definitions. 4. There has to be some doubt about the precise timing and
causation of some neurological insults. 5. Algorithms have been published,
and they tend towards the same sort of interventions (transfuse, alter
temperature, change pump flows, modify cardiac output with drugs and
medical interventions, change ventilation management and FiO2, check
cannula positions etc) - but algorithms are probably not universally used
or accepted. 6. There is some evidence, but it does not yet meet the
standards set in large, adequately powered, randomised controlled trials.
7. There is a myriad of complicating factors: the injurious effects of
bypass itself, blood gas management strategy, target haematocrit, use of
antegrade cerebral perfusion, anaesthetic technique and drugs,
cardiopulmonary bypass equipment and technique (and many others). This
will probably make it difficult to define a NIRS-specific effect that
allows for superior neurological outcomes.

<54>
Accession Number
71105054
Authors
Rovira I.
Institution
(Rovira) Universitary Clinic Hospital, Barcelona, Spain
Title
The patient with severe heart disease requiring OLV for non cardiac
surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 121-125), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Session Learning Objective 1: Define severe heart disease and non-cardiac
surgery requiring OLV. Session Learning Objective 2: Describe the
respiratory and haemodynamics effects of OLV and recognize the potential
peri-operative consequences in severe heart disease. Session Learning
Objective 3: Discuss the anaesthetic management and monitoring approach in
patients with severe heart disease during non-cardiac surgery. Session
Learning Objective 4: Discuss postoperative care in severe cardiac
patients after non-cardiac surgery under OLV. Severe heart disease
Patients with severe heart disease submitted to anaesthesia and surgery
are at risk of cardiovascular decompensation and death. The risk could be
even higher if the type of surgery required one lung ventilation (OLV).
Guidelines for evaluation and management of patients with severe heart
disease undergoing non-cardiac surgery have been developed by the American
College of Cardiology (ACC) and the American Heart Association (AHA) [1]
and by the European Society of Cardiology (ESC) and endorsed by the
European Society of Anaesthesiology (ESA) [2]. These practice guidelines
reviewed and updated all the available clinical evidence for prediction,
diagnosis, management and prevention of cardiac events in patients with
severe heart disease undergoing non-cardiac surgery. Clinical predictors
of peri-operative cardiovascular risk regarding heart disease have been
stratified in three categories. 1) Major: unstable angina pectoris, acute
heart failure, significant cardiac arrhythmias, symptomatic valvular heart
disease, recent myocardial infarction and residual myocardial ischaemia.
2) Intermediate: previous MI, mild angina pectoris, compensated chronic
heart failure, insulin therapy or renal failure. 3) Minor: old age, ECG
anomalies or absence of sinus rhythm, low functional capacity, history of
stroke or uncontrolled systemic hypertension. For any of the major
categories (unstable cardiac conditions) scheduled surgery must be
postponed and for the others categories functional capacity must be
assessed. One of the best predictors of cardiac risk is functional
capacity. Functional capacity is measured in metabolic equivalent (METs)
and a low functional capacity (< 4 METs) is associated with an increased
incidence of postoperative cardiac events. After thoracic surgery a poor
functional capacity has been associated with an increased mortality [3].
Patients requiring OLV during surgery, usually have chronic obstructive
lung disease, with an increased risk of peri-operative pulmonary
complications, that can further impair cardiac function. For prognosis,
long-term mortality and cardiac events, some pre-operative biomarkers such
are brain natriuretic peptide (BNP) and N-terminal pro-BNP (NT-proBNP) are
of great value after major non-cardiac vascular surgery. No data is
available for non-cardiac surgery requiring OLV. Nevertheless, according
to guide lines, routine measurement of these biomarkers to identify
cardiac events is not recommended. Diagnosis of the magnitude of the three
cardiac risk markers, the major determinants of adverse postoperative
outcome, left ventricular dysfunction (LV), myocardial ischaemia, and
heart valve alterations, must be performed in patients undergoing
high-risk surgery. A meta-analysis [4] demonstrated that an LV ejection
fraction of < 35% had a sensitivity of 50% and a specificity of 91% for
prediction of peri-operative non-fatal MI or cardiac death after major
vascular surgery. Again, there is no data in patients requiring surgery
under OLV. In addition, left heart disease may cause pulmonary
hypertension (PH) which can be accentuated by PH due to lung disease and
hypoxaemia. PH is associated with significant peri-operative morbidity and
mortality. Moreover, patients with coronary stents are at an increased
risk of peri-operative cardiac morbidity and mortality due to stent
thrombosis. Finally, patients with severe heart disease may have a
pacemarker or implantable cardioverter-defibrillator that requires correct
management during surgery to avoid complications. Regarding the prevention
of cardiac events in patients with LV dysfunction undergoing major
non-cardiac surgery, the use of angiotensin-converting enzyme inhibitors,
beta-blockers, statins, and aspirin is independently associated with a
reduced incidence of in-hospital mortality. Thus, it is recom mended that
they be taken throughout the peri-operative period [6]. Non cardiac
surgery requiring OLV Non cardiac surgery requiring OLV refers to
intrathoracic surgery (pulmonary surgery, thoracic aorta surgery,
oesophageal surgery) and thoracic spine surgery. During this kind of
surgery the collapse of one lung allows an adequate surgical exposure for
performance of the surgery. There are many intrathoracic surgical
procedures that require OLV: video- assisted thoracoscopic surgery (VATS),
open lobectomy, pneumonectomy, repair of thoracic aortic aneurysm or
bronchopleural fistula, unilateral lung cyst, oesophageal resection,
single lung transplant, as well as non-surgical procedures such as
broncoalveolar lavage for alveolar proteinosis. According to the above
mentioned guidelines, cardiac risk for intrathoracic surgery is considered
an intermediate-risk procedure, with a reported cardiac risk (myocardial
infarction and cardiac death within 30 days after surgery) between 1% and
5%.

<55>
Accession Number
71105051
Authors
Baines P.
Institution
(Baines) Wellcome Trust Clinical Ethics Fellow, PICU Consultant Alder Hey
Hospital, Liverpool, United Kingdom
Title
Ethical issues around research in paediatric cardiac surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 117-119), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Research in paediatric cardiac surgery poses awkward ethical problems.
These include problems general to research with children with added
difficulties arising from the emotive nature of cardiac problems and the
urgency of the situation. As well as this there may be incomplete
knowledge of the other congenital abnormalities that the child may have.
Research is often presented as intrinsically bad. It is the sort of thing
from which right minded people should protect children. When attending
introductory research ethics lectures or Good Clinical Practice Courses
for Research (GCP) in the UK, the presenter usually shows a slide of the
Nuremberg War Crimes Trial (a photograph of the Nazi leaders but not the
doctors' trial). The presenters then go on to describe other reports
describing studies where subjects have been harmed, some of which involved
children, for example the Willowbrook studies of hepatitis. The general
tone is that research is intrinsically harmful and needs to be carefully
regulated to avoid excesses perpetrated by enthusiastic researchers
interested only in their study. But the other side of the coin is that
there are enormous benefits from research and science in medicine, from
the smartphone in my pocket giving me access to the dramatic improvements
in outcome from illnesses. As examples the survival following ALI in
children has increased from 2% in the 1950s to 80-90% currently. An
example from cardiac surgery is the longer term survival of children with
congenital heart disease that had been fatal before the 1950s. For the
improvements to continue, we will need to continue research. Children (and
women and especially pregnant women) have been protected from research
with added safeguards because they are vulnerable. This has however
created the problem that the number of research projects carried out in
children (the evidence base) is sorely limited so that much of paediatric
therapy has to be extrapolated from adult medicine. If children are
vulnerable, then their vulnerability is compounded by the limited evidence
base in paediatrics. Attempts have been made to encourage paediatric
research but it is still lacking. Two ways in which research and our
treatment of children is conceptualised cause problems. The first is the
primacy of the notion of consent, the second is the notion of the child's
best interests. Consent Children's participation in research is modelled
on adults. Consent is at the core of an adult's participation in research.
So, in the Nuremberg Code "The voluntary consent of the human subject is
absolutely essential. the person involved should have legal capacity to
give consent; should be so situated as to be able to exercise free power
of choice, without the intervention of any element of force, fraud,
deceit, duress, overreaching or other ulterior form of constraint or
coercion." [Trials 1947, p. 181] Though this is not the first reference to
consent in research. Ironically amongst the first of requirements for
informed consent in research comes from the Prussian Parliament. In 1900,
the Minister for Religious, Educational and Medical Affairs directed ".all
medical interventions for other than diagnostic, healing and immunisation
procedures.are excluded under all circumstances if 1) the human subject is
a minor or not competent due to other reasons 2) the human subject has not
given his unambiguous consent." [Nicholson p 156]. The Nuremberg code
excludes children from research, absolutely in so far as the participant
should have legal capacity to consent. This was the absolutist position
argued for by a prominent American theologian, Ram- say. He further argued
that parents should not consent to research because it treats a child as
an adult, as a joint adventurer in a common cause. Research was only
acceptable when directly of benefit to the child. Responses to Ramsay
included the idea that we should treat children as they ought to behave
and so in the case of research with consideration for others too. Ramsay's
conception was too individualistic. Other responses include the idea that
children as a class should benefit, though not necessarily the child who
participates. Assent As well as parental consent, emphasis is placed on
the child's assent. However, what is meant by assent is unclear (and is
clearly different between research guidelines from different sources).
Although the standard necessary to consent has been extensively considered
there is little work on what assent means [Baines]. What this may mean is
that modelling a child's research participation on consent is
fundamentally wrong. Children just can't consent, they are not
mini-adults. And the demand for consent (or assent) approaches children's
research participation in the wrong way. This just isn't the way to treat
children. Following O'Neill and Manson's criticisms of consent, what is
important are the norms of how we treat children, and the quality of the
research [Manson & O'Neill]. If this is so, then parental permission is
important, but is different from the consent that an adult provides on
their own behalf. Best interests Another approach to justifying how
children are treated is based on the child's welfare. Usually when acting
for children we will aim to act in the child's best interests. Decisions
are made for what will be best for them. However, in research what is best
for the child may not be clear. If a new treatment is proposed for a child
then whether or not it is better for the child is unknown. Enrolment of
children in randomised controlled trials is unlikely to be in their
interests (if interests are understood as what will benefit them
medically) firstly as research depends on equipoise (at some level the
clinicians are in agreement that either treatment is acceptable) and
secondly that the child will be assigned a treatment at random and will
not necessarily get that which is hoped to be best. Much is made of the
distinction between therapeutic research and non-therapeutic research.
Therapeutic research holds the prospect of benefit for the individual
child and so may be permissible when considering interests, but
non-therapeutic research holds no clinical benefit to the child and so
will expose the child to pain (of venepuncture perhaps) or risks (of
radiation or drug exposure) but without the prospect of benefit. And so
non-therapeutic research is often held to be unjustifiable when
considering the child's interests. However, the problem with therapeutic
research (where a child is offered a new treatment) is that it may not be
research in the true sense: it is therapy. And however impressive the
outcome of series of children treated with a particular treatment, the
gold standard remains a trial with random allocation. Given these concerns
it is unlikely that children's research participation will be in the
child's best interests. However it is important to recognise that parents
do not always act in a child's interests. For example, parents have to
balance the interests of their children one with another in the family
alongside their own concerns. Furthermore parents are allowed to act in
ways that harm their children, by smoking, and by refusing neonatal
screening or vaccination of their child.

<56>
Accession Number
71105036
Authors
Ranucci M.
Institution
(Ranucci) Dept. of Cardiothoracic and Vascular Anesthesia and Intensive
Care, IRCCS Policlinico San Donato, Milan, Italy
Title
New role for colloids and crystalloids?.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 96-98), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Background All the major surgical operations challenge anaesthesiologists
and intensivists with the problem of fluid replacement. Cardiac surgery
introduces additional items to the problem, mainly related to the use of
cardiopulmonary bypass (CPB) and to the haemostatic system alterations. At
present, there is a wide availability of different fluid replacement
solutions, and this wide choice makes the scenario even more confused.
Basically, the main fluid replacement solutions available include 1.
Normal saline (0.9% NaCl) 2. Ringer lactate and Hartmann's solutions 3.
Plasma-Lyte 4. Sterofundin 5. Hypertonic crystalloid solutions (7.5%
hypertonic saline) 6. Gelatins (35-40 g/L) 7. Starches (with different
medium molecular weight, ranging from 130 to 670; different degrees of
substitution, ranging from 0.4 to 0.75; and different concentrations,
ranging from 60 to 100 g/L) 8. Human albumin (4-5%) Quantity: restrictive
or liberal strategies? In non-cardiac surgery settings, recent data
suggest a shift from liberal towards restrictive policies of fluid
replacement. In the setting of cardiac surgery, the main problem is
represented by the need to maintain a correct pre-load, however avoiding
fluid overload. This introduces the need for a correct assessment of the
individual fluid responsiveness that in cardiac patients is affected by a
number of haemodynamic conditions, basically including the systolic and
diastolic function of the left and right ventricles. As a general rule,
colloids are retained longer in the intravascular space than crystalloid
solutions, with a better preservation of colloid osmotic pressure.
However, hypertonic crystalloid solutions may induce a higher
intravascular volume expansion due to their high osmolarity. This effect,
however, seems to be time-limited (about 50 minutes). Various
fluid-responsiveness indices have been proposed to individualize fluid
replacement volume in cardiac surgery. These include pressure-based
parameters (CVP, MAP, PCWP), static volume parameters (EVLW, ITBV),
dynamic parameters (SVV and PPV), and echo-derived parameters (left
ventricle and right ventricle end-diastolic areas). Goaldirected therapies
based on these parameters have been proposed; but the evidence in terms of
better outcomes is still poor in the cardiac surgery setting. Crystalloids
or colloids? A recent meta-analysis [1] of RCTs comparing crystalloid vs.
colloid-based fluid replacement in critical patients demonstrated that the
use of colloids vs. crystalloids for fluid resuscitation did not result in
a lower mortality rate. Additionally, the use of hydroxyethyl starch might
increase mortality. The authors concluded that given the higher cost of
colloids and the absence of a clear benefit, there is little room
available for this approach. It must be considered however that few
studies dealing with cardiac surgery were included in this meta-analysis.
The main concern about the use of hydroxyethyl starch as a fluid
replacement solution is based on the potential for kidney function damage.
A recent study [2] highlighted that hydroxyethyl starch (HES 130/0.4)
exerts a deleterious effect on proximal tubular cells in a dose-dependent
manner and other studies have highlighted the deleterious effects of HES
in the surgical setting [3] for cumulative doses > 33 ml/kg. The cardiac
surgery setting is particularly sensitive for postoperative acute renal
failure; additionally, specific alterations of the haemostatic system
should be considered in the choice of fluid replacement solutions. Various
studies have demonstrated that HES use induces coagulation changes,
basically related to decreased clot firmness. These effects are absent or
less pronounced with gelatins or albumin. However, recent studies have
confuted these findings, and the real clinical impact of decreased clot
firmness is still to be determined. An important point is that quantity,
rather than quality of fluid replacement may induce clinically relevant
coagulation changes, mainly based on fibrinogen deficiency and dilution
coagulopathy. Albumin In adult cardiac surgery, the use of 4-5% albumin is
presently practically abandoned, mainly due to cost implications. However,
it must be highlighted that the great majority of the studies comparing
albumin with other solutions did not find any major negative effect of
albumin. Additionally, albumin competes with fibrinogen when used in
priming solutions, limiting fibrinogen deposition on e foreign surfaces
and consequent platelet adhesion. In paediatric and particularly neonatal
cardiac surgery, albumin is still one of the possible choices for priming
solutions and fluid replacement, as an alternative to fresh frozen plasma.
Conclusions The major volaemic changes induced by cardiac surgery are
represented by the dilutional effects of CPB. Apart from the wellknown
deleterious effects of severe haemodilution in terms of oxygen
availability, dilutional effects include deleterious changes in blood
viscosity and dilution coagulopathy. In this setting, the major challenge
for the anaesthesiologist is preserving the physiology of the circulating
volume, by limiting haemodilution. Therefore, before addressing the
problem of the quality of fluid replacement, its quantity should be
carefully kept under control.

<57>
Accession Number
71105035
Authors
Vives M.
Institution
(Vives) Toronto General Hospital, Toronto, ON, Canada
Title
Perioperative renal protection strategies in cardiac surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 92-96), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Acute Kidney Injury develops in 5% to 42% of patients who undergo cardiac
surgery depending on the definition of AKI, and 1% to 4% of patients
require dialysis. AKI requiring dialysis after cardiac surgery is
associated with an increase of short and long-term mortality and
morbidity, length of stay and cost. Even small increases in serum
creatinine (> 26.5 mumol/L) postoperatively are associated with increased
mortality. Given the significant morbidity and mortality risk associated
with postoperative AKI, the prevention of renal dysfunction is of
paramount importance. Preoperative strategies In the pre-operative period,
the major goals include optimizing cardiac output, avoiding intravascular
volume depletion, and continuing congestive heart failure treatment before
surgery. Optimizing renal function in elective surgery for patients with
reversible AKI should be considered. Pre-operative use (48 h before
surgery) of diuretics has been associated with an increase risk of RRT in
a retrospective study. Patients may benefit from avoiding preoperative
anaemia, defined as haemoglobin < 12.5 mg/dL. A recent pilot study found
that the administration of erythropoietin before surgery reduced the risk
of AKI and improved postoperative renal function. A single-dose
erythropoietin plus an iron supplement given the day before surgery might
be renal protective. They found a significant reduction in AKI (24% vs
54%). It is unclear whether the preserved postoperative renal function was
due to a renoprotective effect of erythropoietin or reduced transfusion
rates. Recent data suggest that transfusing PRBC preoperatively could be
associated with a lower peri-operative free iron and transferin saturation
with a trend towards lower AKI rates after surgery [1]. Further studies
are required to affirm the benefit of transfusing PRBC or optimizing
haemoglobin pre-operatively in anaemic patients. Exposure to radiocontrast
agents should be avoided or minimized, along with time to allow for renal
recovery whenever posible [2]. The pre-operative prophylactic use of RRT
on patients with sCr > 2-2.5 mg/dL (177- 221 mumol/L) has been shown to
decrease morbility and mortality in several trials. However, the results
are difficult to interpret, as RRT directly influences the definition of
AKI. Therefore, these results need to be replicated in further trials.
Cost-effectiveness analysis of pre-operative prophylactic use of RRT
should also be studied. To date, studies optimizing peri-operative
haemodynamics using fluids and/or inotropes have not been designed to
examine renal outcomes. Some data suggested a significant reduction in
length of hospital stay and in postoperative complications associated with
optimization of stroke volume. Data from a prospective study on 268
patients presented at the 29th Autumn ACTA meeting in Newcastle showed a
renal protection benefit from maximising stroke volume using LIDCO during
the first 8 h postoperatively. There was no difference in the amount of
fluids given (2.704 ml/kg vs 2.905 ml/kg), but in the timing these fluids
were given. In the goaldirected therapy group fluid were given earlier
without waiting for low blood pressure to appear. There was a significant
decrease of AKI by postoperative day 3, defined as AKIN stage 1 (6.5% vs
19.9%, P 0.002) and also a significant decrease of RRT (3.3% vs 10.6%, P
0.021) and hospital LOS (6 vs 7 days, P 0.004). No difference was found
regarding in-hospital mortality. Pre-operative intravenous hydration may
reduce the incidence of AKI in patients with Chronic Kidney Disease (CKD)
undergoing cardiac surgery. A small randomized trial, on 45 CKD moderate
to severe patients with GFR < 45 ml/min, using an intravenous infusion of
0.45% normal saline at 1 ml/kg-1/h-1 for 12 h before surgery versus no
hydration, showed some renal protection effects (AKI-D 27% vs 0%, P <
0.001). Even though results need to be validated by larger trials, so far,
data suggest patients should be euvolaemic and off diuretics before
surgery to avoid AKI. Intra-operative strategies An association between
intra-operative anaemia, blood transfusion and AKI has long been noted.
However, there is evidence to suggest that low pre-operative and
intraoperative haemoglobin levels are associated independently with
CSA-AKI [3], but ironically, there is also evidence to suggest that
intra-operative transfusion is independently associated with CSA-AKI. Some
authors suggested that it is not the absolute level of haemoglobin that is
important, but its change from the baseline. The benefits of a tight
glucose control strategy have not been replicated in multicentre studies,
and the lack of benefit and increased potential harm was confirmed again
in a recent meta-analysis. The large multicentre Nice Sugar study
demonstrated no outcome benefit in tight glucose control compared with a
regimen that targeted a blood sugar level of less than 180 mg/dl (9.9
mmol/L) and had an unacceptable incidence of hypoglycaemia. As one of the
main physiopathologic mechanisms of CSA-AKI is the ischaemia-reperfusion
injury, remote ischaemic preconditioning (rIPC) has been proposed as a
potential means to prevent it. rIPC may attenuate myocardial
ischaemia-reperfusion injury in patients undergoing coronary bypass
surgery. Remote ischaemic preconditioning (RIPC) is the concept that brief
ischaemia followed by reperfusion in an organ can reduce subsequent
ischaemia-reperfusion injury in distant organs. Several clinical trials
showed significant myocardial protective effect of remote ischaemic
preconditioning by reducing postoperative cardiac enzymes. To date, the
evidence is still controversial. More robust data will be given to us from
several multicentre trials. Surgical strategies Off-pump coronary artery
bypass graft (OPCABG) allows systemic pulsatile flow and no exposure to an
extracorporeal circuit, thus reducing the inflammatory cytokine response.
Most available data support a decreased risk of AKI associated with OPCABG
procedures [4-6]. An interesting study from the CORONARY trial cohort
looking at renal outcomes 1 year following surgery is planned for
completion this year. Pharmacological renal protection Several
pharmacologic and therapeutic strategies have been used in an attempt to
decrease the incidence of CSA-AKI. Although some appeared promising in
early studies, conclusive evidence to support their widespread use is
still lacking. Fenoldopam Fenoldopam is a synthetic derivative of dopamine
with DA1 receptor selectivity that increases blood flow to the kidneys.
Its use during cardiac surgery has been suggested to have reno-protective
effects. A meta-analysis of 13 randomized and case-matched studies on
1,059 patients undergoing cardiac surgery concluded that the use of
fenoldopam significantly decreased AKI-D, ICU length of stay, and
in-hospital mortality. The results of this analysis may be questioned,
however, due to the heterogeneity of the trials, including an inconsistent
definition of AKI and no clear criteria for RRT initiation.

<58>
Accession Number
71105025
Authors
Della Rocca G. Tripi G. Pompei L.
Institution
(Della Rocca, Tripi, Pompei) Department of Anesthesia and Intensive Care
Medicine, University of Udine, Udine, Italy
Title
Free fluid therapy is best. Liberal or restricted fluid administration:
Are we ready for a proposal of a restricted approch?.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 77-80), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Background Fluid management during surgery represents a great matter of
debate among anaesthesiologists. Several studies have demonstrated that
the strategy of fluid therapy, i.e. total amount and type of fluid, may
influence the post-operative outcome. However an optimal strategy remains
uncertain [1]. The practice of aggressive fluid replacement of
hypothetical third space fluid loss gained widespread popularity in
intra-operative anaesthetic practice although it is more than 30 years
that direct measurements of basal evaporation rate from the skin and
airway during surgery showed that topical fluid loss was 0.5-1.0
mL/kg-1/h-1 in major abdominal surgery [2]. Physiological aspect The
endothelial cell line, as suggested by the Starling Principle, is not the
sole factor for the vascular barrier function. This task is mainly carried
out by the Endothelial Surface Layer (ESL), which seems to act as a
molecular filter. The ESL is involved in many processes (vascular barrier,
inflammation and coagulation) and various agents and pathologic states can
impair its behaviour (ischaemia-reperfusion injury, inflammation response,
several circulating mediators) [3]. Inappropriately high fluids
administration may cause iatrogenic ESL dysfunction by liberation of
atrial nNatriuretic peptide, which leads to fluid shifts into the
extravascular space [4]. This pathologic shift is caused by a dysfunction
of the vascular barrier, basically because of 3 reasons:- surgical
manipulation, reperfusion injury and iatrogenic hypervolaemia, regardless
of the kind of fluids administered (colloids or crystalloids). Fluid
reloading because of an overnight fasting period is unjustified and fluid
loss from insensible perspiration is also overestimated. It should be
adequate to substitute only the losses to maintain a normal intravascular
blood volume. A restrictive approach seems to be rational and supported by
physiology. According to these findings, more recent evidence suggests
that a large amount of fluids can increase peri-operative complications,
so a restricted approach has become more common [5]. Many trials
investigated a liberal or a restricted fluid therapy during the
intra-operative period, but in the literature there is not a clear
definition of what a restricted or liberal fluid approach is. Liberal vs.
restricted: is a definition possible? Holte K, et al. [6] defined a
liberal approach where 30 mL kg-1 h-1 of crystalloid was administered
during surgery and restrictive an infusion of 10 mL/kg-1/h-1 of the same
solution. In another study the same author administered 5-7 mL/kg-1/h-1 of
Ringer's lactate solution plus 7 mL/kg of hydroxyethyl starch (HES)
130/0.4 in the restrictive group, and 18 mL/kg-1/h-1 of Ringer's lactate
solution plus 7 mL/kg of HES 130/0.4 in the liberal group, in patients
undergoing fast-track colonic surgery [7]. Abraham-Nordling M. et al. [8]
identified as a liberal approach the administration of 5 mL/kg-1/h-1 of
Ringer's acetate solution plus 2 mL/kg-1/h-1 of buffered glucose 2.5%, and
only 2 mL/kg-1/h-1 of buffered glucose 2.5% in the restrictive group
intra-operatively. Lobo S. et al. defined a liberal approach by the
administration of 12 mL/kg-1/h-1 of Ringer's lactate solution and
restrictive the administration of 5 mL/kg-1/h-1 of the same fluid [9]. So
a clear and standardized definition of restrictive and liberal approach is
now still impossible. We can only say that the restrictive strategy
represents a lower amount of fluids administered compared with a
traditional approach used in that institution. On the other hand, in high
risk surgical patient (HRSPts - see table 1) [10] undergoing intermediate
or major risk surgery, evidence based medicine support the application of
a goal directed therapy (GDT) where administration of fluid is targeted on
haemodynamic parameters (i.e. stroke volume) aiming to maximize oxygen
delivery and then avoiding oxygen debt [11]. Patient population and type
of surgery The choice of patient is very important in applying a liberal
or restricted fluid management. Patients with compromised pulmonary or
cardiac function are HRSPts and appear to be more prone to complications
than normal counterparts. So these patients would benefit from a GDT [12,
13]. The type of surgery is also another important factor. Many studies
demonstrated that a restrictive approach in major surgery improves
outcome, diminish length of in hospital stay, reduce anastomotic leakage
and surgical site infection [5, 9, 14]. As a conclusion of a systematic
review of 80 randomized clinical trials Holte and Kehlet [15] recommended
avoiding fluid overload in major surgical procedures. Evidence Based
Medicine in restrictive and non restrictive approach In clinical practice
many studies investigated if a restrictive approach especially in major
abdominal surgery setting can improve outcome. Lobo et al. demonstrated an
improved gastrointestinal function after elective colonic resection. They
also demonstrated a reduced length of hospital stay (LOS) from 9 to 6 days
in the restrictive group [16]. Brandstrup demonstrated that in colorectal
surgery reduced post-operative complications and death [5]. Nisanevich
[14] found that in patients who underwent major abdominal surgery there
were less postoperative complications such as pneumonia, wound infection
and arrhythmias. However, other studies showed no difference in outcome
and postoperative complications between liberal vs. restricted fluid
management [17, 18]. Part of the literature seems to suggest that in
low-risk patients undergoing minor or intermediate risk surgery, liberal
strategy (non restrictive) may be preferable. It reduces some
postoperative complications such as nausea, vomiting, drowsiness,
dizziness and length of stay [6,19,20]. In patients undergoing minor
surgery, mostly in the ambulatory setting, liberal fluid administration
may improve early recovery measures and symptoms of dehydration
(dizziness, nausea and thirst) [21]. In conclusion, a well defined and
overall standardized definition of liberal and restrictive is still
impossible with current literature data. We would like to suggest an
approach for intra-operative fluid management (fig. 1), based on human
physiology and the current literature [22]. The steps reported in figure 1
should represent a rational approach to fluid management in ASA I-III
patients who do not need either GDT or an advanced haemodynamic monitoring
during the intra-operative period. * During the intra-operarive period as
much fluid as required by that single patient should be given. Either
hypovolaemia that causes organ hypoperfusion, or hypervolaemia that
increases postoperative complications, should be avoided. * In all
patients ASA I-III undergoing general or other specialized surgery,
excluding cardiac surgery or transplantation, 1 mL/kg-1/ h-1 of
crystalloid solution (if the patients do not observe overnight fasting or
do not have bowel preparation) should be given. * In fasted patients or
those undergone bowel preparation, 3 mL/kg-1/h-1 should be given for the
overall surgical procedure time. * In all those patients who are ASA IV
and/ or HRSPts and/or in those who undergo high risk surgery a Goal Direct
Therapy is strongly suggested. * Blood loss is replaced with colloids
until Hb level is at least over 7 g/dL if the patient does not have
cardiovascular or respiratory coexisting disease. *In case os diuresis
monitoring, the total amount will be replaced with balanced crystalloid
solution (unless contraindicated). * In case of hypotension soon after
general anaesthesia induction or during the intraoperative period, it is
necessary to check the anaesthesia level and consider the use of
vasopressors before administering fluids. * In case postopearative period
it is mandatory to restore oral hydration and feeding as soon as possible
(unless contraindicated).

<59>
Accession Number
71105022
Authors
Hofer C.K.
Institution
(Hofer) Institute of Anaesthesiology and Intensive Care Medicine, Triemli
City Hospital, Zurich, Switzerland
Title
Goal directed monitoring in cardiothoracic and vascular intensive care.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 70-72), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Organ perfusion, i.e. O2 delivery to the tissue in cardiac and vascular
patients with limited cardiopulmonary reserve may be impaired as result of
the body's inability to compensate for changes of cardio-respiratory and
metabolic demands during surgery. Intermittent reduction of the gut
oxygenation due to intraoperative hypovolemia and hypotension has shown to
result in an increased incidence of postoperative complications. Moreover,
impaired O2 delivery and increased O2 extraction after surgery have been
identified as independent predictors of prolonged ICU stay. Goal-directed
therapy (GDT) * GDT using andvanced minimally-invsis (but also invasive)
hemodynamic (HD) monitoring aims at optimizing O2 delivery in order to
prevent perioperative tissue hypoxia. * Cornerstones in the GDT strategy
are pre-oad optimization by fluid administration and modulation of cardiac
contractility by inotropic support according to preset hemodynamic goals.
*In recent years there is growing evidence that GDT has beneficial effects
on outcome in septic and high-risk surgery patients. GDT in Cardiac and
Vascular Surgery * Only a limited number of GDT studies in cardiac and
vascular surgery are available today. In these studies different
strategies in terms of monitoring tools, hemodynamic goals, start of
therapy and measures were used (Table A). * Interestingly, only in 5 of 11
studies newer less-invasive monitoring was applied. * Hemodynamic
parameters used were car- diac index (CI), stroke volume index (SVI),
mixed or central venous oxygenation (S/c/ vO2), standard pressure preload
(CVP/ PcWP) and functional hemodynamic (SVV) parameters. GDT and Outcome
in Cardiac and Vascular Surgery Two meta-analyses (1,2) on GDT in cardiac
and vascular surgery have been performed recently. Results are summarized
in table B. * GDT had no impact on mortality, incidence of complications
and hospital length of stay (HLOS) was reduced in cardiac, but not in
vascular surgery. * The lack of a GDT effect on mortality especially in
cardiac surgery patients may be explained by a low mortality of the
control group. However, these results must be carefully interpreted
considering the very (Table presented) small number of studies and the
obvious heterogeneity of these studies in terms of parameters and
protocols used. Conclusions and perspectives *GDT may have a positive
impact on outcome with a reduction of postoperative complications in
cardiac surgery but not in vascular surgery, but today there is no strong
body of evidence. * Use od HD parametere & HD goals need to be clarified.
* Optimal GDT Protocols for selected patient groups need to be defined and
investigated.

<60>
Accession Number
71105018
Authors
Bastien O.
Institution
(Bastien) Department of Anaesthesiology, Service d'Anesthesie-Reanimation,
Hopital Cardiovasculaire et Pneumologique L. Pradel, University Cl Bernard
Lyon, France
Title
Difficult weaning from CPB: Something different since 2000?.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 61-63), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
As severity of disease and age of patients are increasing, less invasive
procedures including hybrid interventions, mini-CPB, and video surgery are
trying to decrease postoperative complications. Difficult weaning from CPB
is still a challenge for anaesthesiologist in cardiac surgery.
Improvements are related to a pharmacological approach and mechanical
support of the failing heart, but are very different depending on the
aetiology. Three of them are mainly concerned with CPB weaning:
peri-operative ischaemic disease, pre-operative poor left ventricular
function and right ventricular failure related to pulmonary hypertension.
Peri-operative ischaemic disease As many patients are diabetic or
scheduled for redo, assessment of a previous bypass is mandatory and
should be checked if necessary, even in the immediate postoperative
period. The intra-aortic balloon pump (IABP) is now controversial [1, 2]
as many randomised control trials, including metaanalysis, don't
demonstrate any improvement in mortality in acute myocardial shock.
Nevertheless clinical efficiency on endocardial ischaemic episodes as
observed during the peri-operative period is still discussed [3].
Mechanical assistance by a ventricular assist device is now routinely
used. The most simple and easy mode is ECMO, but others systems are
available such as Impella, tandem Heart or Levitronix. No delay and rapid
institution are clearly a goal for success, but mortality is still high
and close to 35% [4]. Pre-operative poor left ventricular function
Ejection fraction of the left ventricle is a simple assessment of systolic
LV function. Progress in mitral valve regurgitation surgery is responsible
for an increasing number of patients scheduled for valvuloplasty with poor
LV function. Many reviews emphasise diastolic dysfunction as detected by
echocardiography but this aetiology is more related to postoperative
instability than to difficult weaning from CPB. All RC trials regarding
mortality with inotropes are non-significant [5, 6] in large series of
heart failure. Nevertheless all these trials are non-surgical patients.
Only small cohorts have been included after cardiac surgery. Enoximone [7]
and levosimendan [8,9] are the more innovative drugs currently used during
this decade, in adults as in paediatrics. New RCTs are necessary with
acceptable methodology [10]. Responders during the early phase is possibly
an option to rational use of these new and cost effective drugs [11].
Right ventricular failure related to pulmonary hypertension RVF and PAH
management is probably the most important improvement postoperatively. iNO
and inhaled prostacycline are widely used in cardiac surgery.
Disappointing results have been published by the Berliner group after left
ventricular assistance, but in a very specific and long term medical
problem. Inhibitors of phospodiesterase V (sildenafil and analogues) are
safe in the postoperative period and could be easily used after
extubation. The dose regimen is still debated especially in children.
Tricuspid regurgitation surgery has been proposed as a complementary
procedure for right dilated heart, but is a high risk for difficult
weaning. Pharmacological innovative drugs and new mechanical assistance
devices could not be optimised if diagnosis and medical algorithms are not
perfect. An important development is to clearly define and classify heart
failure as with the INTERMACS scoring system. It has also been
demonstrated in 2012 that the quality of cardiac surgeons might improve
with a span from 1 to 10 for some complications [12]. This is reason to
develop a bundle between anaesthetist and surgeon for this specific
period.

<61>
Accession Number
71105012
Authors
Von Heymann C.
Institution
(Von Heymann) Department of Anaesthesiology and Intensive Care Medicine,
Charite - University Hospital, Berlin, Germany
Title
Impact of the age of red blood cells and the outcome after cardiac
surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 49-50), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Cardiac surgery and bleeding associated with cardiac surgery consume
relevant proportions of blood donations worldwide. While it has been shown
that blood transfusions are associated with a higher incidence of adverse
outcome after adult [1] and pediatric cardiac surgery [2], the causes for
this association remain not elucidated. As a possible explanation the
duration of red blood cell (RBC) storage has been proposed, as the older
age of RBC was associated with a higher incidence of infectious
complications, longer hospital stay and a higher mortality rate [3, 4].
The rationale behind this hypothesis is the so-called "storage lesion" of
RBC that is described by a depletion of adenosine triphosphate (ATP), 2,3-
diphosphoglycerate (2,3-DPG), S-nitroso- hemoglobin (SNO-Hb) and a
reduction in RBC membrane deformability reducing the RBCs capacity to
deliver oxygen to tissues [5]. Furthermore, an immune response to the
transfusion of allogeneic blood has been discussed to be involved with the
higher incidence of infectious complications after surgery [6, 7]. In this
regard a recent metaanalysis including studies from different clinical
specialties showed that the use of old blood was associated with a higher
risk of death. Of note, this finding was consistent over all surgical
specialties investigated and, therefore, also applied to cardiac surgical
patients. Apart from mortality a significant association between the
incidence of multiple organ dysfunction and pneumonia and the transfusion
of old blood was shown [8]. However, the body of evidence suggesting that
old RBC is associated with adverse events in the cardiac surgical
population is opposed by observational and retrospective data that do not
confirm this association [9, 10]. From a methodological point of view,
most of the data investigating the association of age or RBC and clinical
outcome after cardiac surgery originate from observational or
retrospective studies. So far, there are only 3 prospective randomized
trials with a small number of patients, so that the existing evidence is
still challenged by confounders [11] requiring a prospective randomized
trial that is currently under way in cardiac surgery (RECESS-Trial,
NCT00991341).

<62>
Accession Number
71105002
Authors
Alonso P. Paniagua P. Devereaux P.J.
Institution
(Alonso) Centro Cochrane Iberoamericano, Biomedical Research Institute
(IIB-Sant Pau), Barcelona, Spain
(Paniagua) Dept. Anaesthesia and Critical Care, Hospital Santa Creu i Sant
Pau, Barcelona, Spain
(Devereaux) Population Health Research Institute, Hamilton, ON, Canada
(Devereaux) Department of Clinical Epidemiology and Biostatistics,
McMaster University, Hamilton, ON, Canada
Title
Perioperative myocardial ischemia: Diagnosis, prognostic significance and
therapeutic strategies in vascular surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 34-36), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
Worldwide over 200 million adults have major non-cardiac surgery annually
[1]. Despite benefits associated with surgery, major perioperative
complications, including death, occur. More than 1 million adults
worldwide will die within 30 days of non-cardiac surgery each year, and
myocardial ischaemia is a common cause. Peri-operative risk estimation
identifies patients who require more intensive monitoring and management
in the postoperative period. Moreover, peri-operative risk estimation is
needed to allow for informed decision making regarding the merits of
surgery. Current pre-operative risk prediction models for 30-day mortality
have limitations. Some authors advocate monitoring troponin measurements
after vascular surgery, and inconclusive evidence suggests that troponin
measurements after abdominal aortic surgery may enhance prediction of
short-term mortality. Little is known about optimal troponin threshold(s)
for predicting mortality after non-cardiac surgery. Given this background
we undertook a large international study called the Vascular events In
non-cardiac Surgery patIents cOhort evaluatioN (VISION) Study
(clinicaltrials. gov, identifier NCT00512109) evaluating major
complications after non-cardiac surgery [2]. Participating patients had
Troponin T (TnT) measurements after non-cardiac surgery. We assessed the
relationship between the peak 4th generation TnT measurement after
non-cardiac surgery and 30-day mortality. In this international
prospective cohort study of over 15,000 patients who were >=45 years of
age and underwent non-cardiac surgery who required hospital admission,
multivariable analysis demonstrated that 4th generation peak TnT
thresholds of 0.02 mug/L, 0.03 mug/L, and 0.30 mug/L independently
predicted 30-day mortality [2]. Peak TnT values after non-cardiac surgery
proved the strongest predictors of 30-day mortality, and the population
attributable risk analysis suggested elevated TnT measurements after
surgery may explain 41.8% of the deaths. Based on the identified peak TnT
values, there were marked increases in the absolute risk of 30-day
mortality (i.e., 1.0% for a TnT value <= 0.01 mug/L; 4.0% for a value of
0.02 mug/L; 9.3% for a value of 0.03-0.29 mug/L; and 16.9% for a value >=
0.30 mug/L); 11.6% of patients had a prognostically relevant peak TnT
value >= 0.02 mug/L. The higher the peak TnT value the shorter the median
time to death. Our net reclassification improvement analysis demonstrated
that monitoring TnT values for the first 3 days after surgery
substantially improved 30-day mortality risk stratification compared to
assessment limited to pre-operative risk factors. Although non-cardiac
surgery has enormous potential to help patients, many patients die within
30 days of surgery (1.9% in VISION). Our study demonstrates that
prognostically relevant TnT measurements after surgery strongly predict
who will die within 30-days of surgery. While at present troponin
measurements are not commonly measured after non-cardiac surgery, the
simplicity of this test and its prognostic power suggest it may have
substantial clinical utility. Considering that over 200 million adults
undergo major non-cardiac surgery annually, potentially half of these
patients are >= 45 years of age, and 11.6% of the patients in our study
had a peak TnT value >= 0.02 mug/L, suggests that worldwide more than 10
million adults may have prognostically relevant troponin values after
non-cardiac surgery annually. Because the majority of patients who suffer
a peri-operative myocardial infarction after non-cardiac surgery do not
experience ischaemic symptoms [3], physicians may have missed diagnosing
some of the patients with a prognostically relevant TnT value after
surgery as having a cardiac event. Consistent with our finding, the third
universal definition of myocardial infarction consensus statement
recommends monitoring peri-operative troponin measurements in high-risk
patients undergoing non-cardiac surgery [4]. Although no randomized
controlled trial has established an effective treatment for patients with
an elevated troponin measurement after non-cardiac surgery, the prognosis
of these patients may be modifiable. First, the high-quality evidence for
acetyl-salicylic acid (ASA) and statin therapy in the non-operative
setting, and encouraging observational data from a large international
peri-operative trial showing an association with use of these drugs and
decreased 30-day mortality in patients who have suffered a peri-operative
myocardial injury, suggests that ASA and statin therapy may benefit
patients with an elevated peri-operative troponin measurement. We have
previously demonstrated that a substantial proportion of patients
suffering a myocardial injury after non-cardiac surgery do not receive
these drugs [5]. Second, the timeline from the peak TnT value until death
demonstrates that there is time to intervene. Clinical trials are needed
to establish effective interventions to improve the outcome of patients
suffering a myocardial injury after non-cardiac surgery. We have recently
initiated a trial to determine the impact of dabigatran (a direct thrombin
inhibitor) in patients who have suffered a myocardial infarction after
non-cardiac surgery, and we will use a partial factorial design (for
patients not taking a proton pump inhibitor) to determine the impact of
omeprazole (a proton pump inhibitor) in this setting. We call this RCT the
Management of myocardial infarction After NoncArdiac surGEry (MANAGE)
Trial. There is a clear need for much more research in the peri-operative
setting. The MANAGE Trial is just one of many more clinical trials to
come.

<63>
Accession Number
71105001
Authors
Filipovic M.
Institution
(Filipovic) Institute of Anaesthesiology, Kantonsspital St. Gallen,
Switzerland
(Filipovic) Anaesthesia and Intensive Care, Medical Faculty, University of
Basel, Switzerland
Title
Biomarkers in preoperative risk assessment and optimization in vascular
surgery.
Source
Applied Cardiopulmonary Pathophysiology. Conference: 28th Annual Meeting
of the European Association of Cardiothoracic Anaesthesiologists, EACTA
2013 Barcelona Spain. Conference Start: 20130606 Conference End: 20130608.
Conference Publication: (var.pagings). 17 (2) (pp 31-34), 2013. Date of
Publication: 2013.
Publisher
Pabst Science Publishers
Abstract
The cardiac evaluation of patients with suspected heart failure is based
on symptoms, ECG, chest x-ray, echocardiography and measurement of
natriuretic peptides (NP) [1, 2]. 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, 5] or acute coronary syndromes (ACS) [7, 8].
Moreover, relative changes of NP after initiation of therapy for heart
failure were shown to be highly predictive for future outcome [9]. In
addition, NP guided management of heart failure compared to standard care
was associated with favourable outcome [10,11]. It was hypothesised that
the survival benefit was based on a more appropriate drug use and dosage
regime. Heart failure is also a leading cause of cardiac morbidity and
mortality after noncardiac surgery [13, 14]. In accordance with the data
in non-surgical populations, multiple studies proved strong associations
between pre-operatively elevated NP values and the postoperative major
adverse cardiac events (including mortality) [15-22]. This association was
also confirmed in meta-analyses [23-26]. Despite the strong association
between NP elevation and adverse outcome, the positive predictive value of
NP elevation is low. However, the negative predictive value of
non-elevated NP level before non-cardiac surgery was shown to be very
high: In vascular surgical patients it was 0.965 (95% CI: 0.879-0.996) in
case of a pre-operative BNP value below 50 pg/l [20]. Similar results were
reported in other studies in patients undergoing vascular surgery [27] and
non-vascular surgery [16] and were confirmed in a recent meta-analysis by
Lurati where the negative predictive value of low NT levels before surgery
was 0.94 (95% CI: 0.88-0.97) [25]. However, the optimal cut-off value is a
matter of debate. The meta-analysis by Rodseth and colleagues used
individual patient data and proposed an optimal "general" cut-off value
for BNP of 116 pg/ml and a diagnostic cut-off value of 372 pg/ml [26].
These numbers are remarkably near to the cut-off values used in the
non-surgical population [2]. According to the European 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 peri-operative and late cardiac
events in high-risk patients (Class IIa, level of evidence B) [28].
Troponins are structural proteins of the contractile apparatus of skeletal
and myocardial myocytes. Cardiac troponins are released into circulation
only upon the occurrence of cardiac cell death. Postoperative troponin
analyses are widely used for diagnostic and prognostic reasons [29-38].
Recently, new high-sensitive troponin tests have been introduced in
clinical practice. First promising results in the peri-operative setting
show high prognostic information of these analyses [39]. However, their
impact in surgical patients has still to be determined. The peri-operative
role of troponin analyses will be discussed in detail in the next talk.
Other biomarkers have been tested in nonsurgical populations. However,
data in surgical patients are lacking. In conclusion, we use pre-operative
BNP measurements to 1) confirm or rule out diagnosis of congestive heart
failure, 2) monitor advances in heart failure treatment in patients who
presented with symptomatic heart failure, and 3) as a prognostic marker
(focussing on the high negative predictive value). We use troponin
analyses to rule out or confirm myocardial cell damage after surgery.
However, more studies are needed to establish how biomarker-guided
management will improve care and outcome of patients at cardiac risk
undergoing major non-cardiac surgery [40].

<64>
Accession Number
71104808
Authors
Gup Z. Ju W. He M. He X.
Institution
(Gup, Ju, He, He) Organ Transplant Center, 1st Affiliated Hospital of Sun
Vat-sen University, Guangzhou, China
Title
The effects or gender on transplant outcomes: A meta-analysis.
Source
Liver Transplantation. Conference: 19th Annual International Congress of
the International Liver Transplantation Society, ILTS 2013 Sydney, NSW
Australia. Conference Start: 20130612 Conference End: 20130615. Conference
Publication: (var.pagings). 19 (6 SUPPL. 1) (pp S293-S294), 2013. Date of
Publication: June 2013.
Publisher
John Wiley and Sons Ltd
Abstract
Background There are hot debates on whether and how donor/recipient gender
affects transplant outcomes. Herein, wc performed a meta-analysis to
evaluate the effects of donor/recipient gender alone, match and pairing on
major organ transplant outcomes. .Methods PubMcd/Medlinc, Eimbasc. and
Cochrane library databases were researched for studies comparing
transplant outcomes between donor/ recipient gender match and mismatch, as
well as tour gender pairs. Survival rates were pooled and ranked among
lour gender pairs. Results Twelve studies (174177 patients) for kidney;
four studies (29815 patients) lor liver, and four studies t I9LS4
patients) tor heart transplantation were included. Compared with
donor/recipient gender match, gender mismatch was associated with
significantly lower I-, 3-, 5-year kidney grail survivals (1-year OR 0.91
(95% confidence interval, O.SB-0.94); 3-year: 0.92 (0,90-0,94); 5-year:
0,94 (0.92-0.9G))T liver graft survivals (1-year: 0.S1 (0.76-0.B6-;
3-year: O.K5 (O.SI-0.90); and 5-year: U.S9 (OJS54).94))and heart patieni
survivals (1-year: 0.81 (0.740.89); 3-year: 0.83 (0.77-0.89); 5-year; 0.S3
(O.7S-0.&9)). (Figure presented) Compared with female to male pairing,
male to male pairing has significant advantage in kidney grafl survival
(5-year: 22(CIS-1-26)), liver graft survival (5-year: 1.2I ( I. I l-l
.32)) and heart patient survival (5-year: 1.15(1.11-1.32)). Conclusions
(tender matching significantly alVecls transplant outcomes in major organ
transplantation. Female to male pairing has the worst prognosis in kidney
and liver transplantation: while male lo female pairing has long term
advantageous potential. Male to male pairing has the most favorable
outcomes in all ihree lynes ol transp I antalion. These results provide
important information for allograft allocation.