Fluid Therapy With Gelatin May Have Deleterious Effects on Kidney Function: An Observational Trial.

OBJECTIVE: To explore the effects of fluid therapy with the synthetic colloids hydroxyethyl starch (HES) and gelatin (GEL) on the incidence of acute kidney injury (AKI) and need for renal replacement therapy (RRT) in patients undergoing cardiac surgery. DESIGN: Secondary analysis of a prospective observational study in cardiac surgical patients. DESIGN: University hospital. PARTICIPANTS: The study included 584 elective patients (excluding patients on preoperative dialysis). MEASUREMENTS AND MAIN RESULTS: Anamnestic and surgical core data, hemodynamics, and hemodynamic treatments were recorded intraoperatively and postoperatively. Postoperative kidney dysfunction was graded according to the Acute Kidney Injury Network criteria from perioperative changes in plasma creatinine and urine flow. Statistical analyses were performed descriptively, by logistic and probit regression, omitting inotropic and vasoactive medications as established renal risk factors. The incidence of AKI and new renal replacement therapy was 28.6% and 7.5%, respectively. Patients with AKI were older, had a higher additive Euroscore, lower preoperative glomerular filtration rates and hemoglobin level, and presented with a longer duration of cardiopulmonary bypass and surgery and higher postoperative drainage loss. HES (1 [0-2] units of 500 mL) and GEL (3 [2-5] units of 500 mL) were used in 317 and 563 patients, respectively. Crystalloids were used in all patients (4,560 [4,080-5,042] mL). Patients presenting with AKI or new RRT were treated with significantly higher amounts of GEL. The use of HES and crystalloids did not differ between these groups. Probit regression showed significant dose-response relationships between the amount of infused gelatin and the probability of AKI and new RRT. Probit regression showed significant (p = 0.0001 and 0.0003, respectively) dose-response relationships between the total units of gelatin polysuccinate infused and the probability of AKI and new RRT (Fig 1). Logistic regression revealed a statistically significant odds ratio (OR) of 1.9741 (95% CI: 1.3104-2.9740; p = 0.0011) for an association between the number of gelatin units infused and AKI (grade 1-3) but no direct association between the number of gelatin units administered and new RRT. No association between a decrease in kidney function and the application of HES was observed. CONCLUSIONS: Taking into account the limitations of the small sample size and a low event rate, the nonconsideration of established renal risk factors such as inotropes and vasopressors, and potentially unmeasured confounders, these findings suggested that gelatin solutions may have deleterious effects on renal function in cardiac surgical patients. The adverse clinical effects of HES on kidney function observed in other studies may have been blunted by the restrictive use of this synthetic colloid.

The effects of systemic oxygenation on cerebral oxygen saturation and its relationship to mixed venous oxygen saturation: A prospective observational study comparison of the INVOS and ForeSight Elite cerebral oximeters.

PURPOSE: The present study aimed to test the hypothesis that cerebral oxygen saturation (ScO2) measurements with the INVOS-5100-C and the ForeSight-Elite cerebral oximeters vary in their correlation with mixed venous oxygen saturation (SvO2) upon changes in systemic oxygenation in extubated cardiac surgical patients. Additionally, we aimed to elucidate whether the ScO2 measurements of both devices can be used interchangeably to detect reduced SvO2. METHODS: Forty-eight spontaneously breathing patients extubated after cardiac surgery were included in this prospective observational study. The patients were exposed to both high (10 oxygen L·min-1 via face mask) and low (room air) inspiratory oxygen concentrations. Bi-hemispherical ScO2 was determined with the INVOS and ForeSight Elite cerebral oximeters. The SvO2 was measured with a pulmonary artery catheter. RESULTS: Significant changes in oxygen delivery, ScO2 (by both cerebral oximeters), and SvO2 were observed upon variation of oxygenation. The minimum mean (standard deviation) ScO2 (ScO2min) using the INVOS and ForeSight did not differ significantly during high oxygen delivery [63.1 (8.6) % vs 65.8 (4.7) %, respectively; P = 0.07], but during low oxygen delivery, the INVOS value was significantly lower than that of the ForeSight oximeter [56.7 (8.9) % vs 61.3 (4.4) %, respectively; P = 0.003]. Both devices differed in the correlation between ScO2min and SvO2 for the combined oxygenation data (0.59, INVOS vs 0.28, ForeSight; correlation difference, 0.31; Bonferroni-adjusted 95% confidence interval [CI], 0.08 to 0.54; P = 0.008). The receiver-operating curve analysis revealed an area under the curve of 0.83 (95% CI, 0.74 to 0.9; P = 0.005) for detecting an SvO2 below 50% by ScO2min with the INVOS and 0.51 (95% CI, 0.41 to 0.62; P = 0.92), respectively, with the ForeSight. CONCLUSIONS: These findings suggest that the cerebral oximeters tested react differently to variations in systemic oxygenation and in their relationship with SvO2 and thus give different information on cardiopulmonary function. These findings raise doubt about whether these devices should be used interchangeably.

Survival and reoperation after valve-sparing root replacement and root repair in acute type A dissection.

OBJECTIVE: Optimal treatment of the dissected root in type A dissection is still controversial. Valve-sparing techniques offer the advantage of better valve performance compared with mechanical valves or bioprostheses. The role of the different valve-preserving methods-root repair and replacement-needs further evaluation. METHODS: Follow-up data (median follow-up, 11.4 years; 95% confidence interval [CI], 10.1-12.7; range, 0-22.1 years) of 179 patients with acute type A dissection and root involvement, who underwent a valve-sparing root replacement using reimplantation (n = 44) or remodeling (n = 39) or a valve-sparing root repair (n = 96) between 1993 and 2017 were analyzed with respect to survival and reoperation. RESULTS: Median age of patients with reimplantation was 56.9 (range, 20.2-78), with remodeling 62.6 (range, 31-79.1), and with valve-sparing root repair 64.5 (range, 31-89.6) years. Thirty-day mortality for these groups was 15.9%, 15.4%, and 12.5% (P = .829), late mortality at 15 years was 43.2% (95% CI, 28.1-66.5), 36.7% (95% CI, 19.7-68.1), and 36.5% (95% CI, 23.0-57.9; P = .504). Risk factors for overall mortality were age, connective tissue disease, total arch replacement, surgical time, cross-clamp time, circulatory arrest, and the reimplantation technique. Cumulative incidence of reoperation at 15 years was 13.4% (95% CI, 2.1-24.7), 20% (95% CI, 6.3-33.6), and 13.3% (95% CI, 4.8-21.7; P = .565), respectively. CONCLUSIONS: With the different conditions in each group in this study on patients with acute type A dissection the valve-preserving root repair technique has similar long-term rates of survival and reoperation compared with root replacement techniques, underlining its usefulness as a less complex and even faster surgical technique if individually indicated.

Is the outcome in acute aortic dissection type A influenced by of femoral versus central cannulation?

BACKGROUND: The purpose of this study was to evaluate the single-center experience in initial femoral versus central cannulation of the extracorporeal circulation for acute aortic dissection type A (AADA). METHODS: Between January 2003 and December 2015, 235 patients underwent repair of AADA. All patients were evaluated for the type of arterial cannulation (femoral vs. central) for initial bypass. Demographic data and outcome parameters were accessed. RESULTS: One hundred and twenty seven (54.0%) were initially cannulated in the central aortic vessels (ascending aorta or subclavian/axillary artery) and 108 (46.0%) in the femoral artery. Patients were comparable between age (62.4±14.4 vs. 62.9±14.4 years, P=0.805), gender (male, 62.2 vs. 69.4%, P=0.152) and previous sternotomy (15.7 vs. 16.7%, P=0.861) between both cannulation groups; while EuroSCORE I (11.5±4.0 vs. 12.7±4.2, P=0.031) and ASA Score (3.5±0.81 vs. 3.8±0.57, P=0.011) were significantly higher in the femoral artery cannulation group. Bypass (249±102 vs. 240±81 min, P=0.474), X-clamp (166±85 vs. 157±67 min, P=0.418) and circulatory arrest time (51.6±28.7 vs. 48.3±21.7 min, P=0.365) were similar between the groups as were lowest temperature (18.1±2.0 vs. 18.1±2.2, P=0.775). Postoperative neurologic deficit and 30-day mortality were comparable between both cannulation groups (11.7 vs. 7.2%, P=0.449 and 20.2 vs. 16.9%, P=0.699, central vs. peripheral cannulation). Multivariate analysis revealed only EuroScore I above 13 as single preoperative predictor for mortality. CONCLUSIONS: AADA can be operated with both femoral and central cannulation with similar results. Risk for early mortality was driven by the preoperative clinical and hemodynamic status before operation rather than the cannulation technique.

A novel rigid annuloplasty ring for aortic valve reconstruction: an in vitro investigation.

BACKGROUND: Remodeling of the dilated valve annulus with a prosthetic ring for repair of valve insufficiency is a well-established concept in mitral and tricuspid valve surgery and may also be suitable for aortic valve reconstruction. A novel rigid aortic annuloplasty ring was tested in vitro. METHODS: Ten fresh porcine aortic roots were investigated in a pulsatile flow simulator before surgery (group N), after patch dilatation of the annulus (group D), and after reconstruction using a rigid annuloplasty ring (group R). The ring was designed to (1) prevent contact with the leaflets, reducing the risk of contact injury, (2) be applicable to all valve phenotypes, (3) prevent injury to the conduction bundle, and (4) be implantable from inside the aortic root (subvalvular). For each group pressure gradient, leakage volume, and coaptation height were measured. RESULTS: With the annuloplasty ring, regurgitation volume decreased from -8.50 ± 1.91 mL (group D) to -4.75 ± 1.66 mL (group R; p < 0.0003), not different from group N. Coaptation height of the leaflets increased from 0.62 ± 0.08 mm (group D) to 0.77 ± 0.11 mm (group R; p < 0.005), similar to group N. Mean pressure gradient increased from 2.98 ± 0.38 mm Hg (group D) to 3.72 ± 0.40 mm Hg (group R; p < 0.0001). CONCLUSIONS: This novel aortic annuloplasty ring has the potential for supporting aortic valve reconstruction by remodeling the subvalvular area.