The association between cerebral blood flow variations during on-pump coronary artery bypass grafting surgery and postoperative delirium.

INTRODUCTION: Postoperative delirium (POD) has a major impact on patient recovery after cardiac surgery. Although its pathophysiology remains unclear, there could be a correlation between cerebral blood flow (CBF) variations during cardio-pulmonary bypass (CPB) and POD. Our study aimed to evaluate whether variations in on-pump CBF, compared to pre-anesthesia and pre-CPB values, are associated with POD following coronary artery bypass grafting (CABG) surgery. METHODS: This prospective observational cohort study included 95 adult patients undergoing elective on-pump CABG surgery. Right middle cerebral artery blood flow velocity (MCAV) was assessed using Transcranial Doppler before anesthesia induction, before CPB and every fifteen minutes during CPB. Pre-anesthesia and pre-CPB values were chosen as baselines. Individual values, measured during CPB, were converted as percentage changes relative to these baselines and named as %MCAV0 and %MCAV1, respectively. POD was assessed using the Confusion Assessment Method for ICU (CAM-ICU) during the first 48 post-operative hours and with the 3-Minute Diagnostic Interview for Confusion Assessment Method (3D-CAM) on the fifth post-surgical day. RESULTS: Overall POD incidence was 17.9%. At 30 minutes of CPB, %MCAV0 was higher in POD group than in no-POD group (p = .05). %MCAV0 at 45 minutes of CPB was significantly higher in POD group (87 (±17) %) than in no-POD group (68 (±24) %), p = .04. %MCAV1 at 30 and 45 minutes of CPB were higher in POD group than in no-POD group, at the limit of statistical significance. We found %MCAV1 > 100% in POD group, but not in no-POD group. CONCLUSIONS: Significant differences in %MCAV0 became evident after 30 minutes of CPB, whereas differences in %MCAV1 at 45 minutes of CPB were at limit of statistical significance. In POD group %MCAV1 was higher than 100% at 30 and 45 minutes of CPB, which is supposed to be a sign of cerebral hyperperfusion. Monitoring CBF during CPB could have prognostic value for POD.

Vacuum assisted and gravitational venous drainage in aortic valve surgery: A propensity-match study.

INTRODUCTION: Vacuum assisted venous drainage (VAVD) is widely adopted in minimally invasive cardiac surgery. VAVD enables the advantage of using smaller cannulae in a reduced surgical field while allowing satisfactory drainage and pump flow. The production of gaseous micro-emboli is a recognized risk associated with VAVD, however no difference in clinical endpoints have been reported between patients operated on with gravity venous drainage (GVD) or with VAVD. Due to the paucity of data on selected surgical populations, we sought to evaluate the early outcomes of patients undergoing isolated aortic valve replacement using VAVD or GVD. METHODS: Data on 521 patients between 09/2016 and 09/2022 were retrieved from our internal database. Patients were divided into two groups according to use VAVD or GVD. A propensity match analysis was performed to account for difference between the two groups. RESULTS: The propensity match provided two well balanced cohorts with 129 patients each. A minimally invasive access was used in 97% of the cases in VAVD group vs 98% in GVD group (p = .68). Mean cardiopulmonary by-pass (CPB) time was 71 vs 73 min (p = .74), respectively. There was no difference in lactates peak (p = .19) and urine output during CPB (p = .74). We registered two in-hospital deaths in VAVD cohort (1.6%) vs. no mortality in GVD group (p = .5). Postoperative cerebral stroke occurred in 1 patient in GVD cohort vs. 0 in VAVD (p = 1). Severe postoperative acute kidney injury complicated the course in 16 patients in GVD group and in 5 patients who had VAVD (p = .012). VAVD was associated with a higher number of patients with elevated postoperative AST (p = .07) and Troponin I (p = .01) values. CONCLUSIONS: The use of VAVD during isolated aortic valve replacement was not associated with increased risks of postoperative complications and in-hospital mortality with results that were at least similar to those registered in a matched cohort of patients operated on with GVD.

Minimally invasive aortic valve replacement: extracorporeal circulation optimization and minimally invasive extracorporeal circulation system evolution.

Treatment of aortic valve disease has become less and less invasive during the last years, thanks to progress in anesthesiology, surgical techniques, and perfusion management. In fact, it has been demonstrated that shorter skin incision, combined with ultra-fast-track anesthesia and minimized extracorporeal circuit could improve clinical outcomes. Current evidence shows that minimally invasive extracorporeal circulation system is associated with reduced red blood cells' transfusion rate, improved end-organ perfusion, decreased incidence of postoperative atrial fibrillation, air embolism leakage, and so less cerebral accidents with better neurological outcomes. Moreover, the use of a closed circuit seems to be more physiologic for the patients, reducing systemic inflammatory response due to less air-blood contact and the use of biocompatible surfaces. In the literature, the benefits of minimally invasive extracorporeal circulation are described mostly for coronary surgery but few data are nowadays available for minimally invasive extracorporeal circulation during aortic valve replacement. In this article, we describe our perfusion protocol in minimally invasive aortic valve replacement.

Tissue oxygen saturation changes and postoperative complications in cardiac surgery: a prospective observational study.

BACKGROUND: Cardiac surgery with extracorporeal circulation (ECC) can induce microvascular dysfunction and tissue hypoperfusion. We hypothesized that the alterations in near-infrared spectroscopy (NIRS)-derived parameters would be associated with post-operative complications in cardiac surgery patients. METHODS: Prospective observational study performed at two University Hospitals. Ninety patients undergoing cardiac surgery with ECC were enrolled. The NIRS sensor was applied on the thenar eminence. A vascular occlusion test (VOT, 3-min ischemia) was performed at baseline (t0), at Intensive Care Unit (ICU) admission (t1), 3 (t2) and 6 (t3) hours later. Baseline tissue oxygen saturation (StO2), oxygen extraction rate and microvascular reactivity indices were calculated. RESULTS: In the first hours after cardiac surgery, StO2 tended to increase (86% [80-89] at T3 versus 82% [79-86] at T0, p = ns), while both tissue oxygen extraction and microvascular reactivity tended to decrease, as indicated by increasing occlusion slope (- 8.1%/min [- 11.2 to - 7] at T3 versus - 11.2%/min [- 13.9 to - 7.9] at T0, p = ns) and decreasing recovery slope (1.9%/sec [1.1-2.9] at T3 versus 3.1%/sec [2.3-3.9] at T0, p = ns). No substantial differences were found in NIRS-derived variables and their changes over time between patients with complications and those without complications. CONCLUSIONS: Peripheral tissue oxygen extraction and microvascular reactivity were reduced during the first hours after cardiac surgery. NIRS-derived parameters were not able to predict complications in this population of cardiac surgery patients.

On-table extubation is associated with reduced intensive care unit stay and hospitalization after trans-axillary minimally invasive mitral valve surgery.

OBJECTIVES: Few data are available regarding early extubation after mitral valve surgery. We sought to assess the impact of an enhanced recovery after surgery-based protocol-ultra-fast-track protocol-in patients undergoing minimally invasive transaxillary mitral valve surgery. METHODS: Data of patients who underwent transaxillary mitral valve surgery associated with ultra-fast-track protocol between 2018 and 2023 were reviewed. We compared preoperative, intraoperative and postoperative data of patients who had fast-track extubation (≤6 h since the end of the procedure) and non-fast-track extubation (>6 h) and, within the fast-track group, patients who underwent on-table extubation and patients who were extubated in intensive care unit within 6 h. Multivariable logistic regression was used to study the association of extubation timing and intensive care unit stay, postoperative stay and discharge home. RESULTS: Three hundred fifty-six patients were included in the study. Two hundred eighty-two patients underwent fast-track extubation (79%) and 160 were extubated on table (45%). We found no difference in terms of mortality and occurrence of major complications (overall mortality and cerebral stroke 0.3%) according to the extubation timing. Fast-track extubation was associated with shorter intensive care unit stay, discharge home and discharge home within postoperative day 7 when compared to non-fast-track extubation. Within the fast-track group, on-table extubation was associated with intensive care unit stay ≤1 day and discharge home within postoperative day 7. CONCLUSIONS: Fast-track extubation was achievable in most of the patients undergoing transaxillary minimally invasive mitral valve surgery and was associated with higher rates of day 1 intensive care unit discharge and discharge home. On-table extubation was associated with further reduced intensive care unit stay and hospitalization.

The Enhanced Recovery after Surgery Approach in Heart Valve Surgery: A Systematic Review of Clinical Studies.

Background: Enhanced recovery after surgery (ERAS) protocols aim to reduce postoperative complications and promote earlier recovery. Although it is well established in noncardiac surgery fields, the ERAS approach has only recently been adopted in cardiac surgery. The aim of this review is to evaluate the status and implementation of ERAS protocols in patients undergoing heart valve surgery and to summarise associated clinical results. Methods: A literature search for the period January 2015 and January 2024 was performed through online databases. Clinical studies (randomised controlled trials and cohort studies) on patients undergoing heart valve surgical procedures and comparing ERAS and conventional approaches were included. The data extracted covered studies and populations characteristics, early outcomes and the features of each ERAS protocol. Results: There were 14 studies that fulfilled the final search criteria and were ultimately included in the review. Overall, 5142 patients were identified in the 14 studies, with 2501 in ERAS groups and 2641 patients who were representative of control groups. Seven experiences exclusively included patients who underwent heart valve surgery. Twelve out of fourteen protocols involved multiple interventions from the preoperative to postoperative phase, while two studies reported actions limited to intraoperative and postoperative care. We found high heterogeneity among the included protocols regarding key actions targeted for improvement and measured outcomes. All the studies showed that ERAS pathways can be safely adopted in cardiac surgery and in most of the experiences were associated with shorter mechanical ventilation time, reduced postoperative opioid use and reduced ICU and hospital stays. Conclusions: As demonstrated in noncardiac surgery, the adoption of structured ERAS protocols has the potential to improve results in patients undergoing heart valve surgery. Further evidence based on larger populations is needed, including more homogenous pathways and reporting further outcomes in terms of patient satisfaction, recovery and quality of life after surgery.

Evolution of Cardiogenic Shock Management and Development of a Multidisciplinary Team-Based Approach: Ten Years Experience of a Single Center.

Background: The management of cardiogenic shock (CS) after ACS has evolved over time, and the development of a multidisciplinary team-based approach has been shown to improve outcomes, although mortality remains high. Methods: All consecutive patients with ACS-CS admitted at our CICU from March 2012 to July 2021 were included in this single-center retrospective study. In 2019, we established a "shock team" consisting of a cardiac intensivist, an interventional cardiologist, an anesthetist, and a cardiac surgeon. The primary outcome was in-hospital mortality. Results: We included 167 patients [males 67%; age 71 (61-80) years] with ischemic CS. The proportion of SCAI shock stages from A to E were 3.6%, 6.6%, 69.4%, 9.6%, and 10.8%, respectively, with a mean baseline serum lactate of 5.2 (3.1-8.8) mmol/L. Sixty-six percent of patients had severe LV dysfunction, and 76.1% needed ≥ 1 inotropic drug. Mechanical cardiac support (MCS) was pursued in 91.1% [65% IABP, 23% Impella CP, 4% VA-ECMO]. From March 2012 to July 2021, we observed a significative temporal trend in mortality reduction from 57% to 29% (OR = 0.90, p = 0.0015). Over time, CS management has changed, with a significant increase in Impella catheter use (p = 0.0005) and a greater use of dobutamine and levosimendan (p = 0.015 and p = 0.0001) as inotropic support. In-hospital mortality varied across SCAI shock stages, and the SCAI E profile was associated with a poor prognosis regardless of patient age (OR 28.50, p = 0.039). Conclusions: The temporal trend mortality reduction in CS patients is multifactorial, and it could be explained by the multidisciplinary care developed over the years.

Enhanced recovery after minimally invasive heart valve surgery: Early and midterm outcomes.

BACKGROUND: Although the use of protocols for "enhanced recovery after surgery" (ERAS) have been associated with improved results in different surgical specialties, only a few data are available for ERAS in cardiac surgery. This study aimed to compare 30-day outcomes of patients undergoing ultra-fast-track minimally invasive valve surgery (UFT-MIVS) versus conventional MIVS (c-MIVS). METHODS: The key features of UFT-MIVS approach involves: 1) less invasive valve surgery techniques, 2) normothermic cardiopulmonary bypass management, 3) UFT-anesthesia with table extubation, 4) immediate rehabilitation therapy and patient-family contact. Five-hundred and seventy-six consecutive patients who underwent aortic or mitral MIVS were analyzed (2016-2020). Treatment selection bias (UFT-MIVS vs. c-MIVS) was addressed by the use of propensity score (PS) matching. After PS-matching 2 well-balanced groups of 152 patients each were created. RESULTS: In the matched cohort, the overall 30-day mortality and stroke rates were 0.3% and 0.7%, respectively, with no difference between groups. UFT-MIVS resulted in lower rates of respiratory insufficiency and agitation/delirium compared with c-MIVS. Patients receiving UFT-MIVS were associated with significantly shorter intensive care unit length of stay and hospital stay. CONCLUSIONS: Our study confirms that MIVS is associated with excellent results in terms of early mortality and major postoperative complications rates. The implementation of UFT-MIVS protocol showed to be safe and was associated with improved clinical outcomes in regard to respiratory insufficiency, delirium and lengths of stay.

The role of transthoracic echocardiography in the diagnosis and management of acute type A aortic syndrome.

BACKGROUND: Transthoracic echocardiography (TTE) has been traditionally considered inadequate for the diagnosis of acute type A aortic syndrome (AAAS). In the last decade, high-resolution probes and harmonic imaging have been implemented in new echocardiographic systems. However, studies assessing the diagnostic accuracy of TTE for the identification of AAAS in large populations using modern ultrasound technology are lacking. METHODS: The diagnostic value of harmonic imaging TTE was assessed in 270 consecutive patients with suspected AAAS in whom TTE was the initial diagnostic test. RESULTS: Acute type A aortic syndrome was diagnosed in 67 patients and excluded in 203 patients (disease prevalence 25%). Sixty-two patients had a classic acute type A aortic dissection, and 5, an acute type A intramural hematoma. Image quality achieved was considered optimal in 244 patients (90%). In the whole study population, TTE had sensitivity, specificity, positive predictive value, and negative predictive value for the diagnosis of AAAS of 87%, 91%, 75%, and 95%, respectively. When evaluating only patients with optimal image quality, these values increased to 97%, 100%, 100%, and 99%, respectively. Forty-seven patients with clear-cut evidence of AAAS were transferred immediately to the operative room, where transesophageal echocardiography confirmed the diagnosis obtained by TTE in all patients. CONCLUSIONS: Transthoracic echocardiography is a useful imaging modality for the diagnosis of classic acute type A aortic dissection. It cannot be used as the sole screening technique for detecting AAAS, but in the light of the predictive values observed, patients with optimal image quality and clear-cut diagnosis of AAAS should proceed to the operative room, whereas in patients with negative or indeterminate studies, other imaging techniques are needed to refine the diagnosis.

Candidemia in intensive care units over nine years at a large Italian university hospital: Comparison with other wards.

PURPOSE: Candidemia is an alarming problem in critically ill patients including those admitted in intensive care units (ICUs). We aimed to describe the clinical and microbiological characteristics of bloodstream infections (BSIs) due to Candida spp. in patients admitted to ICUs of an italian tertiary referral university hospital over nine years. METHODS: A retrospective observational study of all cases of candidemia in adult patients was carried out from January 1, 2010 to December 31, 2018 at a 980-bedded University Hospital in Ancona, Italy, counting five ICUs. The incidence, demographics, clinical and microbiologic characteristics, therapeutic approaches and outcomes of ICU-patients with candidemia were collected. Non-ICU patients with candidemia hospitalized during the same time period were considered for comparison purposes. Early (7 days from the occurrence of the episode of Candida BSI) and late (30 days) mortality rates were calculated. RESULTS: During the study period, 188/505 (36%) episodes of candidemia occurred in ICU patients. Cumulative incidence was 9.9/1000 ICU admission and it showed to be stable over time. Candida albicans accounted for 52% of the cases, followed by C. parapsilosis (24%), and C. glabrata (14%). There was not a significant difference in species distribution between ICU and non-ICU patients. With the exception of isolates of C. tropicalis which showed to be fluconazole resistant in 25% of the cases, resistance to antifungals was not of concern in our patients. Early and late mortality rates, were 19% and 41% respectively, the latter being significantly higher than that observed in non-ICU patients. At multivariate analysis, factors associated with increased risk of death were septic shock, acute kidney failure, pulmonary embolism and lack of antifungal therapy. The type of antifungal therapy did not influence the outcome. Mortality did not increased significantly over time. CONCLUSION: Neither cumulative incidence nor crude mortality of candidemia in ICU patients increased over time at our institution. However, mortality rate remained high and significantly associated with specific host-related factors in the majority of cases.

[One-year outcomes of surgical aortic valve replacement: a single, high-volume center experience]. / Risultati ad un anno dopo chirurgia sostitutiva della valvola aortica: esperienza di un centro ad alto volume.

BACKGROUND: The introduction of transcatheter aortic valve replacement (AVR) mandates attention to outcomes after surgical AVR (SAVR). The aim of this study was to assess 1-year outcomes in a contemporary large cohort of patients undergoing AVR. METHODS: Data from 520 patients who underwent isolated SAVR between October 2016 and April 2019 were prospectively collected. RESULTS: The mean age of the study population was 72.8 ± 10.1 years and the average EuroSCORE II was 1.8 ± 1.5%. SAVR was performed using minimally invasive approaches (MI-AVR) in 306 patients (58.9%). However, the rate of MI-AVR considerably increased over the observational period from 47.9% to 86.7% (p<0.001). MI-AVR patients received rapid deployment valves in 40% of cases, minimally invasive extracorporeal circulation system in 34.4% and ultra fast track anesthetic management with table extubation in 38.2%. Overall 30-day mortality was 0.4% (n=2). The rates of postoperative stroke and atrioventricular block requiring pacemaker implantation were 0.6% (n=3) and 3.8% (n=20), respectively. At 1 year, the estimated survival, stroke and rehospitalization rates were 97.3%, 1% and 4.5%, respectively. Overall, the estimated incidence of the composite endpoint - death, stroke and rehospitalization - was 7%. CONCLUSIONS: Contemporary SAVR in a high-volume center yields excellent clinical outcomes with very low mortality and morbidity. In this setting, the extensive use of minimally invasive approaches combined with the modern techniques and technologies demonstrated to improve clinical outcomes and increase patient and family satisfaction.

Minimally invasive versus standard extracorporeal circulation system in minimally invasive aortic valve surgery: a propensity score-matched study.

OBJECTIVES: The impact of minimally invasive extracorporeal circulation (MiECC) systems on the clinical outcomes of patients undergoing minimally invasive aortic valve replacement (MI-AVR) has still to be defined. This study compared in-hospital and 1 year outcomes of MI-AVR interventions using MiECC systems versus conventional extracorporeal circulation (c-ECC). METHODS: Data from 288 consecutive patients undergoing primary isolated MI-AVR using MiECC (n = 102) or c-ECC (n = 186) were prospectively collected. Treatment selection bias was addressed by the use of propensity score matching (MiECC vs c-ECC). After propensity score matching, 2 groups of 93 patients each were created. RESULTS: Compared with c-ECC, MiECC was associated with a higher rate of autologous priming (82.4% vs 0%; P < 0.001) and a greater nadir haemoglobin (9.3 vs 8.7 g/dl; P = 0.021) level and haematocrit (27.9% vs 26.4%; P = 0.023). Patients who had MiECC were more likely to receive ultra-fast-track management (60.8% vs 26.9%; P < 0.001) and less likely to receive blood transfusions (32.7% vs 44%; P = 0.04). The in-hospital mortality rate was 1.1% in the MiECC group and 0% in the c-ECC group (P = 0.5). Those in the MiECC group had reduced rates of bleeding requiring revision (0% vs 5.3%; P = 0.031) and postoperative atrial fibrillation (AF) (30.1% vs 44.1%; P = 0.034). The 1-year survival rate was 96.8% and 97.5% for MiECC and c-ECC patients, respectively (P = 0.4). CONCLUSIONS: MiECC systems were a safe and effective tool in patients who had MI-AVR. Compared with c-ECC, MiECC promotes ultra-fast-track management and provides better clinical outcomes as regards bleeding, blood transfusions and postoperative AF. Thus, by reducing surgical injury and promoting faster recovery, MiECC may further validate MI-AVR interventions.

[Surgical treatment of aortic valve disease: early results of a 360° minimally invasive approach]. / Trattamento chirurgico della valvulopatia aortica: esperienza iniziale di un approccio mini-invasivo a 360°.

BACKGROUND: Over the years, with the introduction of minimally invasive techniques and technologies aimed at reducing surgical trauma, aortic valve surgery has considerably developed and improved. Our approach includes: reduced incisions (upper "J" ministernomy or anterior right minithoracotomy), "ultra fast-track" anesthesia protocols, sutureless and rapid deployment valve prostheses and miniaturized circuits of extracorporeal circulation. The aim of this study was to evaluate the clinical outcomes associated with this multidisciplinary approach. METHODS: Between October 2016 and November 2018, 429 patients underwent isolated aortic valve replacement at the Cardiac Surgery Unit of the "Ospedali Riuniti" of Ancona, Italy. Overall, 91 patients (21.2%) were operated according to our minimally invasive approach. A severe aortic valve stenosis was the indication for surgery in 90.1% of patients, aortic valve insufficiency in the remaining 18.7%. RESULTS: There were neither in-hospital deaths nor major or minor neurological events. Atrial fibrillation was the main postoperative complications (n=26, 28.6%). Four patients (4.4%) underwent permanent pacemaker implantation due to third-degree atrioventricular block, and a surgical bleeding revision was performed in 3.3%. No episodes of respiratory failure were reported. The median length of hospital stay was 6 days (5-8 days). CONCLUSIONS: Our initial experience with a 360° minimally invasive approach for the treatment of patients undergoing aortic valve replacement shows encouraging clinical outcomes; this approach may lead to an improved perception of surgery both by patients and their families. However, further clinical studies are needed to evaluate the long-term results.

Ultra fast-track minimally invasive aortic valve replacement: going beyond reduced incisions.

Aortic valve replacement (AVR) via a median sternotomy approach has been largely reported to be safe and long-term efficacious, and currently represents the 'gold standard' approach for aortic stenosis treatment. However, aortic valve surgery has undergone continuous development over the last years, involving less invasive techniques and new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Indeed, minimally invasive AVR and transcatheter aortic valve replacement caseload have steadily increased leading to a paradigm shift in the treatment of aortic valve disease. In this setting, we have established a multidisciplinary minimally invasive programme to treat patients who require AVR. Herein, we present our approach including (i) reduced chest incision (through a J ministernotomy), aiming to reduce the traumatic impact of the surgical procedure, to decrease blood loss, postoperative pain and wound complications and to increase patient's satisfaction; (ii) rapid-deployment AVR, to reduce operative times, to facilitate minimally invasive approach and to improve haemodynamic outcomes; (iii) minimal invasive extracorporeal circulation system, to improve end-organ protection, to decrease systemic inflammatory response and to promote fast-track anaesthesia and (iv) ultra fast-track anaesthesia, to decrease the rate of postoperative complications and assure better and earlier recovery.

Ultra fast track surgery: a rapid deployment aortic valve replacement through a J-ministernotomy.

Aortic valve surgery has been undergone continuous development over the last years, involving less invasive techniques and the use of new technologies to reduce the traumatic impact of the intervention and extend the operability toward increasingly high-risk patients. Minimally invasive aortic valve replacement (AVR) has gradually been recognized as a less traumatic technique compared to median sternotomy, becoming first choice approach in numerous experienced centers. Herein we present our multidisciplinary minimally invasive approach for AVR, involving: (I) reduced chest incision; (II) rapid deployment AVR; (III) minimally invasive extracorporeal circulation system; and (IV) ultra fast track (UFT) anaesthetic management.

Delayed systolic anterior motion after mitral valve repair.

A rare case of systolic anterior motion (SAM) after mitral valve repair is described. A temporary postoperative left ventricular (LV) dysfunction protected against this complication during the early postoperative period. Only on day 9 postoperatively did the left ventricle recover and SAM develop, with significant obstruction of the LV outflow tract. Subsequently, mitral valve replacement was required. This case demonstrates the importance of the LV geometrical relationships that predispose to this complication.

Mechanical ventilation affects inflammatory mediators in patients undergoing cardiopulmonary bypass for cardiac surgery: a randomized clinical trial.

OBJECTIVES: Respiratory support for patients recovering from cardiopulmonary bypass and cardiac surgery uses large tidal volumes and a minimal level of positive end-expiratory pressure. Recent data indicate that these ventilator settings might cause pulmonary and systemic inflammation in patients with acute lung injury. We examined the hypothesis that high tidal volumes and low levels of positive end-expiratory pressure might worsen the inflammatory response associated to cardiopulmonary bypass. METHODS: Forty patients undergoing elective coronary artery bypass were randomized to be ventilated after cardiopulmonary bypass disconnection with high tidal volume/low positive end-expiratory pressure (10-12 mL/kg and 2-3 cm H2O, respectively) or low tidal volume/high positive end-expiratory pressure (8 mL/kg and 10 cm H2O, respectively). Interleukin 6 and interleukin 8 levels were measured in the bronchoalveolar lavage fluid and plasma. Samples were taken before sternotomy (time 0), immediately after cardiopulmonary bypass separation (time 1), and after 6 hours of mechanical ventilation (time 2). RESULTS: Interleukin 6 and interleukin 8 levels in the bronchoalveolar lavage fluid and plasma significantly increased at time 1 in both groups but further increased at time 2 only in patients ventilated with high tidal volume/low positive end-expiratory pressure. Interleukin 6 and interleukin 8 levels in the bronchoalveolar lavage fluid and in the plasma at time 2 were higher with high tidal volume/low positive end-expiratory pressure than with low tidal volume/high positive end-expiratory pressure. CONCLUSION: Mechanical ventilation might be a cofactor able to influence the inflammatory response after cardiac surgery.

'Early' and 'late' timing for renal replacement therapy in acute kidney injury after cardiac surgery: a prospective, interventional, controlled, single-centre trial.

OBJECTIVES: Acute kidney injury after cardiac surgery (CS-AKI) is strongly associated with in-hospital mortality and morbidity. We aimed to investigate whether 'early' or 'late' initiation of renal replacement therapy (RRT) in patients with CS-AKI is associated with a survival benefit or more favourable outcomes. METHODS: All patients who had undergone cardiac surgery at 'Ospedali Riuniti' of Ancona from July 2011 to February 2013 were prospectively enrolled and divided into two treatment groups: the 'early' approach was used during the first 10 months, and the 'late' approach during the next 10 months. 'Early' RRT was started after 6 h of urine output less than 0.5 ml/kg/h, whereas in the 'late' group, therapy started on the basis of persistent (>12 h) oliguria. A total of 1658 patients were enrolled in the trial. The primary outcome was operative mortality, and the secondary outcomes were length of intensive care unit and hospital stay. RESULTS: The total number of patients treated with RRT was 59 (3.6%): 46 (5.5%) in the 'early' group and 13 (1.6%) in the 'late' group (P < 0.0001). Although RRT was significantly less utilized in the 'late' group, no significant difference in the primary and secondary outcomes was found, but a trend towards a better outcome in the 'late' group was observed. Furthermore, we found a significant difference in mortality between the two approaches in the subgroups of patients with preoperative renal dysfunction and in patients suffering from CS-AKI with a clear advantage of the late strategy. CONCLUSIONS: Our results do not support the use of early RRT in CS-AKI. CLINICAL TRIAL REGISTRATION: This trial is registered in the clinicaltrial.gov registry: NCT01961999.