Filter life span in postoperative cardiovascular surgery patients requiring continuous renal replacement therapy, using a postdilution regional citrate anticoagulation continuous hemofiltration circuit.

BACKGROUND: Regional citrate anticoagulation (RCA) is the recommended standard for continuous renal replacement therapy (CRRT). This study assesses its efficacy in patients admitted to critical care following cardiovascular surgery and the influence of standard antithrombotic agents routinely used in this specific group. METHODS: Consecutive cardiovascular surgery patients treated with postdilution hemofiltration with RCA were included in this prospective observational study. The primary outcome of the study was CRRT circuit life-span adjusted for reasons other than clotting. The secondary outcome evaluated the influence of standard antithrombotic agents (acetylsalicylic acid [ASA], low molecular weight heparin [LMWH] or fondaparinux as thromboprophylaxis or treatment dose with or without ASA) on filter life. RESULTS: Fifty-two patients underwent 193 sessions of continous veno-venous hemofiltration, after exclusion of 15 sessions where unfractionated heparin was administered. The median filter life span was 58 hours. Filter life span was significantly longer in patients receiving therapeutic dose of LMWH or fondaparinux (79 h [2-110]), in comparison to patients treated with prophylactic dose of LMWH or fondaparinux (51 h [7-117], p < 0.001), and patients without antithrombotic prophylaxis (42 h [2-91], p < 0.0001). 12 bleeding episodes were observed; 8 occurred in patients receiving treatment dose anticoagulation, 3 in patients receiving prophylactic dose anticoagulation and 1 in a patient with no antithrombotic prophylaxis. CONCLUSIONS: A postdilution hemofiltration with RCA provides prolonged filter life span when adjusted for reasons other than clotting. Patients receiving treatment dose anticoagulation had a significantly longer filter life span than those who were on prophylactic doses or ASA alone.

Ionic homeostasis, acid-base balance and the risk of citrate accumulation in patients after cardiovascular surgery treated with continuous veno-venous haemofiltration with post-dilution regional citrate anticoagulation - An observational case-control study.

BACKGROUND: Patients after cardiovascular surgery, requiring renal replacement therapy, can benefit from adequate non-heparin circuit anticoagulation. Simplified regional citrate anticoagulation (RCA) protocol proposes the use of citric acid dextrose formula A (ACD-A) during post-dilutional continuous veno-venous hemofiltration (CVVH) with standard bicarbonate buffered calcium containing replacement solution. Citrate accumulation diagnosed upon total to ionized calcium ratio (tCa/iCa) and low ionized calcium (iCa) are considered as the biggest risks related to regional citrate accumulation. METHODS: This prospective observational case-control study evaluated electrolyte and acid-base homeostasis in cardiovascular surgery patients treated with post-dilution CVVH with a simplified RCA protocol with ACD-A. In total, 50 consecutive cardiovascular surgery patients were evaluated. Base excess, pH, bicarbonate, lactate, Na+, Cl-, Mg++, and inorganic phosphate concentrations, the total to ionized calcium ratio (tCa/iCa), and high anion gap metabolic acidosis were assessed during haemofiltration treatment in survivors and non-survivors. RESULTS: Thirty-three (66%) patients died. The therapies were very well balanced in sodium and chloride homeostasis. The lactate concentration and anion gap decreased during CVVH sessions lasting longer than 72 hours, but no inter-group difference was observed. The tCa/iCa ratio exceeded 4.5% and was significantly higher in non-survivors (p=0.037). Initial lactate concentration did not correlate with tCa/iCa ratio during haemofiltration. Magnesium and phosphate concentrations decreased and additional supplementation with magnesium was necessary. The magnesium concentration was lower in the non-survivors. CONCLUSIONS: The incidence of citrate accumulation exceeded 4% and was significantly higher in non-survivors. Supplementation with magnesium and phosphate ions is needed in CVVH with RCA.

Brain and Muscle Oxygen Saturation Combined with Kidney Injury Biomarkers Predict Cardiac Surgery Related Acute Kidney Injury.

BACKGROUND: Early identification of patients at risk for cardiac surgery-associated acute kidney injury (CS-AKI) based on novel biomarkers and tissue oxygen saturation might enable intervention to reduce kidney injury. AIMS: The study aimed to ascertain whether brain and muscle oxygenation measured by near-infrared spectroscopy (NIRS), in addition to cystatin C and NGAL concentrations, could help with CS-AKI prediction. METHODS: This is a single-centre prospective observational study on adult patients undergoing cardiac surgery using cardiopulmonary bypass (CPB). Brain and muscle NIRS were recorded during surgery. Cystatin C was measured on the first postoperative day, while NGAL directly before and 3 h after surgery. RESULTS: CS-AKI was diagnosed in 18 (16%) of 114 patients. NIRS values recorded 20 min after CPB (with cut-off value ≤ 54.5% for muscle and ≤ 62.5% for the brain) were revealed to be the most accurate predictors of CS-AKI. Preoperative NGAL ≥ 91.5 ng/mL, postoperative NGAL ≥ 140.5 ng/mL, and postoperative cystatin C ≥ 1.23 mg/L were identified as independent and significant CS-AKI predictors. CONCLUSIONS: Brain and muscle oxygen saturation 20 min after CPB could be considered early parameters possibly related to CS-AKI risk, especially in patients with increased cystatin C and NGAL levels.

Transfermoral transcatheter aortic valve implantation using self-expanding Allegra bioprosthesis: One-year single-center outcomes.

BACKGROUND: The NAUTILUS study aimed to evaluate the safety and performance of the Allegra bioprosthesis in high-risk recipients undergoing transcatheter aortic valve implantation and previously reported 30-day outcomes. In the current investigation 1-year results of the trial are presented. METHODS: Twenty-seven recipients with severe, symptomatic aortic valve stenosis at high surgical risk, who underwent treatment using the next-generation self-expanding Allegra via transfemoral approach were prospectively enrolled. Clinical endpoints assessed were: mortality, stroke, permanent pacemaker implantation, New York Heart Association class and re-hospitalizations. Prosthetic valve performance evaluation comprised of: mean gradient, effective orifice area and paravalvular leak. RESULTS: Patients were elderly (82.8 ± 4.2 years) and predominantly female (n = 19, 70.4%). All of them were deemed to be at high surgical risk with a mean logistic EuroSCORE of 12.5 ± 6.7. The bioprosthesis was successfully implanted in 92.6% of the cases (n = 25). At 1-year, all-cause mortality was 12.0% (n = 3) and stroke was 4.0% (n = 1). Three (12%) of patients developed complete atrioventricular block and received permanent pacemakers. 84% of patients were in New York Heart Association class II or lower. Need for subsequent hospitalization arose in 48% patients. The echocardiographic assessment confirmed an acceptable hemodynamic profile of the Allegra with low mean transprosthetic gradient (9.5 ± 3.4 mmHg), absence of severe paravalvular leak and a 20%-presence of moderate paravalvular leak. CONCLUSIONS: The current follow-up observation study shows that the Allegra was associated with a satisfactory safety profile and hemodynamic performance at 1-year after implantation.

The new insight into extracellular NAD+ degradation-the contribution of CD38 and CD73 in calcific aortic valve disease.

Nicotinamide adenine dinucleotide (NAD+ ) is crucial for cell energy metabolism and many signalling processes. Recently, we proved the role of ecto-enzymes in controlling adenine nucleotide-dependent pathways during calcific aortic valve disease (CAVD). This study aimed to investigate extracellular hydrolysis of NAD+ and mononucleotide nicotinamide (NMN) in aortic valves and aorta fragments of CAVD patients and on the inner aortic surface of ecto-5'-nucleotidase knockout mice (CD73-/-). Human non-stenotic valves (n = 10) actively converted NAD+ and NMN via both CD73 and NAD+ -glycohydrolase (CD38) according to our analysis with RP-HPLC and immunofluorescence. In stenotic valves (n = 50), due to reduced CD73 activity, NAD+ was degraded predominantly by CD38 and additionally by ALP and eNPP1. CAVD patients had significantly higher hydrolytic rates of NAD+ (0.81 ± 0.07 vs 0.56 ± 0.10) and NMN (1.12 ± 0.10 vs 0.71 ± 0.08 nmol/min/cm2 ) compared with controls. CD38 was also primarily engaged in human vascular NAD+ metabolism. Studies using specific ecto-enzyme inhibitors and CD73-/- mice confirmed that CD73 is not the only enzyme involved in NAD+ and NMN hydrolysis and that CD38 had a significant contribution to these pathways. Modifications of extracellular NAD+ and NMN metabolism in aortic valve cells may be particularly important in valve pathology and could be a potential therapeutic target.

Statin treatment of patients with calcific aortic valve disease modulates extracellular adenosine metabolism on the cell surface of the aortic valve.

Statins efficiently prevent cardiovascular events by lipid-dependent and independent mechanisms. We hypothesize that part of these protective effects could be associated with an increased extracellular adenosine signaling. We demonstrated previously that aortic valves obtained from patients with calcific aortic valve disease (CAVD) disclosed disturbances in extracellular adenosine metabolism. This study aimed to analyze the impact of statin treatment on extracellular nucleotides and adenosine metabolism in aortic valves originated from CAVD patients and to elucidate potential mechanisms that are involved in the regulation of ecto-enzyme activities by statins. Aortic valves of CAVD patients treated with statins (n = 45) revealed higher adenosine production and its lower degradation than in non-treated patients (n = 28). Statin treatment was also related to the improvement in pre-operative echocardiographic data indicating milder aortic valve stenosis and a better function of the left ventricle. The rates of aortic valve adenosine conversions correlated with plasma lipid profile parameters, within both statin-treated and non-treated groups. Valvular extracellular AMP hydrolysis correlated negatively, while adenosine deamination positively with plasma total and LDL cholesterol. Atorvastatin treatment of murine heart endothelial cells led to the enhanced ecto-5'nucleotidase (CD73) and decreased ecto-adenosine deaminase (eADA) activity. When endothelial cells were stimulated with thrombin that induces endothelial cell exocytosis, activities of both cell-surface CD73 and eADA were increased, while co-treatment with atorvastatin reversed only thrombin-induced eADA activity. In conclusion, early intervention with statins may provide beneficial effects for CAVD therapy. Here, we presented results showing that these protective outcomes could be mediated via the regulation of extracellular adenosine metabolism pathways.

Prognostic Factors for Nonasphyxia-Related Cardiac Arrest Patients Undergoing Extracorporeal Rewarming - HELP Registry Study.

OBJECTIVE: Extracorporeal rewarming is the treatment of choice for patients who had hypothermic cardiac arrest, allowing for best neurologic outcome. The authors' goal was to identify factors associated with survival in nonasphyxia-related hypothermic cardiac arrest patients undergoing extracorporeal rewarming. DESIGN: All 38 cardiac surgery departments in Poland were encouraged to report consecutive hypothermic cardiac arrest patients treated with extracorporeal life support. All variables collected were analyzed in order to compare survivor and nonsurvivor groups. The parameters available at the initiation of extracorporeal rewarming were considered as potential predictors of survival in a logistic regression model. The primary outcome was survival to discharge from the intensive care unit. The secondary outcome was neurologic status. SETTING: Multicenter retrospective study. PARTICIPANTS: Ninety-eight cases in the final analysis. INTERVENTIONS: All patients in nonasphyxia-related hypothermic cardiac arrest rewarmed with extracorporeal life support. MEASUREMENTS AND MAIN RESULTS: The survival rate was 53.1%, and 94.2% of survivors had favorable neurologic outcome. The lowest reported core temperature with cerebral performance category scale 1 was 11.8°C. A univariate analysis identified 3 variables associated with survival, namely: age, initial arterial pH, and lactate concentration. In a multivariate analysis, 2 independent predictors of survival were age (0.957; 95% confidence interval [CI] 0.924-0.991) and lactates (0.871; 95% CI 0.789-0.961). The area under the receiver operating characteristics curve for this fitted model was 0.71; 95% CI 0.602-0.817. CONCLUSIONS: Favorable survival with good neurologic outcome in nonasphyxiated hypothermic patients treated with extracorporeal life support was reported. Age and initial lactate level are independently associated with survival.

Nucleotide ecto-enzyme metabolic pattern and spatial distribution in calcific aortic valve disease; its relation to pathological changes and clinical presentation.

BACKGROUND: Extracellular nucleotide metabolism contributes to chronic inflammation, cell differentiation, and tissue mineralization by controlling nucleotide and adenosine concentrations and hence its purinergic effects. This study investigated location-specific changes of extracellular nucleotide metabolism in aortic valves of patients with calcific aortic valve disease (CAVD). Individual ecto-enzymes and adenosine receptors involved were analyzed together with correlation with CAVD severity and risk factors. RESULTS: Nucleotide and adenosine degradation rates were adversely modified on the aortic surface of stenotic valve as compared to ventricular side, including decreased ATP removal (1.25 ± 0.35 vs. 2.24 ± 0.61 nmol/min/cm2) and adenosine production (1.32 ± 0.12 vs. 2.49 ± 0.28 nmol/min/cm2) as well as increased adenosine deamination (1.28 ± 0.31 vs. 0.67 ± 0.11 nmol/min/cm2). The rates of nucleotide to adenosine conversions were lower, while adenosine deamination was higher on the aortic sides of stenotic vs. non-stenotic valve. There were no differences in extracellular nucleotide metabolism between aortic and ventricular sides of non-stenotic valves. Furthermore, nucleotide degradation rates, measured on aortic side in CAVD (n = 62), negatively correlated with echocardiographic and biochemical parameters of disease severity (aortic jet velocity vs. ATP hydrolysis: r = - 0.30, p < 0.05; vs. AMP hydrolysis: r = - 0.44, p < 0.001; valvular phosphate concentration vs. ATP hydrolysis: r = - 0.26, p < 0.05; vs. AMP hydrolysis: r = - 0.25, p = 0.05) while adenosine deamination showed positive correlation trend with valvular phosphate deposits (r = 0.23, p = 0.07). Nucleotide and adenosine conversion rates also correlated with CAVD risk factors, including hyperlipidemia (AMP hydrolysis vs. serum LDL cholesterol: r = - 0.28, p = 0.05; adenosine deamination vs. total cholesterol: r = 0.25, p = 0.05; LDL cholesterol: r = 0.28, p < 0.05; triglycerides: r = 0.32, p < 0.05), hypertension (adenosine deamination vs. systolic blood pressure: r = 0.28, p < 0.05) and thrombosis (ATP hydrolysis vs. prothrombin time: r = - 0.35, p < 0.01). Functional assays as well as histological and immunofluorescence, flow cytometry and RT-PCR studies identified all major ecto-enzymes engaged in nucleotide metabolism in aortic valves that included ecto-nucleotidases, alkaline phosphatase, and ecto-adenosine deaminase. We have shown that changes in nucleotide-converting ecto-enzymes were derived from their altered activities on valve cells and immune cell infiltrate. We have also demonstrated a presence of A1, A2a and A2b adenosine receptors with diminished expression of A2a and A2b in stenotic vs. non-stenotic valves. Finally, we revealed that augmenting adenosine effects by blocking adenosine deamination with deoxycoformycin decreased aortic valve thickness and reduced markers of calcification via adenosine-dependent pathways in a mouse model of CAVD. CONCLUSIONS: This work highlights profound changes in extracellular nucleotide and adenosine metabolism in CAVD. Altered extracellular nucleotide hydrolysis and degradation of adenosine in stenotic valves may affect purinergic responses to support a pro-stenotic milieu and valve calcification. This emphasizes a potential mechanism and target for prevention and therapy. .

Clinical, biochemical and genetic risk factors for 30-day and 5-year mortality in 518 adult patients subjected to cardiopulmonary bypass during cardiac surgery - the INFLACOR study.

There is increasing evidence that genetic variability influences patients' early morbidity after cardiac surgery performed using cardiopulmonary bypass (CPB). The use of mortality as an outcome measure in cardiac surgical genetic association studies is rare. We publish the 30-day and 5-year survival analyses with focus on pre-, intra-, postoperative variables, biochemical parameters, and genetic variants in the INFLACOR (INFLAmmation in Cardiac OpeRations) cohort. In a prospectively recruited cohort of 518 adult Polish Caucasians, who underwent cardiac surgery in which CPB was used, the clinical data, biochemical parameters, IL-6, soluble ICAM-1, TNFα, soluble E-selectin, and 10 single nucleotide polymorphisms were evaluated for their association with 30-day and 5-year mortality. The 30-day mortality was associated with: pre-operative prothrombin international normalized ratio, intra-operative blood lactate, postoperative serum creatine phosphokinase, and acute kidney injury requiring renal replacement therapy (AKI-RRT) in logistic regression. Factors that determined the 5-year survival included: pre-operative NYHA class, history of peripheral artery disease and severe chronic obstructive pulmonary disease, intra-operative blood transfusion; and postoperative peripheral hypothermia, myocardial infarction, infection, and AKI-RRT in Cox regression. Serum levels of IL-6 and ICAM-1 measured three hours after the operation were associated with 30-day and 5-year mortality, respectively. The ICAM1 rs5498 was associated with 30-day and 5-year survival with borderline significance. Different risk factors determined the early (30-day) and late (5-year) survival after adult cardiac surgery in which cardiopulmonary bypass was used. Future genetic association studies in cardiac surgical patients should account for the identified chronic and perioperative risk factors.

Revised protocol of extracorporeal membrane oxygenation (ECMO) therapy in severe ARDS. Recommendations of the Veno-venous ECMO Expert Panel appointed in February 2016 by the national consultant on anesthesiology and intensive care.

Extracorporeal Membrane Oxygenation (ECMO) has become well established technique of the treatment of severe acute respiratory failure (Veno-Venous ECMO) or circulatory failure (Veno-Arterial ECMO) which enables effective blood oxygenation and carbon dioxide removal for several weeks. Veno-Venous ECMO (V-V ECMO ) is a lifesaving treatment of patients in whom severe ARDS makes artificial lung ventilation unlikely to provide satisfactory blood oxygenation for preventing further vital organs damage and progression to death. The protocol below regards exclusively veno-venous ECMO treatment as a support for blood gas conditioning by means of extracorporeal circuit in adult patients with severe ARDS. V-V ECMO does not provide treatment for acutely and severely diseased lungs, but it enables patient to survive the critical phase of severe ARDS until recovery of lung function. Besides avoiding patients death from hypoxemia, this technique can also prevent further progression of the lung damage due to artificial ventilation. Recent experience of ECMO treatment since the outbreak of AH1N1 influenza pandemic in 2009, along with technical progress and advancement in understanding pathophysiology of ventilator-induced lung injury, have contributed to significant improvement of the results of ECMO treatment. Putative factors related to increased survival include patients retrieval after connecting them to ECMO, and less intensive anticoagulation protocols. The aim of presenting this revised protocol was to improve the effects of ECMO treatment in patients with severe ARDS, to enhance ECMO accessibility for patients who might possibly benefit from this treatment, to reduce time until patient's connection to ECMO, and to avoid ECMO treatment in futile cases. The authors believe that this protocol, based on recent papers and their own experience, can provide help and advice both for the centers which develop V-V ECMO program, and for doctors who will refer their patients for the treatment in an ECMO center.

Aortic cross-clamping phase of cardiopulmonary bypass is related to decreased microvascular reactivity after short-term ischaemia of the thenar muscle both under intravenous and volatile anaesthesia: a randomized trial.

OBJECTIVES: The purpose of the present study was to assess, by near-infrared spectroscopy with an INVOS oximeter during the vascular occlusion test (VOT), the influence of cardiopulmonary bypass (CPB) on tissue saturation in the thenar muscle. The secondary aim was to compare the effects of propofol and sevoflurane anaesthesia on tissue saturation. METHODS: This was a prospective, randomized, open-label study. Sixty cardiac surgery patients received either propofol or sevoflurane anaesthesia. Three-minute VOT was performed at the following time points: 30 min after anaesthesia induction, directly after sternotomy, 20 and 40 min after aortic cross-clamping, 20 min after aortic cross-clamp removal and 45 min after weaning of cardiopulmonary bypass. Group and time effects on tissue saturation were analysed with RM-ANOVA and the post hoc Tukey test. RESULTS: In both groups at baseline, the lowest and the highest tissue saturation and the rate of saturation recovery during the reperfusion phase of the vascular occlusion test were lower during aortic cross-clamping in comparison to the values before CPB. Lower nadir tissue saturation during ischaemia was observed under propofol in comparison to sevoflurane anaesthesia (P = 0.018). CONCLUSIONS: This study demonstrated that the aortic cross-clamping phase of CPB cardiac surgery is associated with lower values of tissue saturation and a decreased rate of saturation recovery under both propofol and sevoflurane anaesthesia. Aortic cross-clamp release is followed by accelerated tissue desaturation during VOT. Propofol anaesthesia for CPB cardiac surgery results in greater reduction of nadir tissue saturation during the ischaemic phase of VOT in comparison to that of sevoflurane. TRIAL REGISTRATION NUMBER: NCT02593448.

Tissue oximetry in anaesthesia and intensive care.

Conventional monitoring during surgery and intensive care is not sufficiently sensitive to detect acute changes in vital organs perfusion, while its good quality is critical for maintaining their function. Disturbed vital organ perfusion may lead to the development of postoperative complications, including neurological sequel and renal failure. Near-infra-red spectroscopy (NIRS) represents one of up-to-date techniques of patient monitoring which is commonly used for the assessment of brain oximetry in thoracic aorta surgery, and - increasingly more often -in open-heart surgery. Algorithms for maintaining adequate brain saturation may result in a decrease of neurological complications and cognitive dysfunction following cardiac surgery. The assessment of kidney and visceral perfusion with tissue oximetry is gaining increasing interest during pediatric cardiac surgery. Attempts at decreasing complications by the use of brain oximetry during carotid endarterectomy, as well as thoracic and abdominal surgery demonstrated conflicting results. In recent years NIRS technique was proposed as a tool for muscle perfusion assessment under short term ischemia and reperfusion, referred to as vascular occlusion test (VOT). This monitoring extension allows for the identification of early disturbances in tissue perfusion. Results of recent studies utilizing VOT suggest that the muscle saturation decrease rate is reduced in septic shock patients, while decreased speed of saturation recovery on reperfusion is related to disturbed microcirculation. Being non-invasive and feasible technique, NIRS offers an improvement of preoperative risk assessment in cardiac surgery and promises more comprehensive intraoperative and ICU patient monitoring allowing for better outcome.

Increased activity of vascular adenosine deaminase in atherosclerosis and therapeutic potential of its inhibition.

AIMS: Extracellular nucleotides and adenosine that are formed or degraded by membrane-bound ecto-enzymes could affect atherosclerosis by regulating the inflammation and thrombosis. This study aimed to evaluate a relation between ecto-enzymes that convert extracellular adenosine triphosphate to adenine dinucleotide phosphate, adenosine monophosphate, adenosine, and inosine on the surface of the vessel wall with the severity or progression of experimental and clinical atherosclerosis. Furthermore, we tested whether the inhibition of adenosine deaminase will block the development of experimental atherosclerosis. METHODS AND RESULTS: Vascular activities of ecto-nucleoside triphosphate diphosphohydrolase 1, ecto-5'-nucleotidase, and ecto-adenosine deaminase (eADA) were measured in aortas of apolipoprotein E-/- low density lipoprotein receptor (ApoE-/-LDLR-/-) and wild-type mice as well as in human aortas. Plaques were analysed in the entire aorta, aortic root, and brachiocephalic artery by Oil-Red O and Orcein Martius Scarlet Blue staining and vascular accumulation of macrophages. The cellular location of ecto-enzymes was analysed by immunofluorescence. The effect of eADA inhibition on atherosclerosis progression was studied by a 2-month deoxycoformycin treatment of ApoE-/-LDLR-/- mice. The vascular eADA activity prominently increased in ApoE-/-LDLR-/- mice when compared with wild type already at the age of 1 month and progressed along atherosclerosis development, reaching a 10-fold difference at 10 months. The activity of eADA correlated with atherosclerotic changes in human aortas. High abundance of eADA in atherosclerotic vessels originated from activated endothelial cells and macrophages. There were no changes in ecto-nucleoside triphosphate diphosphohydrolase 1 activity, whereas ecto-5'-nucleotidase was moderately decreased in ApoE-/-LDLR-/- mice. Deoxycoformycin treatment attenuated plaque development in aortic root and brachiocephalic artery of ApoE-/-LDLR-/- mice, suppressed vascular inflammation and improved endothelial function. CONCLUSIONS: This study highlights the importance of extracellular nucleotides and adenosine metabolism in the atherosclerotic vessel in both experimental and clinical setting. The increased eADA activity marks an early stage of atherosclerosis, contributes to its progression and could represent a novel target for therapy.

Accelerated heart function recovery after therapeutic plasma exchange in patient treated with biventricular mechanical circulatory support for severe peripartum cardiomyopathy.

We describe a case of severe peripartum cardiomyopathy treated with biventricular mechanical circulatory support, where rapid haemodynamic recovery was observed after therapeutic plasma exchange, used as an adjunct to the inhibition of prolactin release. The patient recovered and after 2 months was discharged from the hospital without clinical symptoms of heart disease.

Comparison of haemodynamics and myocardial injury markers under desflurane vs. propofol anaesthesia for off-pump coronary surgery. A prospective randomised trial.

BACKGROUND: Several studies have highlighted that volatile anaesthetics improve myocardial protection in cardiopulmonary bypass coronary surgery. However, the haemodynamic effect of desflurane in off-pump coronary surgery has not been clarified yet. Our study hypothesis was that desflurane-fentanyl anaesthesia could decrease myocardial injury markers and improve haemodynamics compared to propofol-fentanyl in patients undergoing off-pump coronary surgery. DESIGN: Prospective, randomised open-lable study. Sixty elective patients with left ventricular ejection fraction above 30% received either desflurane (group D, n = 32) or propofol (group P, n = 28), in addition to fentanyl and vecuronium bromide anaesthesia for off-pump coronary surgery. Assessment of haemodynamic function included thermodilution continuous cardiac output and right ventricular end diastolic volume. RESULTS: No significant differences in cardiac output, stroke volume and mean arterial pressure were noted between groups. The only observed difference in haemodynamic profile was that group D demonstrated improved stability, expressed as left ventricular stroke work index (LVSWI). Decrease in LVSWI after performing distal anastomoses was smaller in D compared to P (median value: -14.3 and -19.8 [g m m⁻² beat⁻¹]), respectively (P = 0.029). Oxygen uptake index (VO2I) and oxygen extraction ratio (OER) after skin incision were lower in D, while blood lactate concentration was slightly higher after surgery in D compared to P. The groups did not differ with respect to CK-MB and troponin I concentration. CONCLUSIONS: This study demonstrated no difference between desflurane and propofol anaesthesia for off-pump coronary surgery in major haemodynamic parameters, as well as in myocardial injury markers and the long-term outcome. However, the study indicated that desflurane might accelerate recovery of myocardial contractility, as assessed by LVSWI. Lower oxygen uptake and elevated lactate under desflurane anaesthesia indicated a discrete shift towards anaerobic metabolism. CLINICAL TRIAL REGISTRATION INFORMATION: NCT00528515 (http://www.clinicaltrials.gov/ ct2/show/NCT00528515?term = NCT00528515&rank = 1).

Use of dexmedetomidine in the adult intensive care unit.

Sedation and analgesia, which are universally used in intensive care units (ICUs), provide patients with comfort and safety. The current trends aim at light sedation; the objective is to ensure the minimal sedation level for improving patients' autonomy and enabling the professional staff to assess the patients' neurological status and cognitive functions. Reports in the literature have indicated that a sedative or an entire sedation procedure can affect cognitive processes, the duration of mechanical ventilation and treatment outcomes in critically ill patients. At present, special attention is given to post-sedation delirium. Although sedatives differ in their uptake points, which can influence the quality of sedation, their common characteristic is substantial impairment of cognitive functions, memory and respiration. Alpha 2-adrenergic receptor agonists, which comprise a novel group of agents, are used frequently for sedation. One of these medications is dexmedetomidine, which is designed to sedate adult ICU patients who exhibit a score ≥ -3 according to the Richmond Agitation-Sedation Scale. Recent studies comparing the use of dexmedetomidine and the other sedative agents that are most commonly administered in ICUs demonstrated that the former largely fulfils the expectations of intensivists.

Off-pump coronary surgery may reduce stroke, respiratory failure, and mortality in octogenarians.

BACKGROUND: Octogenarians are a challenging group of patients referred for cardiac surgery. The aim of this study is to assess early outcomes of coronary artery bypass grafting (CABG) performed in the elderly population. METHODS: We performed a meta-analysis of all published observational studies comparing early results of conventional CABG surgery and off-pump CABG surgery in patients aged 80 years or older. The outcomes of interest were mortality, stroke, respiratory failure, renal failure, incidence of support with intraaortic balloon pump, and incidence of postoperative atrial fibrillation. The random effects model was used. RESULTS: Fourteen studies were analyzed. The total number of included subjects was 4,991, of whom 3,113 underwent conventional CABG surgery (62.4%), and 1,878 (37.6%) underwent off-pump CABG surgery. The rates of mortality, stroke, and respiratory failure were significantly higher in the conventional CABG surgery group. CONCLUSIONS: These results confirm that off-pump CABG surgery remains a valuable option of surgical myocardial revascularization, and may optimize the outcome in senior patients.

High-volume hemofiltration as adjuvant therapy for refractory shock after pericardiocentesis.

BACKGROUND: Pericardiocentesis for the treatment of chronic cardiac tamponade can occasionally result in acute pulmonary edema or biventricular failure. A sudden increase in heart filling pressures and right-to-left ventricular-output mismatch have been proposed underlying mechanisms. CASE REPORT: We report the case of 16-year-old patient who underwent pericardiocentesis for chronic cardiac tamponade 6 weeks after undergoing a Bentall procedure. The patient developed circulatory shock 6 hours after pericardiocentesis. High-volume hemofiltration was used as a rescue therapy after treatment with positive inotropic drugs proved ineffective. An improvement in circulatory function observed after commencement of the hemofiltration treatment was followed by hemodynamic deterioration when the hemofiltration procedure was ceased. DISCUSSION: The mechanism of the observed hemodynamic improvement is unclear. Hemodynamic recovery related in time to high-volume hemofiltration treatment indicates the possible removal of inflammatory mediators. Visceral vasoconstriction resulting from cardiac tamponade and subsequent improvement in gut perfusion after pericardiocentesis that led to washout of inflammatory mediators might have contributed to the development of acute heart failure. Cytokine removal by high-volume hemofiltration and the procedure's relationship to hemodynamic improvement have previously been demonstrated in clinical and experimental studies of septic shock. CONCLUSIONS: We conclude that high-volume hemofiltration can be helpful as an adjuvant treatment for refractory shock after pericardiocentesis for chronic cardiac tamponade. The mechanism of the observed hemodynamic improvement remains to be investigated.