Role of Using a Thromboelastometry-Based Protocol for Transfusion Management in Combined Coronary Artery Bypass Grafting and Valve Surgery: A Randomized Clinical Trail.

The aim of this study was to evaluate the impact of using a thromboelastometry-based protocol on transfusion requirements in patients undergoing combined coronary artery bypass grafting (CABG) and valve surgery. 80 adult patients scheduled for elective combined CABG and valve surgery were included in this clinical trial study. Patients were randomly allocated to the thromboelastometry (ROTEM) (n = 40) or control groups (n = 40). In the ROTEM group, transfusion was directed according to a thromboelastometry-based protocol. In the control group, transfusion was conducted according to the routine practices including conventional coagulation testing and clinical judgments. Finally, transfusion requirements were compared between groups. Use of thromboelastometry- based protocol resulted in 67% reduction in blood products units' consumption as well as 23% in the percentage of patients transfused. This reduction was especially evident in relation to fresh frozen plasma (FFP) and platelet consumption. No significant differences were found both in the percentage of patients receiving RBC and number of transfused RBC units. Using thromboelastometry tests incorporated a protocol results in reduction of transfusion requirements in patients undergoing elective combined CABG and valve surgery.

Relationship between maximum clot firmness in ROTEM® and postoperative bleeding after coronary artery bypass graft surgery in patients using clopidogrel.

BACKGROUND: The aim of the present study was to investigate the relationship between maximum clot firmness (MCF) in rotational thromboelastometry (ROTEM®) and postoperative bleeding in patients on clopidogrel after emergency coronary artery bypass graft surgery (CABG). METHODS: This observational study recruited 60 patients posted for emergency CABG following unsuccessful primary percutaneous coronary intervention (PCI) while on 600 mg of clopidogrel. The study population was divided into 2 groups on the basis of their MCF in the extrinsically activated thromboelastometric (EXTEM) component of the (preoperative) ROTEM® test: patients with MCF <50 mm (n = 16) and those with MCF ≥50 mm (n = 44). Postoperative chest tube drainage amount, need for blood product transfusion, postoperative complications, and duration of mechanical ventilation after CABG were recorded. Results: No significant differences were observed between the two groups regarding duration of surgery, cardiopulmonary bypass, and aortic cross-clamp time. Chest tube drainage at 6, 12, and 24 h after Intensive Care Unit admission were significantly higher in the patients with MCF below 50 mm. The need for blood product transfusion was higher in the group with MCF <50 mm. In patients who experienced postoperative bleeding of 1000 mL or more, the ROTEM® parameters of INTEM (Intrinsically activated thromboelastomery) α and MCF, EXTEM α and MCF, and HEPTEM (INTEM assay performed in the presence of heparinase) MCF (but not FIBTEM (Thromboelastometric assay for the fibrin part of the clot) values) were significantly lower than those with postoperative bleeding <1000 mL (P ≤ 0.05). CONCLUSIONS: When platelet aggregometry is not available, the ROTEM® test could be useful for the prediction of increased risk bleeding after emergency CABG in patients who have received a loading dose of clopidogrel.

A randomized controlled trial on the hemostasis of femoral artery using topical hemostatic agent.

OBJECTIVE: Evaluation of the effect of using a topical hemostatic agent named "ChitoHem(®)" on different factors on patients undergoing diagnostic coronary angiography. METHODS: The present blind, randomized, controlled study included 124 patients randomly divided into 2 groups. In the treatment group following femoral sheath removal, ChitoHem(®) powder and in the control group conventional hemostatic procedure was applied. RESULTS: In the treatment group, time to hemostasis, ambulation, and the use of sandbag were significantly shorter compared with the control group, respectively (4.6 ± 1.3 vs 12.4 ± 4.4 minutes, 3.5 ± 2.7 vs 23.0 ± 1.73 hours and 1.6 vs 98.4%; P < .05). There were no significant differences in hematoma formation and re-bleeding between the 2 groups. CONCLUSION: It was exhibited ChitoHem(®) topical hemostatic powder used on treatment patients undergoing diagnostic coronary angiography was statistically superior at reducing the time to hemostasis and ambulation as well as the use of sandbags compared with manual compression in control group.

Comparison of the response of the right ventricle with endovascular occlusion and surgical closure in adults with atrial septal defect one year after intervention.

BACKGROUND: Use of the Amplatzer septal occluder (ASO) for the closure of secundum atrial septal defect (ASD) has recently become the procedure of choice, while earlier the only treatment for ASD was surgical closure. This study compares the right ventricular indices of the ASO group with the surgical closure group one year after intervention in adults. METHODS: From January 2008 to February 2010, 38 patients with isolated atrial septal defect of the secundum type one year after surgical (n = 20, age = 27 ± 4 years, 13 females, 7 males) or Amplatzer septal occluder closure (n = 18, age = 25 ± 4 years, 12 females, 6 males) were studied. At the same time, thirty-one age-matched normal subjects (age = 26 ± 6 years, 23 females, 9 males) were included as the control group. Strain and strain rate of the right ventricle were measured. RESULTS: The mean values of strain of the midportion were -26% ± 11.7%, -8.9% ± 4.2%, and 24.5% ± 7.4% (P < 0.001). Strain rates of the midportion were -2.19 ± 0.6 s(-1), -1.2 ± 0.4 s(-1), -1.9 ± 0.6 s(-1) (P < 0.001) in ASO, surgery, and control groups, respectively. CONCLUSION: This study showed that the right ventricle might show better performance in the ASO than the surgery group in adults with ASD in midterm follow-up.

Non-invasive assessment of coronary artery stenosis with estimation of myocardial wall stress.

BACKGROUND: More diagnostic techniques require a better understanding of the forces and stresses developed in the wall of the left ventricle. The aim of this study was to differentiate significant coronary artery disease (CAD) patients using a non-invasive quantification of myocardial wall stress in the diastole phase. METHODS: Sixty male subjects with sinus rhythm (30 patients with significant and 30 with moderate left anterior descending coronary artery stenosis in the proximal portion) as well as 35 healthy subjects as the control group were recruited into the present study. By two-dimensional, pulsed wave, and tissue Doppler echocardiography, the average end-diastolic wall stress was calculated at the left ventricle anterior and interventricular septum wall segments using regional wall thickness, meridional and circumferential radii, and non-invasive left ventricular end-diastolic pressure. RESULTS: A comparison of the calculated end-diastolic myocardial wall stress between the patients with significant and moderate coronary stenosis on the one hand and the healthy subjects on the other showed statistically significant differences in the anterior and septum wall segments (p value < 0.05). The patients with significant left anterior descending coronary artery stenosis had higher end-diastolic myocardial wall stress than did those with moderate stenosis and the healthy group in all the anterior and septum wall segments. CONCLUSION: It is concluded that non-invasive end-diastolic myocardial wall stress in coronary artery disease patients is an important index in evaluating myocardial performance.

Doppler echocardiographic assessment of pulmonary prostheses: a comprehensive assessment including velocity time integral ratio and prosthesis effective orifice area.

OBJECTIVE: Few reports have been published on the Doppler-derived echocardiographic data for pulmonary valve prostheses (PVPs). The aim of this study was to provide a comprehensive Doppler echocardiographic assessment of PVPs. METHODS: We studied 40 patients (mean age 24.2) with PVPs: 13 (32.5%) mechanical and 27 (67.5%) bioprosthetic valves. After clinical evaluation, all patients underwent complete, two-dimensional and Doppler studies. RESULTS: In 30 patients with normally functioning PVPs, the mean (SD) peak velocity was 2.33 (0.36) m/s with an average peak pressure gradient of 22.69 (6.7) mm Hg and an average mean pressure gradient of 12.5 (4.1) mm Hg. The mean PVPs velocity time integral (VTI) was 47.49 (12.78) cm with mean right ventricle outflow tract/peak velocity (PV) VTI ratio 0.43 (0.14), mean PVPs effective orifice area was 1.63 (0.36) cm(2). Metallic PVPs had significantly better hemodynamic Doppler study compared with biologic PVPs. In 9 patients with PVP malfunction, average peak PVPs velocity, average peak pressure gradient, mean pressure gradient, PV VTI, PV/left ventricle outflow tract VTI ratio was significantly increased (P < 0.05). CONCLUSION: This study contributes to establishing the normal range for Doppler hemodynamics in various PVPs.

Complete surgical repair of Tetralogy of Fallot in adults, is it ever too late?

A minority of patients with Tetralogy of Fallot (TF) survive into adulthood. These patients have been subjected to a prolong period of cyanosis and hypoxia. The aim of this study is to assess the benefits of total correction of TF in this adult population. From August 1995 to March 2005, fifty one patients underwent total correction of TF. The mean age was 22.2 years (range 16 to 38 years). There were 31 males and 20 females. Twenty two percent of patients were in NYHA functional class III prior to the operation. The mean gradient across the right ventricular outflow tract was 81.7 mmHg (range 30 to 130 mmHg). The operation was performed through the right ventricle in the majority of patients. Transannular patch was used in 33 patients. The mean follow-up period was 42 months ranging from 1 to 116 months. Hospital mortality was 1.9% (1 patient), and one patient died three months after the operation. Post-operatively 87.3% of patients were in NYHA functional class I. During the follow-up period four patients required re-operation; two for residual ventricular septal defect, one for residual pulmonary stenosis and one had pulmonary valve replacement for severe pulmonary regurgitation. Complete repair of TF in adults is feasible with acceptable mortality and morbidity. The main benefit of the operation is functional improvement in this patient population.

Echocardiographic characteristics including tissue Doppler imaging after enhanced external counterpulsation therapy.

This study assessed the effects of a course of enhanced external counterpulsation (EECP) therapy on systolic and diastolic cardiac function using echocardiography to measure left ventricular ejection fraction (LVEF), end-systolic volume (ESV), end-diastolic volume (EDV), systolic wave (Sm), early diastolic wave (Ea), Vp, E/Ea, E/Vp, and diastolic function grade in 25 patients before and after 35 hours of EECP. EECP reduced ESV and EDV and increased ejection fraction significantly in patients with baseline LVEF < or = 50% (P=.018, .013, .002), baseline E/Ea > or = 14 (P=.032, .038, .007), baseline grade II or III diastolic dysfunction (decreased compliance) (P=.014, .032, .027), baseline Ea <7 cm/s (P=.015, .024, .001), and baseline Sm <7 cm/s (P=.017, .016, .006), but not in patients with baseline LVEF >50%, baseline E/Ea <14, baseline normal diastolic function or grade I diastolic dysfunction (impaired relaxation), baseline Ea > or = 7 cm/s, and Sm > or = 7 cm/s. These results demonstrate improved systolic and diastolic function in selected patients and provide new insight into potential clinical applications of EECP.