Influence of cardioplegic solution on incidence of delirium after CABG surgery: Use of Calafiore blood cardioplegia versus HTK - Bretschneider - solution in a single-center retrospective analysis from 2017 to 2021.

BACKGROUND: Purpose of the present study is an evaluation of postoperative incidence for delirium after coronary artery bypass surgery (CABG). Study addressed whether application of Histidine-Tryptophan-Ketoglutarate (HTK) solution (Bretschneider) or blood cardioplegia (Calafiore) is associated with increased of postoperative delirium cases. MATERIALS AND METHODS: In a retrospective, single center evaluation a total number of 273 patients were enrolled in the study from January 2017 to October 2021. There were 124 patients assigned to the Calafiore group blood cardioplegic solution (BCC) and 149 patients were included in the Bretschneider group (HTK). The primary endpoint was the postoperative delirium rate in its frequency of occurrence. Definition of the dilirium status was performed using the Confusion Assessment Method in the Intensive Care Unit (CAM-ICU) score during the first three postoperative days. Secondary endpoints were the time intervals of intensive care duration of stay, mechanical ventilation, total extracorporeal circulation, ischemia and reperfusion. Serum levels of the electrolytes Sodium, Potassium, ionized Calcium, and Chloride were monitored. RESULTS: Although no significant difference in delirium status between the groups were noticed, on third postoperative day, delirium rate dependent on cardioplegia solution used (HTK 12.0%; BCC 3.0%; p = .024) and duration of intensive care stay differed (HTK 4.5 vs. BCC 3.0 days; p = .001). Although Ischemic time (HTK 73.0 vs. BCC 83.0 min; p < .001) and reperfusion time (HTK 35.0 vs. Calafiore 24.0 min; p < .001) were extended in the BCC group less cases of delirium were diagnosed. Serum sodium levels after HTK cardioplegic infusion were decreased (HTK 129.68 vs. BCC 138.96 mmol/l; p < .001). The significant difference persists up to the hundredth extracorporeal circulation circuit min (p = .005). CONCLUSION: The present data suggest an impact of the cardioplegic solution used upon postoperative delirium rates. Optimization of cardiac arrest protocols is needed. Present data encourage further prospective studies regarding the impact of cardioplegic solutions on electrolyte imbalance for postoperative delirium rates in CABG surgery.

Prediction of stroke reconvalescence after coronary bypass surgery indicated by CT scan parameters.

BACKGROUND: Stroke in the postoperative time course after heart surgery remains a serious risk. Cranial computer tomography (CCT) is the first line option to detect severe intracranial damage. However, only few data are available to predict neurological outcome. Using visual rating scales (VRSs), this study addresses reliability and effectivity to indicate neurological status and likelyhood of improvement. METHODS: In a single-center retrospective evaluation, 3719 patients underwent coronary bypass surgery. Because of a delayed recovery phase and neurologic deficits after cardiac surgery 109 patients had a cranial CT scan in the early postoperative period. The incidence of clinically relevant findings within the imaging was rated by an experienced neuroradiologist using two VRS, that is, the age-related white matter changes (ARWMCs) and the Mendes-Ribeiro visual rating scale (MRVRS). Both are computer-assisted measurement schemes to detect stroke-related intracranial damage. Follow-up was investigated with regard to clinical outcome and patient-related risk profiles. RESULTS: Of 109 patients with postoperative cranial CT scans due to prolonged recovery phases or proven neurological damage 44.5% had one cerebral defect in CCT imaging scans only. The others showed multiple defects. During hospital stay, 92.3% experienced neurological improvement exposing reduced ARWMC, while 7.1% had no improvement and correlating high scores. Of both scales, the ARWMC-VRS demonstrated superior accuracy and discrimination. The preoperative ejection fraction (EF), arteriosclerotic degeneration of carotid arteries, and reduced glomerular filtration rate were found to have a high correlation (r = 0.0005) with the latter group. In-hospital mortality of this cohort was 8.18%. CONCLUSION: Both the ARWMC and MRVRS were found to be appropriate. They reliably discriminate the groups of stroke patients after coronary artery bypass grafting (CABG)  in the analysis of CCT images. When applied at the onset of neurological symptoms both scales are able to predict neurological reconvalescence upon hospital dismission. The ARWMC scale appeared superior as it demonstrated better accuracy and discrimination. The use of both VRS in patients with suspected stroke after CABG surgery can give insightful information toward a progression of neurological dysfunction or postoperative improvement.

Left ventricular free wall rupture caused by myocardial ischemia without treatable atherosclerotic coronary disease: a case series.

BACKGROUND: The clinical presentation of left ventricular free wall rupture (LVFWR) varies ranging from uneventful condition to congestive heart failure. Here we report two cases of LVFWR with different clinical presentation and notable outcome. A 53-year-old male presenting emergently with signs of myocardial infarction received immediate coronary angiography and thoracic CT-scan showing occlusion of the first marginal coronary branch without possibility of revascularization and minimal pericardial extravasation. Under ICU surveillance, LVFWR occurred 24 h later and was treated by pericardiocentesis and ECMO support followed by immediate uncomplicated surgical repair. Postoperative therapy-refractory vasoplegia and electromechanical dissociation caused fulminant deterioration and the early death of the patient. The second case is a 76-year old male brought to the emergency room after sudden syncope, clinical sings of pericardial tamponade and suspicion of a type A acute aortic dissection. Immediate CT-angiography excluded aortic dissection and revealed massive pericardial effusion and a hypoperfused myocardial area on the territory of the first marginal branch. Immediate sternotomy under mechanical resuscitation enabled removal of the massive intrapericardial clot and revealed LVFWR. After an uncomplicated surgical repair, an uneventful postoperative course, the patient was discharged with sinus rhythm and good biventricular function. One year after the operation, he is living at home, symptom free. DISCUSSION: Whereas the younger patient, who was clinically stable at hospital admission received delayed surgery and did not survive treatment, the older patient, clinically unstable at presentation, went into immediate surgery and had a flawless postoperative course. Thus, early surgical repair of LVFWR leads to best outcome and treating LVFWR as a high emergency regardless of the symptoms improve survival.

Reduction of volume loss after left atrial injury by balloon occlusion-an experimental study.

Background: Advanced-stage lung cancers sometimes require an extensive surgical approach. There is a risk of severe bleeding due to injury to the cardiac atria. Due to the fact that in most cases the surgical planning does not involve the expertise of a heart surgeon or the availability of a heart lung machine, only rapid effective action can avert this life-threatening complication. Methods: In an experimental study of porcine heart-lung packs, three different methods were used to investigate the most effective way of controlling mass hemorrhage due to left atrial injury. In order to obtain a realistic model, the heart-lung packet was connected to a heart-lung machine after appropriate preparation and perfused with volume support. The damage control to the left atrial injury was either performed by manual compression, surgical clamping or balloon catheter occlusion. Results: In addition to manual compression and clamping, the use of a balloon catheter inserted into the atrial lesion was found to be the most effective method. The blood loss of 41.88±7.53 mL (vs. 105.00±31.74 and 106.00±50.67 mL) proved to be the lowest value. Conclusions: For extensive resections of lung carcinoma, balloon catheters of different sizes should be kept ready to rapidly control massive blood loss due to injury of the cardiac atria.

Impact of the underlying aortic pathology on postimplantation syndrome after endovascular thoracic aortic repair.

BACKGROUND: Thoracic endovascular aortic repair (TEVAR) is the treatment option of choice for almost all pathologies of the descending thoracic aorta. The aim of the present study was to determine the impact of aortic pathology on the occurrence of postimplantation syndrome (PIS) after TEVAR. METHODS: Seventy-four patients undergoing TEVAR for aortic dissection (TAD, 25), aortic aneurysm (TAA, 26), and aortic rupture or perforated ulcer (TAR/PAU, 23) were included in this retrospective study. The clinical outcome measures were persistent inflammation at hospital discharge and in-hospital mortality. RESULTS: PIS was assessed in 22.97% of all patients, predominantly in the TAD group (P=0.03). CRP increased after TEVAR (156.6±94.5, P<0.001; 108.1±57.7, P<0.01 and 117.8±70.4, P<0.05) vs. baseline (58.1±77.5, 31.94±52.1 and 31.9±52.1 mg/L, in TAD, TAA and TAR/PAU, respectively) and this increase was more accentuated in TAD group (P<0.05). Stent-length was similar in all groups (P=0.226) but correlated with postoperative CRP only in TAD (R=0.576, P=0.013). Fresh parietal thrombus correlated with CRP (R=0.4507, P=0.0005) and is (OR=1.0883, P=0.0001), together with the pathology of aortic dissection (OR=6.2268, P=0.0288), a predictor of PIS after TEVAR. Whereas mortality (5.4%) did not correlate with PIS (P=0.38) either with aortic pathology (P=0.225), hospital stay after TEVAR was significantly prolonged by PIS (P=0.03). CONCLUSIONS: Aortic dissection is associated with more inflammation after TEVAR than aortic aneurysm, rupture or perforated ulcer, with the amount of fresh parietal thrombus playing the most significant role in the occurrence of PIS. Importantly, PIS prolongs hospital stay but not mortality after TEVAR.