Assessment of three methods for removing massive air in a cardiopulmonary bypass circuit: simulation-based multi-discipline training in West China Hospital.

BACKGROUND AND OBJECTIVE: A multi-discipline cardiac and cardiopulmonary bypass (CPB) team simulation scenario was established to compare three different de-airing approaches dealing with massive air embolism in CPB, so as to formulate a standardized procedure to handle this adverse acute event more proficiently and ensure clinical safety. METHOD: A simulation-based clinical CPB massive air embolism scenario was developed by a cardiac and CPB team. Study Objects: Five licensed perfusionists and five CPB trainees were matched randomly into five pairs. Each pair would simulate the three different de-airing approaches separately as followed: (1) Conventional Method: arterial line filter (ALF) de-airing purge line and oxygenator self-recirculation bypass were used to de-air; (2) Arterial-Venous Loop (A-V Loop) Method: surgeons reconnected the arterial and venous lines to de-air by restoring the original priming A-V loop configuration; (3) Isolation of the ALF Method: this ensures de-bubbling of the CPB circuit, but bypasses the ALF function. Assessment Criteria: (1) Times to recovery (duration of the circulation suspension); (2) Subjective evaluation of skill and non-skill performances. RESULTS: As to times to recovery, the Conventional Method group took 290.6 s ± 36.2, the A-V Loop Method group took 196.8 s ± 52.0 and the Isolation of ALF group took 99.4 s ± 15.1. The statistical difference is significant among the three groups (p<0.01). The subjective evaluation of training performance indicates that this simulation-based training is effective in assessing both skill and non-skill abilities. CONCLUSION: CPB simulation-based training was effective in comparing de-airing strategies and can instruct perfusion practices how to optimize techniques. For well-trained, multi-discipline cardiac teams, the A-V Loop Method is highly efficient and reliable in managing CPB massive air embolism. For cardiac teams that do not have this sophisticated training, the Isolation of ALF Method should be their alternative option.

Effect of intralipid on myocardial injury during valve replacement surgery with concomitant radiofrequency ablation: A randomized controlled trial.

BACKGROUND: This study aimed to evaluate the effect of intralipid postconditioning (ILPC) on myocardial damage in patients undergoing valve replacement surgery with concomitant radiofrequency ablation (RFA) for atrial fibrillation (AF). METHODS: Randomized patient and assessor-blind controlled trial conducted in adult patients undergoing valve replacement surgery with concomitant RFA. Sixty-nine patients were randomly assigned to ILPC group (n = 34) or control group (n = 35): ILPC group received an intravenous infusion of 20% intralipid (2 mL/kg) just 10 minutes before aortic cross-unclamping, and control group received an equivalent volume of normal saline. Serum cardiac troponin-T (cTnT) and creatine kinase-MB (CK-MB) was measured before surgery and at 4, 12, 24, 48, and 72 hours after surgery. The primary endpoints were the 72-hour area under the curve (AUC) for cTnT and CK-MB. RESULTS: The total 72-hour AUC of cTnT (P = .33) and CK-MB (P = .52) were comparable between 2 groups. The left ventricle ejection fraction at discharge (P = .011) was higher in the ILPC group than that in the control group, while the AF recurrence did not differ significantly between 2 groups. CONCLUSIONS: There was no observed beneficial effect of ILPC on myocardial injury documented by the cardiac biomarkers in patients undergoing valve replacement surgery with concomitant RFA, and the effect of intralipid against myocardial I/R injury is undetectable within the background of massive biomarker release following ablation owing to localized myocardial necrosis. Besides, there are no other published data about the cardioprotective role of intralipid in patients undergoing this procedure and benefits of this protection need further studies to validate.

Effect of intralipid postconditioning on myocardial injury in patients undergoing valve replacement surgery: a randomised controlled trial.

OBJECTIVE: This study was conducted to determine whether the administration of intralipid just before aortic cross-unclamping would reduce myocardial injury in patients undergoing valve replacement surgery. METHODS: Seventy-three adult patients, scheduled for elective aortic or mitral valve surgery without significant coronary stenosis (>70%), were randomly assigned to the intralipid postconditioning (ILPC) group (n=37) or control group (n=36): the ILPC group received an intravenous infusion of 20% intralipid (2 mL/kg) just 10 min before aortic cross-unclamping, and the control group received an equivalent volume of normal saline. Serum cardiac troponin T (cTnT) and creatine kinase-MB (CK-MB) was measured before surgery and at 4, 12, 24, 48 and 72 hours after surgery. The primary end points were the 72-hour area under the curve (AUC) for cTnT and CK-MB. RESULTS: No significant difference between the ILPC and control arm was observed, including the age, sex or number of aortic versus mitral valves or left ventricular ejection fraction at baseline. The total 72-hour AUC of cTnT and CK-MB in patients assigned to ILPC were significantly reduced by 32.3% (p=0.004) and 26.4% (p=0.0185) compared with control, respectively. None of the treated patients had abnormal blood lipid metabolism, abnormal renal or hepatic function or significant related complications. CONCLUSION: The protective effect of postischaemic administration of intralipid prior to aortic cross-unclamping on reperfusion injury was found when determined by biomarkers of myocardial injury but not by cardiac function or other clinical outcomes in patients undergoing valve replacement surgery. Hence, clinical benefits of this protection need larger clinical trials to confirm. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov ID: ChiCTR-IOR-14005318.