Perioperative steroids administration in pediatric cardiac surgery: a meta-analysis of randomized controlled trials*.

OBJECTIVE: To evaluate the effects of prophylactic perioperative corticosteroid administration, compared with placebo, on postoperative mortality and clinical outcomes (renal dysfunction, duration of mechanical ventilation, and ICU length of stay) in pediatric patients undergoing cardiac surgery with cardiopulmonary bypass. DATA SOURCES: MEDLINE and Cochrane Library were screened through August 2013 for randomized controlled trials in which perioperative steroid treatment was adopted. STUDY SELECTION: Included were randomized controlled trials conducted on pediatric population that reported clinical outcomes about mortality and morbidity. DATA EXTRACTION: Eighty citations (PubMed, 48 citations; Cochrane, 32 citations) were identified, of which 14 articles were analyzed in depth and six articles fulfilled eligibility criteria and reported mortality data (232 patients), two studies reported ICU length of stay and mechanical ventilation duration (60 patients), and two studies reported renal dysfunction (49 patients). DATA SYNTHESIS: A nonsignificant trend of reduced mortality was observed in steroid-treated patients (11 [4.7%] vs 4 [1.7%] patients; odds ratio, 0.41; 95% CI, 0.14-1.15; p = 0.089). Steroids had no effects on mechanical ventilation time (117.4 ± 95.9 hr vs 137.3 ± 102.4 hr; p = 0.43) and ICU length of stay (9.6 ± 4.6 d vs 9.9 ± 5.9 d; p = 0.8). Perioperative steroid administration reduced the prevalence of renal dysfunction (13 [54.2%] vs 2 [8%] patients; odds ratio, 0.07; 95% CI, 0.01-0.38; p = 0.002). CONCLUSION: Despite a demonstrated attenuation of cardiopulmonary bypass-induced inflammatory response by steroid administration, a systematic review of randomized controlled trials performed so far reveals that steroid administration has potential clinical advantages (lower mortality and significant reduction of renal function deterioration). A larger prospective randomized study is needed to verify clearly the effects of steroid prophylaxis in pediatric patients.

When it's neighbor's fault, a complicated ascending aortic aneurysm mimicking pulmonary embolism: A case report.

Thoracic aortic aneurysms represent a potentially life-threatening disease with increasing prevalence, probably related to the increasing mean age of the global population; the complications of thoracic aortic aneurysms can show multiple modes of presentation in the acute phase based on various factors, including the involvement of the structures with which the aneurysm is in close anatomical relationship. With this case report we want to show how it is possible that a complicated ascending aortic aneurysm can mimic an acute pulmonary embolism/acute cor pulmonale in the acute phase; the earliest possible differential diagnosis between pulmonary embolism and acute aortic disease is of crucial importance due to the opposite implications that the treatment of these two diseases have. .

Relation of Prolonged Pacemaker Dependency After Cardiac Surgery to Mortality.

Permanent pacemaker implantation (PPI) represents a rare complication after cardiac surgery, with no uniform agreement on timing and no information on follow-up. A multicenter retrospective study was designed to assess pacemaker dependency (PMD) and long-term mortality after cardiac surgery procedures. Between 2004 and 2016, PPI-patients from 18 centers were followed. Time-to-event data were evaluated with semiparametric regression Cox models and semiparametric Fine and Gray model for competing risk framework. Of 859 (0.90%) PPI-patients, 30% were pacemaker independent (PMI) at 6 months. PMD showed higher mortality compared with PMI (10-year survival 80.1% ± 2.6% and 92.2% +2.4%, respectively, log-rank p-value < 0.001) with an unadjusted hazard ratio for death of 0.36 (95% CI 0.20 to 0.65, p< 0.001 favoring PMI) and an adjusted hazard ratio of 0.19 (95% CI 0.08 to 0.45, p< 0.001 with PMD as reference). Crude cumulative incidence function of restored PMI rhythm at follow-up at 6 months, 1 year and 12 years were 30.5% (95% CI 27.3% to 33.7%), 33.7% (95% CI 30.4% to 36.9%) and 37.2% (95% CI 33.8% to 40.6%) respectively. PMI was favored by preoperative sinus rhythm with normal conduction (SR) (HR 2.37, 95% CI 1.65 to 3.40, p< 0.001), whereas coronary artery bypass grafting and aortic valve replacement were independently associated with PMD (HR 0.63, 95% CI 0.45 to 0.88, p = 0.006 and HR 0.807, 95% CI 0.65 to 0.99, p = 0.047 respectively). Time-to-implantation was not associated with increased rate of PMI. Although 30% of PPI-patients are PMI after 6 months, PMD is associated with higher mortality at long term.

Acute kidney injury in high-risk cardiac surgery patients: roles of inflammation and coagulation.

AIMS: Acute kidney injury (AKI) is a common complication following cardiac surgery. Cardiopulmonary bypass elicits coagulation and inflammation activation and oxidative stress, all involved in AKI but never simultaneously assessed. We aimed to evaluate relations between oxidative stress, inflammatory and coagulation systems activation and postoperative renal function in patients with normal preoperative renal function. METHODS: Forty-one high-risk patients (EuroSCORE >6 and preoperative haemoglobin <12 g/dl in women and <13 g/dl in men) were prospectively enrolled. Prothrombin fragment 1.2 (coagulation marker), interleukin-6 and interleukin-10 (pro/anti-inflammatory markers) and 8-oxo-2'-deoxyguanosine (oxidative stress marker) were evaluated until postoperative day 5. RESULTS: Patients were divided into two groups according to estimated glomerular filtration rate reduction observed postoperatively (reduction <25% in 26 patients: NO-AKI group; reduction >25% in 15 patients: AKI group). No differences were found for inflammatory markers. Oxidative stress slightly increased in the AKI group. Twenty-four hours after the operation prothrombin fragment 1.2 levels were significantly higher in the AKI group (506.6 ±â€Š548 vs. 999 ±â€Š704.1 pmol/l; P = 0.018), and they were independently associated with estimated glomerular filtration rate reduction, with an area under the receiving operating characteristic of 0.744. CONCLUSION: Thrombin generation is higher in patients with renal function worsening, and it is an independent risk factor for AKI in patients with anaemia, possibly leading to microcirculation impairment and tubular cells damage.

Cardiac troponin I and creatine kinase-MB release after different cardiac surgeries.

AIMS: To conduct a comparative study of cardiac troponin I (cTnI) and MB isoenzyme of serum creatine kinase (CK-MB) after different cardiac surgeries. METHODS: Consecutive cardiac operations under cardiopulmonary bypass (200 adults, 144 men, 68 ±â€Š11 years): 67 coronary artery bypass graft (CABG), 27 aortic valve surgery, 21 mitral valve surgery, 11 thoracic aorta surgery, and 74 combined surgery. Postoperative cTnI and CK-MB were measured on admission to the ICU and at fixed time until the fifth postoperative day. RESULTS: Peak values of cTnI (median 5.8 ng/ml; interquartile range 3.6-11.9) and CK-MB (29.0 ng/ml; 15.6-60.4) were reached mainly within 18 h after the end of surgery (85% of cTnI and 95% of CK-MB highest determinations) without differences among groups. Cardiopulmonary bypass and cross-clamp time significantly correlated with markers' peak values. At multivariate analysis, mitral valve surgery showed greater cTnI, CK-MB, and their cumulative area under the curve than other isolated procedures. Thoracic aorta surgery showed lower cumulative area under the curve for both markers than CABG and combined surgery. Mitral valve surgery had significant later reduction of both markers in comparison with other procedures. No patient in mitral valve surgery group reached cTnI values in the normal laboratory range within 5 postoperative days. CONCLUSION: Release pattern of cTnI and CK-MB after heart surgery depends on the type of procedure. Mitral valve surgery was characterized by highest and longest elevation of postoperative markers' concentration. Determinants of differences in myocardial injury biomarkers and their prognostic value after valve surgery should be accurately assessed.

Haemostasis alterations in coronary artery bypass grafting: comparison between the off-pump technique and a closed coated cardiopulmonary bypass system.

OBJECTIVES: To compare coagulation and fibrinolysis activation in off-pump coronary artery bypass operation and in patients in whom a closed phosphorylcholine-coated cardiopulmonary bypass system was applied. Cardiopulmonary bypass induces activation of coagulative and fibrinolytic systems, which together with intraoperative haemodilution augment the risk of postoperative bleeding and transfusion of blood products. METHODS: Thirty-six off-pump coronary artery bypass and 36 coronary artery bypass grafting patients in whom a closed, phosphorylcholine-coated cardiopulmonary bypass system with a closed-collapsible venous reservoir (Physio group) was used were prospectively enrolled. Activation of coagulation and fibrinolytic systems was assessed evaluating the release of prothrombin fragment 1.2 and plasmin-antiplasmin complex preoperatively (T0), 30 min after heparin administration (T1), 15 min after protamine administration (T2), 3 h after protamin administration (T3) and on postoperative days 1 (T4) and 5 (T5). Platelet function was evaluated through Platelet Function Analyzer 100(®). RESULTS: During the operation, prothrombin fragment 1.2 and plasmin-antiplasmin levels were slightly higher in the Physio group, the difference being not statistically significant. In the off-pump coronary artery bypass group, prothrombin fragment 1.2 was significantly higher at T3 (618.7 ± 282.7 vs 416.6 ± 250.2 pmol/l; P = 0.006), T4 (416.7 ± 278.8 vs 310.2 ± 394.6 pmol/l; P < 0.001) and T5 (629.3 ± 295.2 vs 408.4 ± 409.7 pmol/l; P = 0.002), and plasmin-antiplasmin was significantly higher at T4 (731.1 ± 790 vs 334 ± 300.8 ng/ml; P = 0.019) and T5 (1744.4 ± 820.7 vs 860.1 ± 488.4 ng/ml; P = 0.003). Platelet Function Analyzer 100® closure time values were significantly higher in the Physio group patients at T3 (131.3 ± 105.7 vs 215.6 ± 58.9 s; P = 0.002). The off-pump coronary artery bypass patients had greater chest tube drainage (874.3 ± 371.5 vs 629.1 ± 334.5 ml; P = 0.005). The mean priming volume was 1240 ± 215 ml in the Physio group. Much more Physio patients received red blood cell transfusions (14 vs 25 patient; P = 0.009), because of higher intraoperative transfusion rates (6 vs 15 patients; P = 0.016). Despite similar preoperative haemoglobin levels (13 ± 1.2 vs 12.6 ± 1.4 g/dl; P = 0.2), postoperative haemoglobin levels were significantly lower in the Physio group. CONCLUSIONS: The Physio cardiopulmonary bypass approach does not significantly alter haemostasis during the operation compared with off-pump coronary artery bypass providing a reduced activation in the postoperative period reducing also chest tube drainage. However, further priming volume reduction is required to decrease intraoperative red blood cell transfusion.