Pharmacological prevention of postoperative delirium in patients undergoing cardiac surgery: a bayesian network meta-analysis.

The incidence of postoperative delirium in patients undergoing cardiac surgery is very high and increases morbidity and mortality. The possibility of pharmacological means to reduce its incidence is very attractive. At present, there is still no clear demonstration that any drug can prevent postoperative delirium in these patients. The aim of this Bayesian network meta-analysis (NMA) was to evaluate whether there is evidence that a drug is effective in reducing the incidence of POD in cardiac surgical patients. Our NMA showed that preoperative ketamine at subanesthetic doses can significantly reduce the incidence of POD. Risperidone also decreases the incidence of POD, but not significantly.

The Cardiac Power Index during Abdominal Open Aortic Surgery: Intraoperative Insights into the Cardiac Performance-A Retrospective Observational Analysis.

Background: The Cardiac Power Index (CPI) measures the rate of energy output generated by the heart and correlates this with in-hospital mortality due to cardiogenic shock. In open aortic surgery, both aortic clamping and unclamping expose the heart to abrupt variations of the left ventricle afterload, preload, and contractility, with possible hemodynamic impairment. We investigated how aortic-cross clamping (Ao-XC) and unclamping (Ao-UC) procedures affect the CPI during open aortic surgery. Methods: We retrospectively analyzed our surgical database of 67 patients submitted to open surgical aortic repair at Humanitas Research Hospital, Milan. Patients were monitored by an EV1000-FloTrac SystemTM (Edwards Lifescience, Irvine, CA, USA) beyond the standard intra-operative hemodynamic monitoring. The primary outcome was the variation of basal CPI after aortic clamping and unclamping. Secondary outcomes were variations of the cardiac index (CI), mean arterial pressure (MAP), heart rate, and lactate during aortic clamping and after unclamping. The CPI was computed as: (CI × MAP)/451. Results: The CPI changed significantly after aortic unclamping. CPI: basal = 0.39 ± 0.1 W/m2, after Ao-XC = 0.39 ± 0.1 W/m2, and after Ao-UC = 0.44 ± 0.2 W/m2, p < 0.05. The CI changed during both cross-clamping and unclamping (p < 0.0001), whilst the MAP and heart rate did not during any phase of the surgery. Five subjects (8.3%) needed inotropic support after cross-clamping. Their basal CPI was lower than the general population: 0.31 ± 0.11 W/m2 vs. 0.39 ± 0.1 W/m2. Conclusions: The CPI describes the adaptation of the cardiac function to the changes in preload, contractility, and afterload occurring during aortic cross-clamping and unclamping. It may be used to explore the cardiac performance in real-time and predict cardiac impairment in the intraoperative period in a minimally invasive way, similar to ventriculo-arterial coupling parameters.

Echocardiography in Prone Positioned Critically Ill Patients: A Wealth of Information from a Single View.

In critically ill patients, standard transthoracic echocardiography (TTE) generally does not facilitate good image quality during mechanical ventilation. We propose a prone-TTE in prone positioned patients, which allows clinicians to obtain a complete apical four-chamber (A-4-C) view. A basic cardiac assessment can be performed in order to evaluate right ventricle function and left ventricle performance, even measuring objective parameters, i.e., tricuspid annular plane systolic excursion (TAPSE); pulmonary artery systolic pressure (PAP), from the tricuspid regurgitation peak Doppler velocity; RV end-diastolic diameter and its ratio to left ventricular end-diastolic diameter; the S' wave peak velocity with tissue Doppler imaging; the ejection fraction (EF); the mitral annular plane systolic excursion (MAPSE); diastolic function evaluation by the mitral valve; and annular Doppler velocities. Furthermore, by tilting the probe, we can obtain the apical-five-chamber (A-5-C) view, which facilitates the analysis of blood flow at the level of the output tract of the left ventricle (LVOT) and then the estimation of stroke volume. Useful applications of this technique are hemodynamic assessment, titration of fluids, vasoactive drugs therapy, and evaluation of the impact of prone positioning on right ventricle performance and right pulmonary resistances. We believe that considerable information can be drawn from a single view and hope this may be helpful to emergency and critical care clinicians whenever invasive hemodynamic monitoring tools are not available or are simply inconvenient due to clinical reasons.

Meta-analysis of results of subvalvular repair for severe ischemic mitral regurgitation.

BACKGROUND AND AIM OF THE STUDY: The aim of this meta-analysis was to compare short- and long-term outcomes of patients undergoing mitral annuloplasty (MA) with or without papillary muscle surgery (PMS) for the treatment of ischemic mitral regurgitation (IMR). METHODS: A systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement were performed. RESULTS: Nine studies met the inclusion criteria. This meta-analysis identified 478 patients: 228 patients underwent MA alone and 250 patients underwent concomitant PMS. Early mortality was similar between two groups (odds ratio [OR] 1.14, 95% confidence interval [CI], 0.51-2.53; P = .75). PMS was associated at follow-up with a higher freedom from cardiac-related events (P = .050); moreover, although both surgical techniques had a positive impact on ventricular remodeling, the PMS group showed a significant higher reduction of left ventricle end-diastolic diameter (OR, 4.89, 95% CI, 2.77-7.01; P < .001) and left ventricle end-systolic diameter values (OR, 4.11, 95% CI, 1.98-6.24; P < .001). Finally, PMS compared with MA alone was associated with a significant reduction of recurrent mitral regurgitation at follow-up (OR, 3.25, 95% CI, 1.60-6.59; P = .001). CONCLUSIONS: This meta-analysis demonstrated superiority in terms of ventricular remodeling of a combined approach encompassing PMS and MA over MA alone in IMR. Moreover, the association of subvalvular surgery with restrictive MA decreases the incidence of mitral regurgitation recurrence and cardiac-related events at follow-up.

Viscoelastic Blood Tests Use in Adult Cardiac Surgery: Meta-Analysis, Meta-Regression, and Trial Sequential Analysis.

OBJECTIVES: Postoperative hemorrhage in cardiac surgery is a significant cause of morbidity and mortality. Standard laboratory tests fail as predictors for bleeding in the surgical setting. The use of viscoelastic (VE) hemostatic assays thromboelastography (TEG) and rotational thromboelastometry (ROTEM) could be an advantage in patients undergoing cardiac surgery. The objective of this meta-analysis was to analyze the effects (benefits and harms) of VE-guided transfusion practice in cardiac surgery patients. DESIGN: A meta-analysis of randomized trials. SETTING: For this study, PubMed, EMBASE, Scopus, and the Cochrane Collaboration database were searched, and only randomized controlled trials were included. A systematic review and meta-analysis were performed in accordance with the standards set forth by the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement, using a random-effects model. PARTICIPANTS: The study comprised adult cardiac surgery patients. INTERVENTIONS: VE-hemostatic assays transfusion algorithm compared with transfusion algorithms based on clinicians' discretion. MEASUREMENTS AND MAIN RESULTS: Seven comparative randomized controlled trials were considered, including a total of 1,035 patients (522 patients in whom a TEG- or ROTEM-based transfusion algorithm was used). In patients treated according to VE-guided algorithms, red blood cell (odds ratio 0.61; 95% confidence interval [CI]: 0.37-0.99; p: 0.04; I2: 66%) and fresh frozen plasma transfusions (risk difference 0.22; 95% CI: 0.11-0.33; p < 0.0001; I2: 79%) use was reduced; platelets transfusion was not reduced (odds ratio 0.61; 95% CI: 0.32-1.15; p: 0.12; I2 74%). CONCLUSIONS: This study demonstrated that the use of VE assays in cardiac surgical patients is effective in reducing allogenic blood products exposure, postoperative bleeding at 12 and 24 hours after surgery, and the need for redo surgery unrelated to surgical bleeding.

Sutureless Perceval Aortic Valve Versus Conventional Stented Bioprostheses: Meta-Analysis of Postoperative and Midterm Results in Isolated Aortic Valve Replacement.

BACKGROUND: Aortic stenosis is the most common valvular disease and has a dismal prognosis without surgical treatment. The aim of this meta-analysis was to quantitatively assess the comparative effectiveness of the Perceval (LivaNova) valve versus conventional aortic bioprostheses. METHODS AND RESULTS: A total of 6 comparative studies were identified, including 639 and 760 patients who underwent, respectively, aortic valve replacement with the Perceval sutureless valve (P group) and with a conventional bioprosthesis (C group). Aortic cross-clamping and cardiopulmonary bypass duration were significantly lower in the P group. No difference in postoperative mortality was shown for the P and C groups (2.8% versus 2.7%, respectively; odds ratio [OR]: 0.99 [95% confidence interval (CI), 0.52-1.88]; P=0.98). Incidence of postoperative renal failure was lower in the P group compared with the C group (2.7% versus 5.5%; OR: 0.45 [95% CI, 0.25-0.80]; P=0.007). Incidence of stroke (2.3% versus 1.7%; OR: 1.34 [95% CI, 0.56-3.21]; P=0.51) and paravalvular leak (3.1% versus 1.6%; OR: 2.52 [95% CI, 0.60-1.06]; P=0.21) was similar, whereas P group patients received fewer blood transfusions than C group patients (1.16±1.2 versus 2.13±2.2; mean difference: 0.99 [95% CI, -1.22 to -0.75]; P=0.001). The incidence of pacemaker implantation was higher in the P than the C group (7.9% versus 3.1%; OR: 2.45 [95% CI, 1.44-4.17]; P=0.001), whereas hemodynamic Perceval performance was better (transvalvular gradient 23.42±1.73 versus 22.8±1.86; mean difference: 0.90 [95% CI, 0.62-1.18]; P=0.001), even during follow-up (10.98±5.7 versus 13.06±6.2; mean difference: -2.08 [95% CI, -3.96 to -0.21]; P=0.030). We found no difference in 1-year mortality. CONCLUSIONS: The Perceval bioprosthesis improves the postoperative course compared with conventional bioprostheses and is an option for high-risk patients.

Sutureless aortic valve replacement versus transcatheter aortic valve implantation: a meta-analysis of comparative matched studies using propensity score matching.

OBJECTIVES: The aim of this meta-analysis was to compare outcomes of patients undergoing transcatheter aortic valve implantation (TAVI) with those undergoing surgical aortic valve replacement using sutureless valves. METHODS: A systematic review and meta-analysis in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement was performed. RESULTS: No randomized controlled trials were identified. Six comparative studies using propensity score matching met the inclusion criteria. This meta-analysis identified 1462 patients in that 731 patients underwent surgical aortic valve replacement using sutureless valves (SU) and 731 patients underwent a TAVI. The 30-day or in-hospital mortality was lower in the SU group [odds ratio (OR) 0.54, 95% confidence interval (CI) 0.36-0.80; P = 0.003]. In the TAVI group, the incidence of postoperative stroke was higher (OR 0.36, 95% CI 0.17-0.79; P = 0.01). The incidence of moderate or severe paravalvular regurgitation was higher in the TAVI group (OR 0.22, 95% CI 0.14-0.35; P = 0.001). There were neither differences in the postoperative renal failure (OR 1.44, 95% CI 0.46-4.58; P = 0.53) nor in the number of patients requiring postoperative pacemaker implantation (OR 1.06, 95% CI 0.54-2.08; P = 0.86). Patients in the SU group required more transfusions (OR 4.47, 95% CI 2.77-7.21; P = 0.0001), whereas those in the TAVI group had higher major vascular complications (OR 0.06, 95% CI 0.01-0.25; P = 0.0001). Intensive care unit stay was not different (mean difference 0.99, 95% CI - 1.22 to 1.40; P = 0.53). One-year survival was better in the SU group (Peto OR 0.35, 95% CI 0.18-0.67; P = 0.001), as was the 2-year survival (Peto OR 0.38, 95% CI 0.17-0.86; P = 0.001). CONCLUSIONS: Surgical aortic valve replacement using sutureless valves is associated with better early and mid-term outcomes compared with TAVI in high- or intermediate-risk patients.

May Renal Resistive Index be an early predictive tool of postoperative complications in major surgery? Preliminary results.

BACKGROUND: Patients who undergo high-risk surgery represent a large amount of post-operative ICU-admissions. These patients are at high risk of experiencing postoperative complications. Renal Resistive Index was found to be related with renal dysfunction, hypertension, and posttraumatic hemorrhagic shock, probably due to vasoconstriction. We explored whether Renal Resistive Index (RRI), measured after awakening from general anesthesia, could have any relationship with postoperative complications. METHODS: In our observational, stratified dual-center trial, we enrolled patients who underwent general anesthesia for high-risk major surgery. After awakening in recovery room (or during awakening period in subjects submitted to cardiac surgery) we measured RRI by echo-color-Doppler method. Primary endpoint was the association of altered RRI (>0.70) and outcome during the first postoperative week. RESULTS: 205 patients were enrolled: 60 (29.3%) showed RRI > 0.70. The total rate of adverse event was 27 (18.6%) in RRI ≤ 0.7 group and 19 (31.7%) in RRI > 0.7 group (P = 0.042). Significant correlation between RRI > 0.70 and complications resulted in pneumonia (P = 0.016), septic shock (P = 0.003), and acute renal failure (P = 0.001) subgroups. Patients with RRI > 0.7 showed longer ICU stay (P = 0.001) and lasting of mechanical ventilation (P = 0.004). These results were confirmed in cardiothoracic surgery subgroup. RRI > 0.7 duplicates triplicates the risk of complications, both in general (OR 2.03 93 95% CI 1.02-4.02, P = 0.044) and in cardiothoracic (OR 2.62 95% CI 1.11-6.16, P = 0.027) population. Furthermore, we found RRI > 0.70 was associated with a triplicate risk of postoperative septic shock (OR 3.04, CI 95% 1.5-7.01; P = 0.002).

Effects of fenoldopam mesylate infusion on splanchnic perfusion after myocardial revascularization on cardiopulmonary bypass: an ultrasound Doppler study.

OBJECTIVES: To measure the effects of fenoldopam mesylate infusion on splanchnic blood flow in patients undergoing myocardial revascularization with cardiopulmonary bypass. DESIGN: An experimental observational study. SETTING: A single-institution community hospital. PARTICIPANTS: Eighteen patients undergoing on-pump coronary artery bypass graft surgery. INTERVENTIONS: Fenoldopam mesylate infusion (0.1 µg/kg/min). MEASUREMENTS AND MAIN RESULTS: Blood flow through the celiac artery, superior mesenteric artery, portal vein and hepatic artery were assessed by means of Doppler measurements. The main hemodynamic variables were measured using echocardiography. The infusion of fenoldopam significantly increased the blood flow through both celiac and superior mesenteric arteries by decreasing vascular resistance. The percentage of cardiac output directed to these 2 vessels increased significantly; the increase through the superior mesenteric artery was greater compared with the celiac artery. Portal vein and hepatic artery blood flow also consistently increased. No significant variations were observed with respect to hemodynamic variables. CONCLUSIONS: The infusion of fenoldopam increased the flow through the celiac artery and superior mesenteric artery; the effect was higher for the latter. These changes did not affect the hemodynamic variables.

The effect of various fenoldopam doses on renal perfusion in patients undergoing cardiac surgery.

BACKGROUND: The hypothesis that fenoldopam mesylate, by increasing renal flow, could reduce renal damage in patients undergoing cardiac surgery with cardiopulmonary bypass has gained great interest. The aim of the current study was to quantify the relationship of the increase of the renal blood flow as a function of the fenoldopam dose in these patients and to evaluate renal flow distribution within the renal parenchyma using Doppler. METHODS: Twenty-five patients admitted to cardiac surgery have been enrolled. We used the Doppler technique to measure renal blood flow at the level of the renal, segmental, interlobar, and interlobular arteries. We calculated both the resistive and pulsatility indexes in all the renal segments. Moreover, we calculated echographically all the variables of preload, afterload, and cardiac index. Measurements were performed at baseline and after the infusion of fenoldopam mesylate at the doses of 0.05, 0.1, 0.2, and 0.3 microg x kg(-1) x min(-1). RESULTS: Fenoldopam infusion at doses more than 0.1 microg x kg(-1) x min(-1) significantly increases blood flow in all renal compartments, thus improving the resistive and pulsatility indexes starting at a dose of 0.1 microg x kg(-1) x min(-1). The highest renal flow increase is observed with 0.3 microg x kg(-1) x min(-1). Fenoldopam seems to increase the renal flow directed to the most external kidney areas. Systemic hemodynamically significant changes are observed only in patients receiving doses more than 0.1 microg x kg(-1) x min(-1). CONCLUSIONS: In hemodynamically stable patients undergoing cardiac surgery with preserved renal function, fenoldopam shows a pharmacodynamic dose-dependent profile: it significantly increases renal flow and reduces the resistances of the renal circulation starting at a dose of 0.1 microg x kg(-1) x min(-1).

Effects of fenoldopam mesylate on central hemodynamics and renal flow in patients undergoing cardiac surgery: color Doppler echocardiographic evaluation.

OBJECTIVE: The purpose of this study was to evaluate the effect of 0.1 microg/kg/min of fenoldopam mesylate on renal flow and central hemodynamics measured by echocardiography in hemodynamically stable patients with preserved renal function undergoing cardiac surgery. DESIGN: Experimental observational study. SETTING: Single-institutional community hospital study. PARTICIPANTS: Thirty patients undergoing cardiac surgery. INTERVENTION: Fenoldopam mesylate infusion (0.1 microg/kg/min) in patients undergoing cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS: Doppler measurements of renal blood flow and echocardiographic hemodynamic determinations after Doppler echocardiography measured flux velocities of the main, segmental, and interlobar and interlobular right renal arteries. The authors calculated the resistive index of all the renal segments studied. Moreover, the authors measured the flux of the main renal artery and its diameter as well as the main hemodynamic variables. All the measurements were performed in the intensive care unit setting at baseline and 20 minutes after the infusion of 0.1 microg/kg/min of fenoldopam mesylate. Fenoldopam mesylate infusion significantly increased blood flow in all renal compartments, thus improving the resistive index. The study showed that fenoldopam mesylate infusion does not induce any significant change of the heart rate or arterial pressure, cardiac output, preload, or wall stress. CONCLUSIONS: In hemodynamically stable cardiac surgery patients with preserved renal function, an infusion of 0.1 microg/kg/min of fenoldopam mesylate has no influence on systemic hemodynamics while increasing renal blood flow.

Desflurane preconditioning in coronary artery bypass graft surgery: a double-blinded, randomised and placebo-controlled study.

BACKGROUND: Recent clinical and experimental data indicate that volatile anaesthetics may precondition myocardium against ischaemia and infarction. The present clinical trial was designed to verify the cardioprotective effects of desflurane in patients undergoing elective coronary artery bypass surgery. It was hypothesized that desflurane preconditioning would decrease postoperative release of troponin I and brain natriuretic peptide (NT-proBNP). Besides, we have hypothesized that desflurane preconditioning would preserve the myocardium from the dysfunction following cardioplegic arrest. METHODS: Twenty-eight patients were randomly divided into two groups: Control group (14 patients) and Desflurane group (14 patients). In Desflurane group (DS) patients, preconditioning was elicited after the onset of cardiopulmonary bypass via a 5-min exposure to desflurane (2.5 minimum alveolar concentration), followed by a 10-min washout before aortic cross-clamping and cardioplegic arrest. The control group (C) patients underwent an equivalent period (15 min) of pre-arrest desflurane-free bypass. Haemodynamic measurements were obtained at six different times. The biochemistry markers of cellular damage and myocardial dysfunction (troponin I, NT-proBNP) were determined. Left ventricular (LV) function was assessed using tissue Doppler imaging (TDI) of mitral annulus. Two-factor repeated-measures analysis of variance was used to evaluate differences over time between groups for all parameters determined in plasma samples and for all TDI-derived variables. RESULTS: After surgery, both the troponin I values (2.04+/-1.09 ng/ml vs 1.44+/-0.77 ng/ml, p<0.01 after 24h and 1.62+/-0.96 ng/ml vs 1.00+/-0.24 ng/ml, p<0.01 after 72 h respectively) and those of the NT-proBNP (2187+/-282.9 ng/l vs 885.4+/-117.35 ng/l, p<0.01 after 24h and 3097.9+/-226.2 vs 1393.6+/-312.07 ng/l, p<0.01 after 72 h respectively) were less in the desflurane-treated patients. The values of TDI of mitral annulus were constantly better in desflurane-treated patients. CONCLUSIONS: We can conclude that the use of desflurane in these patients provides a pharmacological preconditioning so as to reduce myocardial necrosis and improve the cardiac performance in the postoperative period.

Prevention of pouch dilatation after laparoscopic adjustable gastric banding.

BACKGROUND: The major long-term complication of laparoscopic adjustable gastric banding (LAGB) is dilatation of the gastric pouch, that is reported with a frequency ranging from 1 to 25%, and often requires removal of the band. In addition to the usual recommendations of bariatric surgery centers and dietetic advice to prevent this complication, over the last 4 years we introduced a technical modification of the procedure. METHODS: From Nov 1993 to Dec 2004, 684 morbidly obese patients underwent adjustable gastric banding, 83 patients by open surgery and 601 patients by laparoscopy. The first 323 patients (group A) were operated by the perigastric approach, and 57 patients (group B) were operated by the pars flaccida approach. Since Dec 2000, 304 patients (group C) were operated with a modified pars flaccida technique, which consisted in suturing the gastric lesser curvature below the band with one or two stitches to the right phrenic crus to secure the band in place. RESULTS: In group A, the most important late complication was irreversible dilatation of the gastric pouch, which occurred in 35 patients (10.8%), and required removal of the band in 30 cases and replacement in 5. In group B, there were 3 pouch dilatations (5.2%). In group C, only 4 dilatations occurred (1.31%), which required 3 band removals and 1 band replacement. CONCLUSION: Dilatation of the gastric pouch appears to be dramatically reduced by our minor technical modification of band placement.

Multivessel distal sutureless off-pump coronary artery bypass grafting procedure using magnetic connectors.

Proximal anastomotic devices for beating heart coronary artery bypass grafting (CABG) have been developed to avoid ascending aortic manipulation. Distal anastomotic devices may become an extremely useful tool to assist in enabling minimally invasive (robotic) multivessel CABG. As a transition phase toward this ultimate goal we have been using a distal anastomotic device for the left internal mammary artery-left anterior descending artery (LIMA-LAD) anastomosis. In addition we recently performed two off-pump coronary artery bypass procedures that were distally completely sutureless.