Left Atrial to Femoral Artery Full Cardiopulmonary Bypass: A Novel Technique for Descending and Thoracoabdominal Aortic Surgery.

Left atrial-femoral artery (LA-FA) bypass with a centrifugal pump and no oxygenator is commonly used for descending and thoracoabdominal aortic (DTAA) operations, mitigating the deleterious effects of cross-clamping. We present our initial experience performing DTAA replacement under LA-FA (left-to-left) cardiopulmonary bypass (CPB) with an oxygenator. DTAA replacement under LA-FA bypass with an oxygenator was performed in 14 consecutive patients (CPB group). The pulmonary vein and femoral artery (or distal aorta) were cannulated and the full CPB machine were used, including oxygenator, roller pump, pump suckers, and kinetically enhanced drainage. The CPB group was compared with 50 consecutive patients who underwent DTAA replacement utilizing traditional LA-FA bypass without an oxygenator (LA-FA group). Perioperative data were collected and statistical analyses were performed. All CPB patients maintained superb cardiopulmonary stability. The pump sucker permitted immediate salvage and return of shed blood. Superb oxygenation was maintained at all times. High-dose full CPB heparin was reversed without difficulty. The CPB group required markedly fewer blood transfusions than the LA-FA group (2.21 vs. 5.88 units, p < 0.004). The 30-day mortality rate was 7.1% ( n = 1) and there were no paraplegia cases in the CPB group versus 7 (14%) deaths and 3 (6%) paraplegia cases in the LA-FA group. Traditional LA-FA bypass without an oxygenator avoids high-dose heparin. In the present era, heparin reversal is more secure. Our experience finds that the novel application of LA-FA CPB with an oxygenator is safe and suggests improved hemodynamics (immediate return of shed blood) and a hemostatic advantage (avoidance of loss of coagulation factors in the cell saver).

US National Trends in the Management and Outcomes of Constrictive Pericarditis: 2005-2014.

BACKGROUND: Patient characteristics, trends in the management strategy, and outcomes of patients with constrictive pericarditis have not been characterized at the national scale. METHODS: Annual trends of patients admitted to hospitals in the United States with constrictive pericarditis were evaluated using the National Inpatient Sample dataset between 2005 and 2014. Poisson regression models adjusting for the US census population estimate were fitted to evaluate trends in the incidence of constrictive pericarditis, isolated pericardiectomy, and cardiopulmonary bypass (CPB) use. Descriptive analyses were performed to compare patient characteristics and in-hospital mortality rates between surgically and medically managed cohorts. RESULTS: During 2005-2014, 29,487 patients were admitted with constrictive pericarditis. Sixteen percent underwent isolated pericardiectomy. The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million, but proportion of patients undergoing isolated pericardiectomy decreased from 18% in 2005 to 15% in 2014 (P = 0.001 for trend). CPB use increased from 15% to 29% (P < 0.001). Compared with medically managed patients, the pericardiectomy cohort was younger (age 57 vs 61 years, P < 0.001), less likely to be female (25% vs 41%, P < 0.001), and harboured fewer comorbidities. In-hospital mortality was 7.3% for those undergoing pericardiectomy and 6.8% for a medically managed cohort (P = 0.58) and operative mortality was stable across years (P = 0.99 for trend). CONCLUSIONS: The prevalence of constrictive pericarditis remained stable between 2005 and 2014 at 9-10 cases per million. Surgical management was infrequent, with younger and less comorbid patients being more likely to be managed operatively. Increasing use of CPB without a change in operative mortality highlights the persisting challenge of this complex disease.

Predictors of Cardiac Surgery Patients Who Tolerate Blood Conservation in Cardiac Surgery.

BACKGROUND: Whether there is a cardiac surgical patient population that does not incur harm from blood conservation is unknown. This study aimed to identify patient characteristics associated with patients who safely tolerate blood conservation. METHODS: We conducted a retrospective review of consecutive patients undergoing isolated coronary artery bypass graft surgery or isolated aortic valve replacement, or concomitant coronary artery bypass graft surgery and aortic valve replacement between 2011 and 2016, during which blood conservation intervention took place. Logistic regression derived from the preintervention cohort was applied to the postintervention cohort to identify patient characteristics associated with those predicted to be transfused in the preintervention era but were not in the postintervention era. RESULTS: In this series of 2,701 adult patients undergoing cardiac operations, blood conservation intervention in 2014 led to a 52% reduction in red blood cell transfusion. Between preintervention and postintervention cohorts, there was no significant difference in the measured outcomes. A regression model derived from the preintervention cohort was applied to the postintervention cohort to identify predictors of cohort that do not derive benefit from liberal transfusion. This model demonstrated such patient characteristics to be age more than 75 years (odds ratio [OR] 1.71, 95% confidence interval [CI]: 1.09 to 2.68, p = 0.033), body mass index less than 30 kg/m2 (OR 1.5, 95% CI: 1.02 to 2.20, p = 0.044), lowest intraoperative hematocrit between 22 and 25 (OR 1.77, 95% CI: 1.16 to 2.68, p < 0.001), and cardiopulmonary bypass use (OR 4.50, 95% CI: 2.25 to 9.01, p < 0.001). CONCLUSIONS: Blood conservation can successfully yield reduction in perioperative blood product use, with associated decrease in the risk of postoperative renal failure. A select patient population who may tolerate blood conservation safely was identified, and that may guide a targeted blood conservation effort.

Extracorporeal life support for pandemic influenza: the role of extracorporeal membrane oxygenation in pandemic management.

The recent global threat of a severe pandemic influenza outbreak has suggested that extracorporeal life support will begin to play an evolving role in the care of critically ill influenza stricken patients. The highly communicable attributes of influenza could result in widespread infection and an associated increased need for advanced life support. Supply and demand equilibrium may be abruptly disrupted, and ethical decisions regarding the allocation of life saving resources will inevitably need to be made. Protocol oriented planning, research analysis, and advanced technologies are critical factors in averting catastrophe. This review article details the epidemiology, diagnostic techniques, and interventions for the influenza A virus, including H1N1.