Levosimendan in aortic valve surgery: cardiac performance and recovery.

OBJECTIVE: The aim of the present study was to test the hypothesis that levosimendan has beneficial effects on cardiac performance and that the need for other vasoactive medications during and after cardiac surgery would be reduced by levosimendan in patients with severe aortic stenosis (AS) and left ventricular (LV) hypertrophy. DESIGN: A prospective, randomized, double-blind, placebo-controlled clinical study. SETTING: A university hospital. PARTICIPANTS: Twenty-four patients scheduled for aortic valve surgery with or without coronary artery bypass graft surgery were enrolled in the study. INTERVENTIONS: Twelve patients received a 24-hour levosimendan infusion (0.2 microg/kg/min) beginning after the induction of anesthesia, and 12 patients received a placebo infusion. MEASUREMENTS AND MAIN RESULTS: Left ventricular ejection fraction, measured before study drug infusion, was lower in the treatment group than in the control group (42% v 54%, p = 0.015). After sternum closure, the ejection fraction dropped in the control group but was maintained at the same level in the treatment group (45% v 48%, not significant). Mixed venous and central venous saturations were significantly lower in the treatment group than in the control group at the baseline, but after the beginning of the study drug infusion, the groups were similar throughout the rest of the follow-up period. The treatment group required more norepinephrine during the operation and less nitroprusside postoperatively. CONCLUSIONS: Low output is a result of myocardial stunning and is common after cardiopulmonary bypass. According to the present results, levosimendan may be useful in patients with severe AS and LV hypertrophy because it may prevent LV function from dropping to a critically low level postoperatively. Levosimendan causes vasodilation and thereby decreases mean arterial pressure, but this can be controlled with the use of norepinephrine.

Hypertonic saline-hydroxyethyl starch solution attenuates fluid accumulation in cardiac surgery patients: a randomized controlled double-blind trial.

BACKGROUND: Significant fluid retention is common after cardiac surgery with the use of cardiopulmonary bypass (CPB). The aim of the study was to evaluate the effects of hypertonic saline-hydroxyethyl starch (HS-HES) solution on fluid accumulation in patients undergoing coronary artery bypass grafting surgery (CABG). METHODS: Fifty adult male patients undergoing coronary bypass surgery were enrolled in this interventional, randomized, double-blinded study to compare HS-HES with saline solution. The study fluid (250 mL) was given into the venous reservoir of the CPB circuit at the time of aortic declamping. RESULTS: Body mass change from the baseline to the first postoperative morning was significantly less in the HS-HES group compared with the control group (3.3 ± 1.5 kg vs. 4.4 ± 1.5 kg, P = 0.022). In the extracellular water (ECW) or ECW-balance, there were no significant differences between the groups. The need for fluids and diuretic medication did not differ between the groups during the perioperative period. CONCLUSIONS: Our study shows that 250 mL of HS-HES solution can reduce perioperative fluid accumulation to some degree in patients undergoing CABG surgery with CPB.

Improved cognitive flexibility after aortic valve replacement surgery.

OBJECTIVES: Aortic valve replacement (AVR) surgery is associated with potential risk to cerebral injury. On the other hand, improved cardiovascular functioning after the surgery may have positive impact on brain health. The aim of this preliminary study was to investigate the impact of AVR surgery on cognition, specifically on higher cognitive control functions, i.e. executive functions, that are typically implicated in cognitive decline due to vascular origin. METHODS: Patients (n = 16) undergoing elective AVR surgery due to aortic stenosis were recruited and their cognitive performance was assessed using a computer-based Executive Reaction Time (RT) test. Testing was performed 1 day prior to AVR surgery and ∼3 months after the surgery. In addition, the Behavior Rating Inventory of Executive Function-Adult Version (BRIEF-A) was used to assess everyday challenges in executive functions and self-regulation. Patient's postoperative test results were compared with each patient's preoperative results to determine changes in executive functions. RESULTS: Subjects' overall cognitive performance improved after AVR surgery. After surgery, patients responded in the Executive RT test more accurately with the same response speed (change from 297 to 298 ms). Their overall probability to commit an error (total errors) was reduced by 47%, reflecting improved executive functions in general (OR = 0.53, 95% CI = 0.46-0.59, error rate change from 44.8 to 28.0%). Furthermore, one key component of executive functions, inhibitory control, was improved after AVR surgery. This was seen in reduced probability of failing to withhold a response, i.e. making a commission error, by 89% (OR = 0.11, CI = 0.08-0.16, error rate change from 11.8 to 2.6%). The probability of missing a response was reduced by 48%, reflecting improved attention (OR = 0.52, 0.44-0.64, error rate change from 18.1 to 11.0%). No statistically significant differences in BRIEF-A scores were found. CONCLUSIONS: There was a marked improvement in cognitive performance following AVR surgery, specifically in executive control functions indicating improved cognitive flexibility. Cognitive improvement, as opposed to the typical trajectory of cognitive decline in an elderly population with vascular disease, emphasizes the importance of these results and points to AVR surgery as having potential benefits on brain health in general. CLINICAL TRIALS IDENTIFIER: NCT01953068. https://www.clinicaltrials.gov/ct2/show/NCT01953068?term=NCT01953068&rank=1.

Cystatin C in diabetics as a marker of mild renal insufficiency after CABG.

PURPOSE: The purpose of this study was to evaluate the accuracy of plasma cystatin C in acute impairment in renal function; plasma cystatin C was compared to plasma creatinine in two hundred patients undergoing elective CABG surgery. METHODS: We performed a prospective clinical study of two hundred patients undergoing coronary bypass surgery. Plasma creatinine and cystatin C were measured preoperatively and on the first and fourth days after surgery. Estimated glomerular filtration rate (GFR) was calculated using one creatinine-based and two cystatin C-based equations. RESULTS: There were 144 non-diabetic and 56 diabetic patients. The need for furosemide was more common among diabetics (80.4% of the patients vs. 53.9%, p = 0.024). Changes in cystatin C-based GFR with both equations were significantly greater in the group of diabetics (-14.3 ± 28.0 and -11.2 ± 19.3 ml/min/1.73 m(2) vs. -4.3 ± 26.9 and -3.1 ± 20.5 ml/min/1.73 m(2), p = 0.025 and 0.016, respectively). Changes in creatinine-based GFR did not differ between the diabetics and the non-diabetics. CONCLUSION: Cystatin C and cystatin C-based estimation of GFR may be useful and more sensitive than creatinine in detecting mild acute renal insufficiency in diabetic patients.

Risk indicators for varicose veins in forty- to sixty-year-olds in the Tampere varicose vein study.

The objectives of the study were to discover the main determinants for the prevalence of varicose veins in a general population, and to assess the possibilities for prevention of this common surgical disease. Varicose veins were evaluated in three defined cohorts of 3284 men and 3590 women aged 40, 50, and 60 years by using a validated questionnaire. The response rate was 75% among men and 86% among women, and varicose veins were determined by self-assessment. Increasing age, female sex, childbirths, standing posture at work, higher weight or height, and positive family history were significantly associated with varicose veins in a univariate analysis. These factors were further taken into a multivariate logistic regression analysis, and female gender (adjusted odds ratio, OR 2.2), increasing age (OR 2.2-2.8), a reported positive family history for varicose veins (OR 4.9), increasing number of births (OR 1.2-2.8), standing posture at work (OR 1.6), and higher weight (OR 1.2) and height (OR 1.4) were found to independent and significant risk indicators of varicose veins. Increasing age, positive family history of varicose veins, and child-births in women were the most important factors in terms of population etiologic fractions. Familial predisposition and pregnancy-related factors bear important associations with varicose veins. Thus prevention of varicose veins appears to be difficult. Varicose veins are nonlethal and, therefore, higher age is related to higher prevalence.