Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first International Consensus Conference on this topic. The consensus was a continuous international internet-based process with a final meeting on 28 June 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons, and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting, and ranking. Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, the use of pre-operative intra-aortic balloon counterpulsation, and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. This International Consensus Conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic ß-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Acute renal failure in the patient undergoing cardiac operation. Prevalence, mortality rate, and main risk factors.

A total of 775 consecutive patients who survived the first 24 hours after cardiac operation were prospectively studied to assess the prevalence, mortality rate, and main risk factors for development of new acute renal failure. Normal renal function before operation (serum creatinine level less than 1.5 mg/dl) was registered in 734 (94.7%) patients. Of these, 111 (15.1%) showed a postoperative renal complication including 84 (11.4%) classified as renal dysfunction (serum creatinine level between 1.5 and 2.5 mg/dl) and 27 (3.7%) as acute renal failure (serum creatinine level higher than 2.5 mg/dl). The mortality rate was 0.8% in normal patients, 9.5% in patients with renal dysfunction, and 44.4% when acute renal failure developed (p < 0.0001). Indeed, the renal impairment proved to be an independent predictor of mortality (p < 0.001), along with the infective (p < 0.001), gastrointestinal (p < 0.001), and cardiovascular (p < 0.05) complications. Multivariate analysis identified the following variables as independent risk factors for postoperative renal impairment: use of intraaortic balloon pump (p < 0.0001), need for deep hypothermic circulatory arrest (p < 0.005), low-output syndrome (p < 0.005), advanced age (p < 0.005), need for emergency operation (p < 0.025), and low urinary output during cardiopulmonary bypass (p < 0.05). The 41 patients (5.3%) with preoperative renal failure showed a significantly higher morbidity and mortality rate than those without renal complications before operation. We conclude that in patients undergoing cardiac operation without preexisting renal dysfunction the likelihood of severe renal complications is reasonably low, but the associated mortality remains high. A prominent role in the development of postoperative acute renal failure must be recognized for preoperative, intraoperative, and postoperative hemodynamic factors, whereas cardiopulmonary bypass seems to be of lesser importance in this respect.

Cardiac cachexia: preoperative and postoperative nutrition management.

The present study examined the hemodynamic and metabolic effects of nutrition support in patients with malnutrition secondary to severe mitral valve disease and congestive heart failure. Pulmonary artery pressure measurements, echocardiographic studies, gas exchange measurements, immune function tests, and clinical evaluations were made on hospitalized patients 2 weeks before and 3 weeks after surgery for valve replacement or annuloplasty. All patients received a total daily energy intake of 20 to 30 kcal/kg, four of the patients preoperatively as a combination of oral food plus parenteral nutrition and these four patients plus two additional patients as only parenteral nutrition in the early postoperative period. All six patients received nutrition support as oral food plus parenteral nutrition in the late postoperative period. Compared with baseline, nutrition support was associated with stable hemodynamic function, unchanged whole-body oxygen consumption and carbon dioxide production, and improved clinical indices both before and after surgery. Comprehensive hemodynamic, metabolic, and clinical studies thus indicate that acceptable levels of nutrition support can be provided to malnourished patients with severe congestive heart failure, which improves their clinical status and does not adversely influence cardiac function.

Autologous pericardium annuloplasty: a "physiological" mitral valve repair.

AIM: Autologous pericardium annuloplasty (APA) is an alternative to prosthetic ring implantation for mitral valve (MV) repair, avoiding the use of foreign material and preserving the mitral annulus' physiological motion. However, data on durability are questionable. Therefore, we analyzed long-term outcomes of treating degenerative mitral regurgitation (MR) with APA. METHODS: Four hundred ninety patients (mean age, 54.3±11.3 years, [15-77 years]; N.=360 men [74.1%]) who had undergone APA and neochordae implantation between July 1988 and December 2006 were retrospectively studied. RESULTS: MR was purely degenerative in 434 (89.3%) patients; endocarditis was present in 44 (9.1%) patients; an anterior, posterior, or bileaflet prolapse was present in 32 (6.6%), 241 (49.6%), and 213 (43.8%) patients, respectively. Clinical follow-up was 100% complete at a median of 6.5 years (5th percentile, 0.9; 95th percentile, 14.9) with an echocardiographic study in 92% of patients. In-hospital mortality was 1% (5 deaths); overall and late cardiac mortality were 7.6% and 3.9% (37 and 19 deaths), respectively. Kaplan-Meier curves for overall survival, late cardiac survival, and freedom from reoperation at 15 years (20 cases) were 86% (95%CI 80-91), 93% (95%CI 88-96), and 93% (95%CI 88-96), respectively. At 15 years, freedom from recurrent MR (28 patients) and endocarditis (6 events) were 86% (95%CI 76-91) and 97% (95%CI 92-99). Dehiscence, significant calcification of APA, and hemolysis never occurred. At reoperations, annular pericardium appeared covered by a smooth layer of tissue. CONCLUSION: APA is feasible, safe, and cost-effective, providing long-term durability, high survival, and a low rate of valve-related complications.

Mortality reduction in cardiac anesthesia and intensive care: results of the first International Consensus Conference.

BACKGROUND: There is no consensus on which drugs/techniques/strategies can affect mortality in the perioperative period of cardiac surgery. With the aim of identifying these measures, and suggesting measures for prioritized future investigation we performed the first international consensus conference on this topic. METHODS: The consensus was a continuous international internet-based process with a final meeting on June 28th 2010 in Milan at the Vita-Salute University. Participants included 340 cardiac anesthesiologists, cardiac surgeons and cardiologists from 65 countries all over the world. A comprehensive literature review was performed to identify topics that subsequently generated position statements for discussion, voting and ranking. RESULTS: Of the 17 major topics with a documented mortality effect, seven were subsequently excluded after further evaluation due to concerns about clinical applicability and/or study methodology. The following topics are documented as reducing mortality: administration of insulin, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, the use of preoperative intra-aortic balloon counterpulsation and referral to high-volume centers. The following are documented as increasing mortality: administration of aprotinin and aged red blood cell transfusion. These interventions were classified according to the level of evidence and effect on mortality and a position statement was generated. CONCLUSION: This international consensus conference has identified the non-surgical interventions that merit urgent study to achieve further reductions in mortality after cardiac surgery: insulin, intra-aortic balloon counterpulsation, levosimendan, volatile anesthetics, statins, chronic beta-blockade, early aspirin therapy, and referral to high-volume centers. The use of aprotinin and aged red blood cells may result in increased mortality.

Fluid responsiveness and right ventricular function in cardiac surgical patients. A multicenter study.

INTRODUCTION: We investigated fluid responsiveness in a population of patients undergoing coronary artery revascularization, with respect to their right ventricular ejection fraction. MATERIALS AND METHODS: This was a multicenter trial involving 11 cardiac surgical Institutions and 65 patients undergoing elective coronary artery revascularization. Hemodynamic parameters were measured before and after volume expansion using a modified pulmonary artery catheter and transesophageal echocardiographic monitoring. Patients demonstrating an increase of stroke volume >20% after volume expansion were considered as responders. Volume expansion with 7 ml/kg of plasma expander was performed when required on a clinical basis. RESULTS: In the overall population, only the change in aortic blood velocity (cut-off 13%) was a predictor of fluid responsiveness. In patients with a reduced (<0.3) right ventricular ejection fraction only the value of mean pulmonary arterial pressure was predictive of fluid responsiveness (cut-off 18 mmHg). Patients with right ventricular ejection fraction ≥0.3 demonstrated three predictors: changes in aortic blood velocity (cut-off 15%), right ventricular end diastolic volume index (cut-off 80 ml/m(2)), and left ventricular end diastolic area index (cut-off 9 cm(2)/m(2)). CONCLUSIONS: When right ventricular systolic function is depressed, the right ventricle inability to fill the left chambers results in a lack of the left-sided responsiveness predictors. When the right ventricular systolic function is preserved, all the classical fluid responsiveness predictors are confirmed. Right ventricular function is therefore to be always considered when addressing the problem of fluid responsiveness.

Surgical treatment of left-ventricular outflow-tract obstruction guided by intraoperative transesophageal echocardiography.

Transesophageal echocardiography may provide additional morphologic information in many cases of cardiovascular disease when compared with the traditional transthoracic approach. In our department 3 male patients underwent surgical treatment with preoperative diagnosis of left-ventricular outflow-tract obstruction. We describe the intraoperative transesophageal echocardiographic findings and in which way they guided the surgical strategy.

[Noninvasive hemodynamic (bioimpedance) evaluation during short anesthesia with propofol]. / Valutazione emodinamica incruenta (bioimpedenza) in corso di anestesia breve con propofol.

The hemodynamic effects of propofol (3 mg/kg) during anesthetic management of 10 patients undergoing minor urologic procedures were evaluated by noninvasive thoracic electrical bioimpedance method. Cardiac output, cardiac index, systolic and diastolic arterial blood pressures and EVI/TFI (an index of myocardial function) decreased significantly in ten minutes from starting of propofol injection, while the heart rate remained unchanged.

Fatal progression of Behçet's disease after cardiac surgery.

The authors describe a patient affected with Behçet's disease who developed, after cardiac surgery, acute clinical manifestations of the syndrome and died of a generalized infection. They also discuss the clinical aspects, the particular clinical course, and the therapy of the disease.