High-dose adenosine versus saline-induced cardioplegic arrest in coronary artery bypass grafting: A randomized double-blind clinical feasibility trial.

BACKGROUND AND OBJECTIVE: In this clinical trial, we evaluated if a short-acting nucleoside, adenosine, as a high-dose bolus injection with blood cardioplegia induces faster arrest and provides better myocardial performance in patients after bypass surgery for coronary artery disease. METHODS: Forty-three patients scheduled for elective or urgent coronary artery bypass grafting were prospectively recruited in two-arm 1:1 randomized parallel groups to either receive 20 mg of adenosine (in 21 patients) or saline (in 22 patients) into the aortic root during the first potassium-enriched blood cardioplegia infusion. The main outcomes of the study were ventricular myocardial performance measured with cardiac index, right ventricular stroke work index, and left ventricular stroke work index at predefined time points and time to asystole after a single bolus injection of adenosine. Conventional myocardial biomarkers were compared between the two groups at predefined time points as secondary endpoints. Electrocardiographic data and other ad hoc clinical outcomes were compared between the groups. RESULTS: Compared with saline, adenosine reduced the time to asystole (68 (95% confidence interval (95% CI) = 37-100) versus 150 (95% CI = 100-210) seconds, p = 0.005). With myocardial performance, the results were inconclusive, since right ventricular stroke work index recovered better in the adenosine group (p = 0.008), but there were no significant overall differences in cardiac index and left ventricular stroke work index between the groups. Only the post-cardiopulmonary bypass cardiac index was better in the adenosine group (2.3 (95% CI = 2.2-2.5) versus 2.1 (95% CI = 1.9-2.2) L/min/m2, p = 0.016). There were no significant differences between the groups in cardiac biomarker values. CONCLUSIONS: A high dose adenosine bolus at the beginning of the first cardioplegia infusion resulted in significantly faster asystole in coronary artery bypass grafting patients but enhanced only partially the ventricular performance.EudraCT number: 2014-001382-26. https://www.clinicaltrialsregister.eu/ctr-search/trial/2014-001382-26/FI.

Anti-factor X activity levels with continuous intravenous infusion and subcutaneous administration of enoxaparin after coronary artery bypass grafting: A randomized clinical trial.

BACKGROUND: Low-molecular-weight heparin enoxaparin is widely used in pharmacological thromboprophylaxis after coronary artery bypass grafting (CABG). The aim of this study was to compare anti-factor X activity (anti-Xa) levels when the thromboprophylactic dose of enoxaparin was provided after CABG, with two different administration routes: continuous intravenous infusion (CIV) and subcutaneous bolus (SCB) injection. We hypothesized that the current standard method of SCB administration might lead to lower anti-Xa levels than recommended in other patient groups, due to reduced bioavailability. METHODS: In this prospective, randomized, controlled clinical trial, 40 patients scheduled for elective CABG were randomized to receive 40 mg of enoxaparin per day either as CIV or SCB for 72 h. Enoxaparin was initiated 6-10 h after CABG. Anti-Xa levels were measured 12-14 times during the study period. The primary outcome, that is, the maximum anti-Xa concentration over 0-24 h (Cmax0-24h ), was calculated from these measured values. Secondary outcomes were Cmax25-72h and the trough concentration of anti-Xa after 72 h of enoxaparin initiation (C72h ). RESULTS: Twenty patients were randomized to the CIV-group and 19 to the SCB-group. The median anti-Xa Cmax0-24h was significantly lower in the CIV-group than in the SCB-group: 0.15 [interquartile range (IQR) 0.13-0.19] IU/ml versus 0.25 (IQR 0.18-0.32) IU/ml, p < .005. The median anti-Xa Cmax25-72h was 0.12 (IQR, 0.1-0.17) IU/ml versus 0.23 (IQR 0.19-0.31) IU/ml, respectively, p < .005. At 72 h, there was no difference between the groups in their anti-Xa levels. CONCLUSIONS: In this low-risk CABG patient population, SCB administration of a thromboprophylactic dose of enoxaparin provided anti-Xa levels that are considered sufficient for thromboprophylaxis in other patient groups. CIV administration resulted in lower anti-Xa levels compared to the SCB route.

The duration of mediastinal chest tube drainage is not associated with postoperative pain or opioid consumption after cardiac surgery.

Objectives. Mediastinal chest tubes are considered to be a significant factor causing postoperative pain after cardiac surgery. The aim of the study was to ascertain whether the duration of mediastinal drainage is associated with postoperative pain and opioid consumption. Design. A total of 468 consecutive patients undergoing cardiac surgery at the Tampere University Hospital between December 2015 and August 2016 were retrospectively analyzed. The first 252 patients were treated according to short and the following 216 patients according to extended drainage protocol, in which the mediastinal chest tubes were habitually removed on the first and second postoperative day, respectively. The oxycodone hydrochloride consumption, as well as daily mean pain scores assessed by numeric/visual rating scales, were compared between the groups. Results. The mean daily pain scores and cumulative opioid consumption were similar in both groups. Patients with reduced ejection fraction, diabetes, and peripheral vascular disease reported lower initial pain scores. The median cumulative oxycodone hydrochloride consumption did not differ according to the drainage protocol but was higher in males, smokers, and after aortic surgery. In contrast, patients with advanced age, hypertension, and peripheral vascular disease had lower consumption. In multivariable analysis, male sex and aortic surgery were associated with higher and advanced age with lower opioid use. Conclusions. The length of mediastinal chest tube drainage is not associated with the amount of postoperative pain or need for opioids after cardiac surgery. Male sex and aortic surgery were associated with higher and advanced age with lower overall opioid consumption.

Early postoperative statin administration does not affect the rate of atrial fibrillation after cardiac surgery.

OBJECTIVES: Postoperative atrial fibrillation is the most frequent complication after cardiac surgery, and the use of statins in preventing them is being extensively studied. The aim of this study was to investigate whether a pause in the administration of statins affects the occurrence of atrial fibrillation after cardiac surgery in a prospective randomized and controlled setting. METHODS: A total of 301 patients without chronic atrial fibrillation with prior statin medication scheduled for elective or urgent cardiac surgery involving the coronary arteries and/or heart valves were prospectively recruited and randomized for statin re-initiation on either the first (immediate statin group) or the fifth (late statin group) postoperative day, using the original medication and dosage. The immediate statin group comprised 146 patients and the late statin group 155 patients. Except for a somewhat higher rate of males (85% vs 73%, P = 0.016) in the immediate statin group, the baseline characteristics and the distribution of procedures performed within the groups were comparable. The occurrence of postoperative atrial fibrillation and the clinical course of the patients were compared between the groups. RESULTS: The incidence of atrial fibrillation was 46% and the median delay after surgery before the onset of atrial fibrillation was 3 days in both groups (P = NS). No differences were observed in the frequency of the arrhythmia in any subgroup analyses or in other major complications or clinical parameters. No adverse effects related to early statin administration were detected. CONCLUSIONS: Early re-initiation of statins does not appear to affect the occurrence of postoperative atrial fibrillation. CLINICAL TRIAL REGISTRATION: European Union Drug Regulating Authorities Clinical Trials Database (EudraCT)-2016-001655-44.

The significance of bicuspid aortic valve after surgery for acute type A aortic dissection.

OBJECTIVE: Decision-making concerning the extent of the repair of acute type A aortic dissection (ATAAD) includes functional and anatomical assessment of the aortic valve. We hypothesized that bicuspid aortic valve (BAV) does not impact outcome after surgery for ATAAD. We therefore evaluated the outcome after ATAAD surgery in relation to the presence of BAV, acute aortic regurgitation (AR), and surgical approach, using the Nordic Consortium for Acute Type A Aortic Dissection database. METHODS: Eight participating Nordic centers collected data from 1122 patients undergoing ATAAD surgery during the years 2005 to 2014. Early complications, reoperations and survival were compared between patients with BAV and tricuspid aortic valves (TAV) before and after propensity score matching for sex, age, AR, organ malperfusion, hemodynamic instability, and site of the tear. Mean follow-up (range) for patients with TAV and BAV was 3.1 years (0-10.4 years) and 3.2 years (0-9.0 years), respectively. RESULTS: Altogether, 65 (5.8%) of the patients had BAV. Root replacement was more frequently performed in the BAV as compared with the TAV group (60% vs 23%, P < .001). Survival, however, did not differ significantly between patients with BAV or TAV, either before (P = .230) or after propensity score-matching (P = .812). Even so, in cohort as a whole, patients presenting with AR had less favorable survival. CONCLUSIONS: Early and mid-term survival did not differ significantly between patients with BAV and TAV.

Is There a Weekend Effect in Surgery for Type A Dissection?: Results From the Nordic Consortium for Acute Type A Aortic Dissection Database.

BACKGROUND: Aortic dissection type A requires immediate surgery. In general surgery populations, patients operated on during weekends have higher mortality rates compared with patients whose operations occur on weekdays. The weekend effect in aortic dissection type A has not been studied in detail. METHODS: The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) registry includes data for 1,159 patients who underwent type A dissection surgery at 8 Nordic centers during 2005 to 2014. This study is based on data relating to surgery conducted during weekdays versus weekends and starting between 8:00 am and 8:00 pm ("daytime") versus from 8:00 pm to 8:00 am ("nighttime"), as well as time from symptoms, admittance, and diagnosis to surgery. The influence of timing of surgery on the 30-day mortality rate was assessed using logistic regression analysis. RESULTS: The 30-day mortality was 18% (204 of 1,159), with no difference in mortality between surgery performed on weekdays (17% [150 of 889]) and on weekends (20% [54 of 270], p = 0.45), or during nighttime (19% [87 of 467]) versus daytime (17% [117 of 680], p = 0.54). Time from symptoms to surgery (median 7.0 hours vs 6.5 hours, p = 0.31) did not differ between patients who survived and those who died at 30 days. Multivariable regression analysis of risk factors for 30-day mortality showed no weekend effect (odds ratio, 1.04; 95% confidence interval, 60.67 to 1.60; p = 0.875), but nighttime surgery was a risk factor (odds ratio, 2.43; 95% confidence interval, 1.29 to 4.56; p = 0.006). CONCLUSIONS: The 30-day mortality in surgical repair of aortic dissection type A was not significantly affected by timing of surgery during weekends versus weekdays. Nighttime surgery seems to predict increased 30-day mortality, after correction for other risk factors.

Malperfusion in acute type A aortic dissection: An update from the Nordic Consortium for Acute Type A Aortic Dissection.

OBJECTIVES: To evaluate the effect of preoperative malperfusion on 30-day and late mortality and postoperative complications using data from the Nordic Consortium for Acute Type A Aortic Dissection (ATAAD) registry. METHODS: We studied 1159 patients who underwent ATAAD surgery between January 2005 and December 2014 at 8 Nordic centers. Multivariable logistic and Cox regression analyses were performed to identify independent predictors of 30-day and late mortality. RESULTS: Preoperative malperfusion was identified in 381 of 1159 patients (33%) who underwent ATAAD surgery. Thirty-day mortality was 28.9% in patients with preoperative malperfusion and 12.1% in those without. Independent predictors of 30-day mortality included any malperfusion (odds ratio, 2.76; 95% confidence interval [CI], 1.94-3.93), cardiac malperfusion (odds ratio, 2.37; 95% CI, 1.34-4.17), renal malperfusion (odds ratio, 2.38; 95% CI, 1.23-4.61) and peripheral malperfusion (odds ratio, 1.95; 95% CI, 1.26-3.01). Any malperfusion (hazard ratio, 1.72; 95% CI, 1.21-2.43), cardiac malperfusion (hazard ratio, 1.89; 95% CI, 1.24-2.87) and gastrointestinal malperfusion (hazard ratio, 2.25; 95% CI, 1.18-4.26) were predictors of late mortality. Malperfusion was associated with significantly poorer survival at 1, 3, and 5 years (95.0% ± 0.9% vs 88.7% ± 1.9%, 90.1% ± 1.3% vs 84.0% ± 2.4%, and 85.4% ± 1.7% vs 80.8% ± 2.7%; log rank P = .009). CONCLUSIONS: Malperfusion has a significant influence on early and late outcomes in ATAAD surgery. Management of preoperative malperfusion remains a major challenge in reducing mortality associated with surgical treatment of ATAAD.

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.

Low rate of reoperations after acute type A aortic dissection repair from The Nordic Consortium Registry.

OBJECTIVES: To describe the relationship between the extent of primary aortic repair and the incidence of reoperations after surgery for type A aortic dissection. METHODS: A retrospective cohort of 1159 patients treated for type A aortic dissection at eight Nordic low- to medium-sized cardiothoracic centers from 2005 to 2014. Data were gathered from patient records and national registries. Patients were separately divided into 3 groups according to the distal anastomoses technique (ascending aorta [n = 791], hemiarch [n = 247], and total arch [n = 66]), and into 2 groups for proximal repair (aortic root replacement [n = 285] and supracoronary repair [n = 832]). Freedom from reoperation was estimated with cumulative incidence survival and Fine-Gray competing risk regression model was used to identify independent risk factors for reoperation. RESULTS: The median follow-up was 2.7 years (range, 0-10 years). Altogether 51 out of 911 patients underwent reoperation. Freedom from distal reoperation at 5 years was 96.9%, with no significant difference between the groups (P = .22). Freedom from proximal reoperation at 5 years was 97.8%, with no difference between the groups (P = .84). Neither DeBakey classification nor the extent of proximal or distal repair predicted freedom from a later reoperation. The only independent risk factor associated with a later proximal reoperation was a history of connective tissue disease. CONCLUSIONS: Type A aortic dissection repair in low- to medium-volume centers was associated with a low reoperation rate and satisfactory midterm survival. The extent of the primary repair had no significant influence on reoperation rate or midterm survival.

Postoperative Delirium in Cardiac Surgery Patients.

OBJECTIVE: The authors studied the incidence of postoperative delirium among cardiac surgery patients using the Intensive Care Delirium Screening Checklist (ICDSC). DESIGN: Prospective screening. SETTING: Two university hospitals. PARTICIPANTS: A total of 1,036 consecutive patients. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: Patients were prospectively screened from day 1 to day 10 after surgery or until hospital discharge. Appropriate perioperative data were collected. The overall incidence of postoperative delirium was 11.5%. In the multivariate logistic regression analysis, age over 70 years, higher EuroSCORE points, longer aortic occlusion time, and profuse drainage increased the incidence of delirium. The duration of mechanical ventilation and intensive care unit length of stay were longer in the group of patients with delirium (10.6 hours [6.6-19.5] v 6.4 hours [4.9-8.6], p < 0.001, and 1.7 days [0.9-4.2] v 0.9 days [0.9-1], p < 0.001). CONCLUSIONS: Postoperative delirium is common after cardiac surgery, and it is associated with the duration of mechanical ventilation.

Hospital volumes and later year of operation correlates with better outcomes in acute Type A aortic dissection.

OBJECTIVES: Acute Type A aortic dissection remains a life-threatening disease, but there are indications that its surgical mortality is decreasing. The aim of this report was to study how surgical mortality has changed and what influences those changes. METHODS: Nordic Consortium for Acute Type A Aortic Dissection is a retrospective database comprising 1159 patients (mean age 61.6 ± 12.2 years, 68% male) treated for acute Type A aortic dissection at 8 centres in Denmark, Finland, Iceland and Sweden from 2005 to 2014. Data gathered included demographics, symptoms, type of procedure, complications and 30-day mortality. RESULTS: The annual number of operations increased significantly from 85 in 2005 to 150 in 2014 (P < 0.001). Chest pain was present in 85% of patients, 24% were hypotensive on presentation and 28% had malperfusion syndrome. Open distal anastomosis technique under hypothermic circulatory arrest was used in 85% of cases and its use increased significantly throughout the study. The 30-day mortality decreased from 24% in 2005 to 13% in 2014 (P = 0.003). Independent predictors for 30-day mortality were preoperative cardiac arrest, malperfusion syndrome, Penn Class C, Penn Class B and C and cardiopulmonary bypass time, whereas later calendar year and higher hospital operative volumes predicted improved survival. CONCLUSIONS: Surgical mortality for acute Type A aortic dissection remains high but has decreased significantly over the last decade. This correlated with later year of operation and increased the number of operations performed per year, indicating that cumulative surgical experience contributes significantly to improved surgical outcomes.

Medium-term survival after surgery for acute Type A aortic dissection is improving.

OBJECTIVES: To report long-term survival and predictors of mortality in patients included in a large, contemporary, multicentre, multinational database: Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD), which consists of 8 centres in 4 Nordic countries. METHODS: Currently, NORCAAD includes 1159 patients operated between 2005 and 2014. In 30-day survivors (n = 955, 82%), the Kaplan-Meier and Cox proportional hazard methods were used to analyse medium-term (up to 8 years) survival and relative survival versus a matched normal population. Pre- and intraoperative predictors were expressed as hazard ratio (HR) with 95% confidence interval (95% CI). RESULTS: Cumulative follow-up was 3514 patient-years with a median of 3.2 years (range 0-10.2 years). Survival was 95% (95% CI 93-96) at 1 year, 86% (95% CI 83-88) at 5 years and 76% (95% CI 72-81) at 8 years. Relative survival versus a matched normal population was 95% (95% CI 94-97) at 1 year, 90% (95% CI 87-93) at 5 years and 85% (95% CI 80-90) at 8 years. In multivariable analysis, increased age (HR 1.05 per year, 95% CI 1.04-1.07), previous abdominal or thoracic aortic repair (HR 3.2, 95% CI 1.6-6.4) and chronic renal disease (HR 2.7, 95% CI 1.2-6.2) were associated with increased medium-term mortality. Open distal anastomosis (HR 0.55, 95% CI 0.35-0.87) and operation in the 2010-2014 period (HR 0.90, 95% CI 0.83-0.97) were associated with decreased medium-term mortality. CONCLUSIONS: Medium-term survival after acute Type A aortic dissection in the NORCAAD registry is satisfactory, close to a matched normal population and improved in the later part of the study period. The use of open distal anastomosis was associated with decreased medium-term mortality.

Incidence, presentation and risk factors of late postoperative pericardial effusions requiring invasive treatment after cardiac surgery.

OBJECTIVES: Occurrence and risk factors of late postoperative pericardial effusions requiring invasive treatment, i.e. pretamponade and tamponade, following cardiac surgery are incompletely described in current literature. The purpose of this study was to define the incidence and presentation of late pretamponade and tamponade as well as to outline significant predisposing factors. METHODS: A cohort of 1356 consecutive cardiac surgery patients treated in a tertiary academic centre between January 2013 and December 2014 was followed up for 6 months after surgery. Pericardial effusion was considered late when presenting after the 7th postoperative day. The incidence, timing and risk factors, as well as symptoms and clinical findings associated with late pretamponade and tamponade in patients surviving at least 7 days was analysed. RESULTS: Of 1308 patients included in the analysis, 81 (6.2%) underwent invasive treatment for late postoperative pericardial effusion, 27 (2.1%) for pretamponade and 54 (4.1%) for tamponade, respectively, with a median delay of 11 (range 8-87) days after the primary operation. Haemodynamic instability was present in 34.6%, signs of cardiac chamber compression in 54.3% and subjective symptoms, mostly dyspnoea, in 56.8% of patients, respectively. Treated patients were younger, had lower EuroSCORE-II rating, less coronary disease, better cardiac function, higher preoperative haemoglobin values and had mostly undergone elective surgery involving cardiac valves. In multivariable analysis, independent risk factors were single valve surgery and high preoperative haemoglobin level, whereas age 60-69 years was associated with lower risk. CONCLUSIONS: Younger, generally healthier patients undergoing valve surgery are at greatest risk for developing late tamponade or pretamponade.

The Nordic Consortium for Acute type A Aortic Dissection (NORCAAD): objectives and design.

OBJECTIVES: The Nordic Consortium for Acute Type A Aortic Dissection (NORCAAD) is a collaborative effort of Nordic cardiac surgery centers to study acute type A aortic dissection (ATAAD). Here, we outline the overall objectives and the design of NORCAAD. DESIGN: NORCAAD currently consists of eight centers in Denmark, Finland, Iceland and Sweden. Data was collected for patients undergoing surgery for ATAAD from 2005 to 2014. A total of 194 variables were retrospectively collected including demographics, past medical history, preoperative medications, symptoms at presentation, operative variables, complications, bleeding and blood transfusions, need for late reoperations, 30-day mortality and long-term survival. RESULTS: Information was gathered in the database for 1159 patients, of which 67.6% were male. The mean age was 61.5 ± 12.1 years. The mean follow-up was 3.1 ± 2.9 years with a total of 3535 patient years. CONCLUSIONS: NORCAAD provides a foundation for close collaboration between cardiac surgery centers in the Nordic countries. Substudies in progress include: short-term outcomes, long-term survival, time interval from diagnosis until operation, effects of surgical techniques, malperfusion syndrome, renal failure, bleeding and neurological complications on outcomes and the rate of late reoperations.

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.

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.

Reconstruction of ruptured patellar tendon after total knee arthroplasty: a case report and a description of an alternative fixation method.

Patellar tendon rupture after total knee arthroplasty is a rare, but often catastrophic complication. Many different reconstruction techniques of patellar tendon rupture have been described with variable and often discouraging results. A case report with patellar tendon rupture after a total knee arthroplasty is presented. Also, an alternative surgical technique of reconstruction of the patellar tendon using a semitendinosus-gracilis (STG) graft with an interference screw and a staple fixation enabling an immediate mobilization is described.

Hypertonic saline (7.5%) decreases perioperative weight gain following cardiac surgery.

OBJECTIVE: To compare the effects of 7.5% hypertonic saline (HS) and 0.9% normal saline (NS) on perioperative weight gain in cardiac surgical patients. DESIGN: Prospective, randomized study. SETTING: University teaching hospital. PARTICIPANTS: Patients (n = 72) scheduled for elective coronary artery bypass graft surgery. INTERVENTIONS: Patients were randomly assigned to receive either 7.5% HS (36 patients) or 0.9% NS (36 patients) as a single dose of 4 mL/kg over 30 minutes during the postoperative rewarming phase in the intensive care unit. MEASUREMENTS AND MAIN RESULTS: Weight gain until the first postoperative morning was significantly greater in the NS group than in the HS group (1.9 plus minus 1.4 kg, median, 2.1 kg; 0.8 plus minus 1.5 kg, median, 0.8 kg; p = 0.005). One-hour diuresis after the fluid infusion was significantly greater in the HS group compared with the NS group (501 plus minus 282 mL and 237 plus minus 173 mL; p < 0.001). In the linear regression model, the 2 most important factors affecting the perioperative weight gain were the volume of fluid infused postoperatively in the intensive care unit (4,098 plus minus 916 mL in the HS group and 4,589 plus minus 1,344 mL in the NS group) and the total diuresis after surgery (3,351 plus minus 1,035 mL in the HS group and 2,942 plus minus 846 mL in the NS group). CONCLUSIONS: HS had an intense diuretic effect, which reduced intraoperative fluid retention. This effect was confirmed by the lesser increase in body weight measured on the first postoperative morning.