First experience with the new Sorin Crown PRT bioprosthetic aortic valve: early postoperative outcome and hemodynamic performance in 90 patients.

AIM: The Crown PRT (The Phospholipid Reduction Treatment) is a new stent bovine bioprosthesis for aortic valve replacement (AVR). Aim of this paper is to report the postoperative clinical and hemodynamic results after ninety consecutive implants. METHODS: After receiving CE mark in July 2014, two European university centers implanted the new Crown PRT (Sorin Group, Burnaby, Canada) for the first time. Up to now, ninety patients underwent aortic valve replacement, in isolated or combined procedures, for aortic stenosis or insufficiency. Intraoperative transesophageal echocardiogram was used to assess the prosthesis's function. In hospital outcomes and echocardiographic parameters were recorded. RESULTS: Age and Log Euroscore were 71.8±7.9 years and 10.2%±4.5 respectively. In-hospital mortality for isolated AVR was 0%; one patient died after a multiple procedure (overall 30-days mortality 1.1%). No adverse device effects were recorded. Intensive Care Unit stay was 2±5.8 days. At discharge, echocardiogram showed no paravalvular leaks and normal postoperative gradients. CONCLUSION: Our starting results showed that the Crown PRT is safe and reliable, with excellent hemodynamic performance. Further clinical results with a larger population and long term follow-up are needed to assess the versatility and the durability of this new device.

Sternal wound dehiscence from intense coughing in a cardiac surgery patient: could it be prevented?

This case report is on a obese patient who underwent a coronary artery bypass. The immediate postoperative phase, on the 8th day, was characterized by sternal dehiscence with diastasis, from intense coughing. At present, for obese patients there are not any guidelines aimed to prevent the sternal diastasis. The use of a sternum support vest after median sternotomy could be a valuable tool in the postoperative care of our patients, in order to avoid chest wall hyperexpansion and to prevent sternal wound dehiscence and diastasis.

Atrial fibrillation ablation induces reverse remodelling and impacts cardiac function.

AIM: Atrio-ventricular anatomo-functional response to successful surgical atrial fibrillation (AF) ablation has been poorly investigated. Determinants of AF recurrence following surgical ablation are still debated. METHODS: Sixty-nine patients underwent AF ablation during major cardiac surgery. Main outcomes were clinical and echocardiographic results after monopolar and/or bipolar ablation were recorded. Secondary outcomes were freedom from AF, rehospitalization and congestive heart failure (CHF) at follow-up. Predictors of AF-recurrence were evaluated. RESULTS: Fifty-three patients (76.8%) were in sinus rhythm (SR) at 31.4±10.6 months of mean follow-up. Overall freedom from AF-recurrence was 61.4±6.6%, from hospital readmission 89.9±3.6%, from CHF 91.9±5.05%. Compared to AF-patients, SR-patients demonstrated better freedom from re-hospitalization (98.1±1.9% vs. 62.5±12.1%; P=0.0001) and CHF (94.7±5.1% vs. 77.8±13.9%; P=0.006). At follow-up SR-patients demonstrated atrial (preoperative 5.9±1.2 cm vs. follow-up 5.2±1.0; P=0.01) and ventricular reverse remodelling (preoperative LVDd 5.8±1.6cm vs. follow-up 5.0±1.3 cm; P=0.002 - preoperative LVDs 4.2±1.8 cm vs. follow-up 3.8±1.2 cm; P=0.045). E/A ratio was normal in 90.6% of SR-patients (69.6% of the total population of the study). TDI at the level of the left lateral annulus showed an improved left ventricular systole (Sm), and diastole (Em, E/Em) for SR-patients compared to AF-patients (Sm 9.30±1.66 vs. 7.81±1.41, P=0.001; Em: 10.55±1.87 vs. 7.44±0.40, P=0.001; E/Em: 0.06±0.02 vs. 0.11±0.05, P=0.0001). Preoperative atrial diameter (OR=23.9; P=0.002) and tricuspid insufficiency at follow-up (OR=3.5; P=0.008) were independent predictors of AF-recurrence. Neither etiology, nor duration of AF, nor even ablation technique influenced SR recovery (P=NS for all measurement). CONCLUSION: Radiofrequency AF ablation achieves 76.8% of SR recovery at follow-up. Maintenance of SR improves clinical, haemodynamic and echocardiographic results.

Impact of bispectral index monitoring on postoperative delirium in patients undergoing aortic surgery.

BACKGROUND: Bispectral index monitoring can facilitate anesthesia care. We evaluated the association of Bispectral index with postoperative neurological outcome and delirium in patients undergoing aortic surgery. METHODS: From 2006 to 2009, 292 consecutive patients undergoing aortic surgery were retrospectively reviewed. Patients were classified into 5 groups according to Bispectral index reduction: Group I (≤15%), Group II (15-20%), Group III (20-25%), Group IV (25-30%), and Group V (>30%). RESULTS: The number of patients in each group was : 52 (17.8%), Group I; 125 (42.8%), Group II;68 (23.3%), Group III; 33 (11.3%), Group IV; 14 (4.8%), Group V. The incidence of delirium and neurological events was higher in Group IV and Group V(90.9% and 18.2% in Group IV, and 71% and 79% in Group V; both p<0.001). Only Group V showed a longer intensive care unit stay compared to Group I (13.5±10.3 vs 5.4±6.6 days; p=0.002), Group II (7.3±8.6 days, p=0.005) and Group III (6.7±6.5 days, p=0.015). Group V also showed a longer intubation time compared to Group I (228±211 vs 73±112 hours; p=0.008) and Group II (105±177 hours, p=0.002). CONCLUSIONS: Our data suggest a higher incidence of neurological deficits in patients with a Bispectral index reduction of >25% from baseline. Explanations for these findings are speculative with regard to the underlying mechanisms, and larger studies are warranted to clarify these issues.

Inflammatory response after cardiopulmonary bypass: a randomized comparison between conventional hemofiltration and steroids.

AIM: Recent reports have shown anti-inflammatory effects with conventional hemofiltration (CUF) in patients undergoing cardiopulmonary bypass (CPB). The aim of this study was to evaluate the immunological and the hemodynamic response to CUF or metilprednisolone in patients undergoing coronary artery bypass grafting. METHODS: Twenty-four consecutive patients were prospectively randomized to receive CUF (12 patients, Group A) or metilprednisolone (12 patients, Group B). Hemodynamic response was evaluated by Swan-Ganz catheter, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpha, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3) and 24 hours (T4). Troponin I was measured at the same time-points. Hematological and coagulative controls were performed. RESULTS: Morbidity and mortality were comparable between the two groups. Group A demonstrated lower cardiac index at T1 (2.1 +/- 0.69 L/min m2 vs. 3.917 +/- 1.28, P = 0.034) without significantly higher indexed-systemic-vascular-resistances at the end of surgery (1 101 +/- 434.3 dyne s cm(-5) m(-2) vs. 797.7 +/- 316.67, P = 0.233). When proinflammatory and anti-inflammatory cytokines were considered, all improved during the postoperative time course, without differences between the 2 Groups (P = NS). Hematological and coagulative data were similar in the two groups, in terms of white blood cells, platelets, prothrombin time, and activated partial thromboplastin time (P = NS). CONCLUSIONS: Anti-inflammatory action of CUF was comparable to steroids, thus determining a similar proinflammatory response to CPB. However, hemodynamics was slightly impaired by CUF. Therefore, there is no reason to prefer CUF to steroids in patients undergoing elective CABG.

Inflammatory response to cardiopulmonary bypass with enoximone or steroids in patients undergoing myocardial revascularization: a preliminary report study.

OBJECTIVE: Recent reports have showed an antiinflammatory effect of phosphodiesterase III inhibitors (PDEi) in patients undergoing cardiopulmonary bypass (CPB). We sought to evaluate the immunological and hemodynamic response to enoximone and methylprednisolone in patients undergoing CABG. DESIGN: Prospective, randomized, controlled study. SETTING: Cardiac surgery unit in a university hospital. PATIENTS: 40 patients undergoing CPB-CABG. INTERVENTIONS: Patients receive enoximone (20, Group A) or methylprednisolone (20, Group B). MEASUREMENTS AND MAIN RESULTS: Hemodynamic response was evaluated by Swan-Ganz catheter serial measurements and perioperative Lactate and Troponin I leakage, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alpah, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3), 24 hs (T4) postoperatively. Morbidity and mortality were comparable between the two groups. Group A demonstrated higher cardiac index at T2 (2.93 l/min m2 vs 2.06, p < 0.001), at T3 (3.01 vs 2.18, p < 0.001), lower indexed systemic vascular resistance at T2 (2,044 dyne s cm-5 m-2 vs 3,132, p < 0.001). Except for higher TNF-alpha in Group B at T2 (15.89 vs 22.68, p = 0.005) proinflammatory cytokines were comparable. IL-10 was higher in Group B at any postoperative time (IL-10: T1 80.74 vs 143.3, p < 0.001, T2 165.7 vs 377.4, p < 0.001, T3 203.4 vs 443.5, p < 0,001, T4 251.8 vs 437.1, p < 0.001), whereas IL-4 and IFN-gamma proved higher in Group A at all time-points (IL-4: T1 45.9 vs 31.2, p = 0.008, T2 67.2 vs 39.7, p < 0.001, T3 77.9 vs 39.2, p < 0.001, T4 102.9 vs 42.2, p < 0.001. IFN-gamma: T1 25.8 vs 15.8, p < 0.001, T2 52.2 vs 30.3, p < 0.001, T3 78.4 vs 40.8, p < 0.001, T4 159.9 vs 67.4, p < 0.001). CONCLUSIONS: Despite comparable major clinical endpoints enoximone showed a different antiinflammatory pattern compared to methylprednisolone, however, the better hemodynamic response in enoximone compared to methylprednisolone suggests enoximone as a potential antiinflammatory tool to improve the outcome in cardiac surgery.

Body perfusion during adult cardiopulmonary bypass is improved by pulsatile flow with intra-aortic balloon pump.

PURPOSE: To evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves body perfusion. METHODS: 158 coronary artery bypass graft (CABG) patients were randomized to linear cardiopulmonary bypass (CPB) (n=71, Group A) or automatic 80 bpm intra-aortic balloon pump (IABP) induced pulsatile CPB (n=87, Group B). We evaluated hemodynamic response by Swan-Ganz catheter, inflammation by cytokines, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate and renal function (estimated glomerular filtration rate (eGFR), creatinine, and incidence of renal insufficiency and failure). RESULTS: IABP induced Surplus Hemodynamic Energy was 15.8-/+4.9 mmHg, with higher mean arterial pressure during cross-clamping (p=0.001), and lower indexed systemic vascular resistances during cross-clamping (p=0.001) and CPB discontinuation (p=0.034). IL-2 and IL-6 were lower, while IL-10 proved higher in Group B (p<0.05). Group B showed lower chest drainage (p<0.05), transfusions (p<0.05), INR (p<0.05), and AT-III (p=0.001), together with higher platelets, aPTT (p<0.05), fibrinogen (p<0.05) and D-dimer (p<0.05). Transaminases, bilirubin, amylase, lactate were lower in Group B (p<0.05); eGFR was better in Group B from ITU-arrival to 48 hours, both in preoperative kidney disease Stages 1-2 (p<0.03) and Stage 3 (p<0.05), resulting in lower creatinine from ITU-arrival to 48 hours (p<0.03). Incidence of renal insufficiency (p=0.004) and need for renal replacement therapy (p=0.044) was lower in Group B Stage 3. Group B PaO2/FiO2 and lung compliance improved from aortic declamping to the first day (p<0.003) with shorter intubation time (p=0.01). CONCLUSION: Pulsatile flow by IABP improves whole-body perfusion during CPB.

Valve preservation in acute type A aortic dissection: 13-year experience.

AIM: Aortic dissection is frequently complicated by regurgitation of the aortic valve resulting from leaflet prolapse or tearing of the annulus or leaflet. The authors have evaluated the results using the technique of aortic valve preservation in patients with acute type A aortic dissection (AAD). METHODS: In a consecutive series of 79 AAD observed from January 1994 to September 2007, 51 (64.6%) presented aortic valve insufficiency (AI). All patients were emergency operated on via median sternotomy and femoral (46/79, 58.2%) or axillary artery-right atrium (33/79, 41.8%) cardiopulmonary bypass with 60 cases (75.9%) of antegrade selective cerebral perfusion. The dissected aorta was resected and the aortic valve was replaced in 2 patients/51 (3.9%) and was preserved in the remaining 49 cases as follows: 42 (85.7%) commissural resuspensions due to commissural prolapse, 3 (6.1%) resuspensions due to cusp prolapse, 3 (6.1%) commissural plication and 1 (2.1%) circumclusion due to annular dilatation. RESULTS: The overall hospital mortality was 20.3% (16/79) with a percentage of 19.6% (10/51) in the AI group. 1 patient presented a type B dissection at 1 months and died after reoperation. The remaining 40 patients with a preserved native valve were followed by echocardiography and computed tomography (CT) (follow-up ranged from 3 to 165 months) with 4 late deaths. Twenty-six patients had absent or grade I AI (72.2%), 8 had grade II AI (22.2%) and 2 presented grade III or IV AI (5.6%). Actuarial freedom from significant AI was 96.2+/-2.4% and 94.2+/-2.3% at 5 and 10 years respectively. CONCLUSION: The experience with this technique demonstrates the effectiveness of valve conservative treatment within a vascular graft. The reconstruction of the sinotubular junction reducing annular dilatation with appropriated sized graft is obviously mandatory. Although this procedure is not applicable to every patient, we firmly believe that is a valid option when a morphologically intact valve is present.

Aortic tube grafts wrapping with hemostatic fleeces reduces postoperative pericardial effusions.

Pericardial effusions often complicate the postoperative course of ascending aortic surgery. We evaluated whether an unconventional use of hemostatic fleeces (TachoSil, Nycomed; Austria), wrapped around aortic tube grafts, may reduce such complication. Twenty-nine consecutive patients undergoing button-Bentall were submitted - according to surgeon's choice - to 360 degrees wrapping of the aortic grafts with hemostatic fleeces immediately before sternal wiring (11 patients - group A) or sternal wiring without any wrapping of the prosthesis (18 patients - group B). Hospital outcome was recorded. No differences were recorded in hospital mortality and major organ morbidity. When pericardial complications were considered, group A showed lower chest drains (P=0.0001), time of chest drainage (P=0.002), pretamponade/tamponade with need for pericardiocentesis (P=0.039), predischarge echocardiographic amount of pericardial effusion (P=0.026), fever (P=0.029), need for anti-inflammatory (P=0.05) or antibiotic drugs (P=0.007), hospital stay (P=0.010) and white blood cell count (P=0.016 on postoperative day 3; P=0.014 on day 6). Wrapping of aortic tube grafts with hemostatic fleeces is effective in reducing pericardial effusion and its deleterious effects following aortic surgery.

Myocardial protection with insulin cardioplegia: who can really benefit?

AIM: The aim of the study was to evaluate the effects on myocardial protection of insulin-enriched warm blood cardioplegia (IWBC) in coronary artery bypass grafting (CABG) and in subgroups of patients with associated cardiac co-morbidities. METHODS: Between May 2000 and December 2002, 268 consecutive patients underwent CABG with warm blood cardioplegia (group A) or IWBC (10 UI/L) (group B). Hospital outcome, ECG, echocardiography and biochemical markers of ischemia were compared. Differences between subgroups of patients with unstable angina (UA), ventricular hypertrophy (VH) and diabetes were assessed. RESULTS: Hospital mortality, incidence of postoperative myocardial infarction and low output syndrome, IABP requirement, postoperative atrial fibrillation, in-hospital and in-ITU stay, postoperative recovery of left ventricular function and enzyme leakage did not show differences between the 2 groups; inotropic support was lower in IWBC. Moreover, patients with UA and IWBC showed a lower troponin I (TnI) (12 h: 0.82+/-0.57 ng/mL vs 2.56+/-1.18, P < 0.0001; 24 h: 0.71+/-0.64 vs 2.16+/-1.52, P < 0.0001; 48 h: 0.69+/-1.13 vs 1.79+/-1.43, P = 0.001; 72 h: 0.44+/-0.83 vs 1.01+/-1.02, P = 0.001), lower incidence of atrial fibrillation (4.2% versus 60.6%; P < 0.0001) and intraoperative defibrillation (0% versus 27.3%; P = 0.007). Furthermore, patients with VH treated with IWBC showed lower level of TnI (12 h: 0.41+/-0.32 ng/mL vs 2.93+/-0.67, P < 0.0001; 24 h: 0.37+/-0.45 vs 2.40+/-1.28, P < 0.0001; 48 h: 0.22+/-0.18 vs 1.95+/-1.33, P < 0.0001; 72 h: 0.12+/-0.12 vs 1.31+/-1.56, P < 0.0001), lower atrial fibrillation (6.5% vs 48%, P < 0.0001) and ventricular defibrillation (0% vs 20%, P = 0.011). CONCLUSIONS: Insulin addiction to blood cardioplegia does not show any benefit in the global population and in diabetics; nevertheless, better myocardial protection can be demonstrated in patients with unstable angina and left ventricular hypertrophy.