Prophylactic corticosteroids for cardiopulmonary bypass in adult cardiac surgery.

BACKGROUND: Cardiac surgery triggers a strong inflammatory reaction, which carries significant clinical consequences. Corticosteroids have been suggested as a potential perioperative strategy to reduce inflammation and help prevent postoperative complications. However, the safety and effectiveness of perioperative corticosteroid use in adult cardiac surgery is uncertain. This is an update of the 2011 review with 18 studies added. OBJECTIVES: Primary objective: to estimate the effects of prophylactic corticosteroid use in adults undergoing cardiac surgery with cardiopulmonary bypass on the: - co-primary endpoints of mortality, myocardial complications, and pulmonary complications; and - secondary outcomes including atrial fibrillation, infection, organ injury, known complications of steroid therapy, prolonged mechanical ventilation, prolonged postoperative stay, and cost-effectiveness. SECONDARY OBJECTIVE: to explore the role of characteristics of the study cohort and specific features of the intervention in determining the treatment effects via a series of prespecified subgroup analyses. SEARCH METHODS: We used standard, extensive Cochrane search methods to identify randomised studies assessing the effect of corticosteroids in adult cardiac surgery. The latest searches were performed on 14 October 2022. SELECTION CRITERIA: We included randomised controlled trials in adults (over 18 years, either with a diagnosis of coronary artery disease or cardiac valve disease, or who were candidates for cardiac surgery with the use of cardiopulmonary bypass), comparing corticosteroids with no treatments. There were no restrictions with respect to length of the follow-up period. All selected studies qualified for pooling of results for one or more endpoints. DATA COLLECTION AND ANALYSIS: We used standard Cochrane methods. Our primary outcomes were all-cause mortality, and cardiac and pulmonary complications. Secondary outcomes were infectious complications, gastrointestinal bleeding, occurrence of new post-surgery atrial fibrillation, re-thoracotomy for bleeding, neurological complications, renal failure, inotropic support, postoperative bleeding, mechanical ventilation time, length of stays in the intensive care unit (ICU) and hospital, patient quality of life, and cost-effectiveness. We used GRADE to assess the certainty of evidence for each outcome. MAIN RESULTS: This updated review includes 72 randomised trials with 17,282 participants (all 72 trials with 16,962 participants were included in data synthesis). Four trials (6%) were considered at low risk of bias in all the domains. The median age of participants included in the studies was 62.9 years. Study populations consisted mainly (89%) of low-risk, first-time coronary artery bypass grafting (CABG) or valve surgery. The use of perioperative corticosteroids may result in little to no difference in all-cause mortality (risk with corticosteroids: 25 to 36 per 1000 versus 33 per 1000 with placebo or no treatment; risk ratio (RR) 0.90, 95% confidence interval (CI) 0.75 to 1.07; 25 studies, 14,940 participants; low-certainty evidence). Corticosteroids may increase the risk of myocardial complications (68 to 86 per 1000) compared with placebo or no treatment (66 per 1000; RR 1.16, 95% CI 1.04 to 1.31; 25 studies, 14,766 participants; low-certainty evidence), and may reduce the risk of pulmonary complications (risk with corticosteroids: 61 to 77 per 1000 versus 78 per 1000 with placebo/no treatment; RR 0.88, 0.78 to 0.99; 18 studies, 13,549 participants; low-certainty evidence). Analyses of secondary endpoints showed that corticosteroids may reduce the incidence of infectious complications (risk with corticosteroids: 94 to 113 per 1000 versus 123 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.76 to 0.92; 28 studies, 14,771 participants; low-certainty evidence). Corticosteroids may result in little to no difference in incidence of gastrointestinal bleeding (risk with corticosteroids: 9 to 17 per 1000 versus 10 per 1000 with placebo/no treatment; RR 1.21, 95% CI 0.87 to 1.67; 6 studies, 12,533 participants; low-certainty evidence) and renal failure (risk with corticosteroids: 23 to 35 per 1000 versus 34 per 1000 with placebo/no treatment; RR 0.84, 95% CI 0.69 to 1.02; 13 studies, 12,799; low-certainty evidence). Corticosteroids may reduce the length of hospital stay, but the evidence is very uncertain (-0.5 days, 0.97 to 0.04 fewer days of length of hospital stay compared with placebo/no treatment; 25 studies, 1841 participants; very low-certainty evidence). The results from the two largest trials included in the review possibly skew the overall findings from the meta-analysis. AUTHORS' CONCLUSIONS: A systematic review of trials evaluating the organ protective effects of corticosteroids in cardiac surgery demonstrated little or no treatment effect on mortality, gastrointestinal bleeding, and renal failure. There were opposing treatment effects on cardiac and pulmonary complications, with evidence that corticosteroids may increase cardiac complications but reduce pulmonary complications; however, the level of certainty for these estimates was low. There were minor benefits from corticosteroid therapy for infectious complications, but the evidence on hospital length of stay was very uncertain. The inconsistent treatment effects across different outcomes and the limited data on high-risk groups reduced the applicability of the findings. Further research should explore the role of these drugs in specific, vulnerable cohorts.

The impact of patient-prosthesis mismatch on early and long-term survival after aortic replacement with the Edwards Perimount valve: A propensity score-matched analysis.

BACKGROUND: To investigate the impact of severe patient-prosthesis mismatch (PPM) related to the Edwards Lifesciences Perimount (EP) bioprosthesis in the aortic position on early in-hospital outcomes and long-term survival. METHODS: A total of 5964 consecutive patients underwent aortic valve replacement at the Bristol Heart Institute between 1998 and 2014, 2667 representing the cohort of this study received EP. PPM was defined severe as EOAi < 0.65 cm2 /m2 . To minimize bias, propensity score matching was conducted and two groups A and B (without and with severe PPM) of 320 patients with similar preoperative characteristics were matched. We assessed early in-hospital outcomes including CVA, re-exploration for bleeding, low cardiac output, wound infection, acute renal injury, length of hospital stay, and long-term survival for both groups in unmatched and matched populations. RESULTS: In the unmatched analysis, 18.3% of patients had severe PPM. Severe PPM was not associated with increased in-hospital mortality (4.5% vs. 2.9%, respectively, p = .09) or any other early adverse outcomes except increased length of hospital stay (10.57 ± 8.2 vs. 11.7 ± 9.4, respectively, p = .01). Long-term survival differed significantly between groups at 2 and 8 years (91.8% vs. 91.4% and 60.5% vs. 55.7%, respectively, p = .02). Matched analysis showed no differences between the groups in early health outcomes and overall survival at 2 and 8 years was also similar (89.7% vs. 91% and 57.3% vs. 58%, group A vs. B, respectively p = .9). CONCLUSION: Presence of PPM does not seem to affect early in-hospital outcomes or late survival when using EP in patients undergoing aortic valve replacement.

Effectiveness and Safety of Aprotinin Use in Thoracic Aortic Surgery.

OBJECTIVE: To determine the effectiveness and safety of aprotinin use in adult patients undergoing thoracic aortic surgery. DESIGN: Single-center, retrospective study. SETTING: All cases performed at a single university hospital. PARTICIPANTS: Between January 2004 and December 2014, 846 adult patients underwent thoracic aortic surgery. Due to missing or duplicated data on primary outcomes, 314 patients were excluded. The final sample of 532 patients underwent surgery on the thoracic aorta. INTERVENTIONS: The patients were divided in the following 2 groups: 107 patients (20.1%) received aprotinin during the surgery, which represented the study group, whereas the remaining 425 patients (79.9%) underwent surgery without the use of aprotinin. MEASUREMENTS AND MAIN RESULTS: To adjust for patient selection and preoperative characteristics, a propensity score-matched analysis was conducted. Mean total blood loss at 12 hours after surgery was similar between the 2 groups. The blood product transfusion rates did not differ in the 2 groups, except for the rate of fresh frozen plasma transfusion being significantly higher in the aprotinin group. Re-exploration for bleeding and the incidence of a major postoperative bleeding event were similar between the groups. Rates of in-hospital mortality, renal failure, and cerebrovascular accidents did not show any statistically significant difference. Aprotinin did not represent a risk factor for mortality over the long term (hazard ratio 1.14, 95% confidence interval 0.62-2.08, p = 0.66). CONCLUSIONS: The use of aprotinin demonstrated a limited effect in reducing postoperative bleeding and prevention of major bleeding events. Aprotinin did not adversely affect early outcomes and long-term survival.

Pulsatile cardiopulmonary bypass with intra-aortic balloon pump improves organ function and reduces endothelial activation.

BACKGROUND: We aimed to evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves organ function and reduces endothelial activation in patients undergoing coronary artery bypass graft (CABG). METHODS AND RESULTS: Five-hundred and one CABG patients were randomized into 2 groups: (Group A n=270) linear cardiopulmonary bypass (CPB); and (Group B n=231) automatic 80 beats/min IABP-induced pulsatile CPB. We evaluated hemodynamic response, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate, renal function (estimated glomerular filtration rate [eGFR], creatinine and any possibility of renal insufficiency or failure), respiratory function and endothelial markers (vascular endothelial growth factor [VEGF] and monocyte chemotactic protein-1 [MCP-1]). IABP, which induced surplus hemodynamic energy, was 21,387 ± 4,262 ergs/cm(3). Group B showed lower chest drainage, transfusions, international normalized ratio, and antithrombin III, together with higher platelets, activated partial thromboplastin time, fibrinogen and D-dimer. Transaminases, bilirubin, amylase, lactate were lower in Group B; there were better results for eGFR in Group B from ICU-arrival to 48 h, resulting in lower creatinine from ICU-arrival to 48 h. The necessity for renal replacement therapy was lower in Group B Stage-3. Group B P(a)O(2)/F(i)O(2) and lung compliance improved with aortic de-clamping on the first day with shorter intubation time. Group B showed lower VEGF and MCP-1. CONCLUSIONS: Pulsatile flow by IABP improves whole-body perfusion and reduces endothelial activation during CPB.

Multicenter Experience With 500 CardioCel Implants Used for the Repair of Congenital Heart Defects.

BACKGROUND: The purpose of this study was to assess the performance of more than 500 tissue-engineered bovine pericardial implants (CardioCel; Admedus, Toowong, Queensland, Australia) used for the repair of congenital heart defects. METHODS: Clinical data were collected for all patients who received a CardioCel implant at three centers (Brisbane, Australia; and Leicester and Bristol, United Kingdom). During this period, 501 CardioCel patches were implanted in 377 patients. The primary endpoint was CardioCel-related surgical or catheter intervention. Secondary endpoints included implant-related thromboembolism, residual shunt, infection, calcification leading to loss of function, and hemodynamic compromise. Mortality or reintervention was considered early if the event occurred within 30 days of implantation. RESULTS: The median follow-up was 31 months (range, 1 to 60). There were 11 deaths (2.9%), 1 related to CardioCel. There was no echocardiographic or radiologic evidence of patch calcification in any patient. Overall freedom from reintervention 3 and 5 years after implantation was 96% (95% confidence interval, 93% to 98%). Fourteen implants (2.8%) required 18 reinterventions (3.6%) at the site of implantation (9 catheter based and 9 operative). There was no difference in the incidence of reintervention in the pulmonary arterial or systemic circulations (P = .18). There was no difference in performance of CardioCel in neonates (aged 0 to 28 days), infants (aged 29 to 365 days), or children aged more than 1 year (P = .22). CONCLUSIONS: CardioCel has good durability when used for the repair of congenital heart defects. It performs comparably in the systemic and pulmonary circulations in neonates, infants, and older children.

Propensity-matched analysis of outcomes after mitral valve surgery between trainees and consultants (institutional report).

OBJECTIVES: We aimed to determine whether early outcomes and long-term survival after mitral valve surgery performed by trainee residents are equivalent in terms of safety and efficacy when compared with consultant surgeons. METHODS: Between January 2000 and December 2015, a total of 1742 patients who underwent mitral valve surgery were identified. Of these, 1622 operations were performed by consultants (Group I) and 120 operations were performed by trainees (Group II). A propensity score-matched analysis has been used to minimize selection bias. Early postoperative outcomes were defined as in-hospital mortality, cerebrovascular accident, postoperative requirement of renal replacement therapy, reoperation for bleeding and postoperative length of hospital stay. Long-term outcomes were evaluated using late survival data after discharge. RESULTS: Before matching, the 2 groups differed significantly in terms of gender and reduced left ventricular ejection fraction, but these differences were solved after matching. Also, Group I included significantly more patients with mitral regurgitation (83% vs 62%; P < 0.01), but after matching, this difference was corrected (62% vs 59%; P = 0.71). Consultant group was associated with a higher in-hospital mortality (6% vs 2%; P = 0.04) in the unmatched population. Moreover, in the unmatched cohort, this group had longer cross-clamp time compared with the trainees group (91 ± 38 vs 89 ± 26 min; P = 0.47) and longer cardiopulmonary bypass time (132 ± 58 vs 121 ± 33 min; P = 0.27); these differences were not statistically significant. There were no significant differences in postoperative dialysis, cerebrovascular accident, reoperation for bleeding and length of hospital stay. Even after matching, no significant differences were found in terms of perioperative complications. The Kaplan-Meier survival curves at 1, 5 and 10 years were similar between the 2 groups. CONCLUSIONS: Mitral valve surgery can be safely performed by trainees and provides similar short- and long-term results compared with consultant surgeons.

Impact of Isolated Tricuspid Valve Repair on Right Ventricular Remodelling in an Adult Congenital Heart Disease Population.

BACKGROUND: Surgical repair of isolated congenital tricuspid valve (TV) disease is rare with no well-defined indication and outcomes. Moreover, the role of right ventricle (RV) in this context has not yet been investigated. OBJECTIVES: We sought to assess the impact of congenital TV repair on cardiac remodelling and clinical-functional status and the importance of the RV function in an adult congenital heart disease (ACHD) population. METHODS AND RESULTS: From January 2005 to December 2015, 304 patients underwent TV surgery in our centre. Of these, 27 (ACHD) patients had isolated TV repair. Patients were evaluated with preoperative and postoperative transthoracic echocardiogram. Survival rate has been investigated with a mean clinical follow-up (FU) of 3.7 ± 2.3 years, whereas the mean echocardiographic FU was 2.9 ± 1.8 years. The clinical and functional status of patients showed a statistically significant improvement after the surgical repair in terms of New York Heart Association class (66.7 vs 7.4%; p < 0.01), clinical signs of heart failure (29.6 vs 7.4%; p < 0.01), and left ventricular function (14.8 vs 7.4%; p < 0.01). The RV and right atrium diameter were significantly reduced after surgery (5.15 ± 1.21 vs 4.32 ± 1.16; p < 0.01) and (44.7 ± 16.7 vs 26.7 ± 9.2; p < 0.01), respectively. The degree of postoperative pulmonary hypertension was also significantly reduced (40.7 vs 7.4%; p < 0.01). The survival rate was 96.3% at 1 year and 93.7% at 5 years. One patient (3.7%) had early failure of the tricuspid repair requiring a reoperation. CONCLUSION: Isolated TV repair for adult congenital disease significantly improved patients' clinical and functional status and allowed right ventricular remodelling and functional improvement.

Early health outcome and 10-year survival in patients undergoing redo coronary surgery with or without cardiopulmonary bypass: a propensity score-matched analysis.

OBJECTIVES: To investigate the in-hospital health outcome and 10-year survival in patients undergoing redo coronary surgery with (redo-CABG) or without (redo-OPCAB) cardiopulmonary bypass. METHODS: A total of 349 redo coronary surgery patients were identified from our registry. Of these, 143 redo-OPCAB patients (40.97%) were compared with 206 redo-CABG patients. To minimize the bias, we also conducted propensity score matching. In Matched Analysis A, 111 redo-OPCAB patients with any type of primary cardiac operation were compared with 111 redo-CABG cases. In Matched Analysis B, 84 redo-OPCAB patients with isolated coronary surgery as their primary operation were compared with 84 redo-CABG patients. We assessed for all 3 analyses a composite of in-hospital mortality, acute kidney injury, stroke and severe low cardiac output requiring intra-aortic balloon pump. In addition, we assessed 1-, 5-, and 10-year survival. RESULTS: In the unmatched analysis, redo-CABG was associated with higher usage of intra-aortic balloon pump (10 vs 3%, P = 0.01) and composite compared with redo-OPCAB (25 vs 16%, P = 0.06) and similar 10-year survival (67.2 vs 68.5%, log-rank test: P = 0.78). Matched Analysis A showed similar rates of composite (15 vs 21%, P = 0.25) and 10-year survival (65.1 vs 60.8%, log-rank test: P = 0.5). Matched Analysis B showed reduction of the composite (19 vs 8%, P = 0.04), less in-hospital mortality (5 vs 0%, P = 0.13), 4.5 times less need for intra-aortic balloon pump (2 vs 11%, P = 0.02) favouring redo-OPCAB and a similar 10-year survival (71.6 vs 71.7%, log-rank test: P = 0.61). CONCLUSIONS: Redo-OPCAB surgery is feasible, safe and effective with improved in-hospital outcome and similar 10-year survival compared to redo-CABG.

Right internal thoracic artery or radial artery? A propensity-matched comparison on the second-best arterial conduit.

OBJECTIVES: We conducted propensity score matching to determine whether the use of the right internal thoracic artery (RITA) confers a survival advantage when compared with the radial artery (RA) as second arterial conduit in coronary artery bypass grafting. METHODS: The study population included a highly selected low-risk group of patients who received the RITA (n = 764) or the RA (n = 1990) as second arterial conduit. We obtained 764 matched pairs that were comparable for all pretreatment variables. A time-segmented Cox regression model that stratified on the matched pairs was used to investigate the effect of treatment on late mortality. RESULTS: After a mean follow-up of 10.2 ± 4.5 years (maximum 17.3 years), survival probabilities at 5, 10, and 15 years were 96.4% ± 0.7% versus 95.4% ± 0.7%, 91.0% ± 1.1% versus 89.1% ± 1.2%, and 82.4% ± 1.9% versus 77.2% ± 2.5% in the RITA and RA groups, respectively. During the first 4 years, RITA and RA were comparable in terms of mortality (hazard ratio [HR], 1.00; 95% confidence interval [CI], 0.56-1.78; P = .98). However, after 4 years RITA was associated with a significant reduction in late mortality (HR, 0.67; 95% CI, 0.48-0.95; P = .02). RITA was superior to RA when the experimental conduit was used to graft the left coronary system (HR, 0.69; 95% CI, 0.47-0.99; P = .04) but not the right coronary system (HR, 0.98; 95% CI, 0.59-1.62; P = .93). CONCLUSIONS: In a highly selected low-risk group of patients, the use of the RITA as second arterial conduit instead of the RA was associated with better survival when used to graft the left but not the right coronary artery.

Gentamicin-Impregnated Collagen Sponge: Effectiveness in Preventing Sternal Wound Infection in High-Risk Cardiac Surgery.

Sternal wound infections represent one of the most frequent complications after cardiac surgery and are associated with high postoperative mortality. Several preventive methods have been introduced, and recently, gentamicin-impregnated collagen sponges (GICSs) have shown a promising effect in reducing the incidence of this type of complications. Gentamicin is an aminoglycoside antibiotic that has been widely used to treat infections caused by multiresistant bacteria; despite its effectiveness, its systemic use carries a risk of toxicity. GICSs appear to overcome this side effect, topically delivering high antibiotic concentrations to the wound and thus reducing the toxic-related events. Although several retrospective analyses and randomized controlled trials have studied the use of GICSs in cardiac surgery, conclusions regarding their efficacy in preventing sternal wound infection are inconsistent. We have reviewed the current literature focusing on high-risk patients.

Off-pump coronary artery bypass grafting in high-risk patients: a review.

The role of off-pump coronary artery bypass (OPCAB) grafting in high risk patients remains controversial. While there have been studies showing the potential benefits of it, there is still a lot to be learned from the application of this technique in this sub-group of patients. The results of the different trials and papers that we reviewed seem to indicate a benefit in the OPCAB group. Despite of the fact that trials were significantly different in methodology, especially when choosing the risk score stratification tool or the cut-off to define high risk the literature seems to suggest a benefit from the use of OPCAB surgery. Here, we present a review which focussed on early and late outcome in high risk patients undergoing on- and off-pump coronary revascularization.

Impact of off-pump coronary artery bypass grafting on survival: current best available evidence.

The superiority of either off-pump (OPCAB) or on-pump (ONCAB) coronary artery bypass grafting (CABG) remains unclear despite a large body of literature evidence comparing the two approaches. The potential advantages of avoiding cardiopulmonary bypass (CPB), minimizing aortic manipulation and maintaining pulsatile flow may be associated with reduced inflammatory responses and embolic events. Numerous studies compared OPCAB with ONCAB and the cumulative data have been presented in meta-analyses of both randomized and observational studies. Although there is an abundance of data with respect to the operative morbidity and mortality and the short-term outcomes associated with these two strategies, not much is known about how they impact long-term survival and recurrence of myocardial ischaemic events. Recent studies and meta-analyses have focused on long-term survival and major secondary outcomes in OPCAB vs. ONCAB within the general population. Significant limitations in methodology, however, have raised concerns about the strength of several randomized trials with restrictive inclusion criteria that reduced the populations to those at low risk only, thus creating result bias. Here, we present a review of the best available evidence with a focus on long-term outcomes.

Intra-aortic balloon pumping recruits graft flow reserve by lowering coronary resistances.

BACKGROUND: The intra-aortic balloon pump (IABP) is used worldwide as an anti-ischemic strategy and to reduce myocardial workload. However, whether IABP augments coronary flow after coronary bypass via a passive increase in diastolic pressure or an active response of the coronary bed remains uncertain. METHODS: We analyzed transit-time flow measurements and the contemporary changes in coronary resistances obtained during 1:1 IABP and during its cessation in 144 consecutive patients receiving prophylactic IABP before isolated coronary artery bypass grafting (n=340 graft segments). RESULTS: Normally functioning grafts showed lower coronary resistances, greater percentage decrease in resistance, and greater increases in average maximum diastolic and mean flow during 1:1 IABP compared with IABP cessation (P<.001). Arterial and sequential saphenous vein grafts showed better flowmetry and greater reductions in coronary resistances compared with single venous grafts. Accordingly, graft flow reserve (defined as mean flow during 1:1 IABP/mean flow with IABP off) was recruited (graft flow reserve >1) during 1:1 IABP in all normally functioning grafts, with higher values in single arterial or sequential saphenous vein grafts than in single venous grafts (both P<.001). Coronary resistances were higher in 7 failed grafts versus normal-functioning grafts at baseline; these did not decrease during 1:1 IABP and showed worse transit-time flow results. CONCLUSIONS: IABP recruits graft flow reserve by lowering coronary resistance in functioning grafts. Arterial and sequential venous grafts showed greater reduction in coronary resistance compared with single saphenous grafts.

Leukocyte filtration improves pulmonary function and reduces the need for postoperative non-invasive ventilation.

OBJECTIVES: Leukocyte depletion (LD) has been reported to reduce inflammatory damage during cardiopulmonary bypass (CPB). We evaluated the role of LD in pulmonary function and inflammatory response. METHODS: Seventy consecutive CABG patients were randomized (1:1) to receive LD on both arterial and cardioplegia lines (Filters) or standard arterial filters (Controls) during CPB. Estimates of pulmonary function, inflammatory and anti-inflammatory cytokines were collected pre-, intra- and postoperatively. RESULTS: Hospital mortality, intensive care and in-hospital lengths of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukodepleted patients showed higher PaO2/FiO2 (p-between groups = 0.005; ICU arrival p = 0.023; 24 hours p = 0.039; 48 hours p<0.001) and lower need for postoperative non-invasive ventilation (NIV), (p = 0.029). Moreover, Filters showed lower inflammatory burst at 24 hours (IL-6 p<0.001; IL-8 p = 0.002) and 48 hours (IL-6 p = 0.015). This was associated with a lower release of the anti-inflammatory IL-10 (p-between groups = 0.030; ICU admission p = 0.002; 24 hours p = 0.003). Furthermore, IL-2 concentration proved higher in Filters (p-between groups = 0.013; ICU arrival p = 0.029; 24 hours p = 0.040; 48 hours p = 0.021) in association with lower leukocyte and platelet counts at ICU admission. CONCLUSIONS: LD resulted in lower inflammatory burst and less need for release of anti-inflammatory cytokines. Although hospital outcomes were similar in terms of mortality and length of stay, improvements in pulmonary function and reduced need for postoperative NIV support the use of LD.

Unexpected embolization of Teflon pledget in the left main stem during: a Bentall operation.

We report the case of an 83-year-old man in whom acute left ventricular failure with ventricular arrhythmic storm developed during a Bentall operation. During re-exploration of the annular and coronary ostial anastomoses, no abnormality was seen, and none of the common sequelae of aortic root replacement was evident. The application of retrograde cardioplegia yielded a Teflon pledget that had migrated into the distal part of the left main stem. The pledget was removed, the anastomoses were reestablished, and the patient recovered uneventfully. This case suggests that left ostial anastomosis re-exploration should be carefully considered when no other cause of coronary insufficiency is obvious, and that retrograde cardioplegia may be useful to detect embolization in the left coronary system.

Leukocyte depletion during extracorporeal circulation allows better organ protection but does not change hospital outcomes.

BACKGROUND: Leukocyte filtration has been reported to reduce inflammatory damage during cardiopulmonary bypass. We evaluated the role of leukocyte filtration on hospital outcome and postoperative morbidity. METHODS: Eighty-two consecutive patients who underwent isolated coronary artery bypass grafting were randomly assigned (1:1) to receive leukocyte filters on both arterial and cardioplegia lines or standard arterial filters during cardiopulmonary bypass. Hospital outcome, postoperative markers of morbidity, and biochemical assays were compared. Data were collected preoperatively, intraoperatively, and postoperatively. Costs for patients receiving intraoperative leukofiltration were compared with control patients getting standard arterial filters. RESULTS: Hospital mortality and intensive care unit and hospital length of stay were similar. Although duration of ventilation and incidence of pneumonia were comparable, leukocyte-depleted patients showed a higher ratio of arterial partial pressure of oxygen to fraction of inspired oxygen (p = 0.008) and lower need for postoperative noninvasive ventilation (p = 0.041). Control patients showed higher need for continuous furosemide infusion (p = 0.013) and for renal replacement therapy (p = 0.014), in association with higher serum creatinine (p = 0.038) and blood urea (p = 0.18) and lower glomerular filtration rate (p = 0.038). Leukocyte-depleted patients required lower doses of inotropic agents (p = 0.56), whereas troponin I leakage and incidence of postoperative atrial fibrillation were comparable. No differences were found in terms of postoperative cerebral dysfunction or neutrophil and platelet counts, as well as postoperative bleeding and need for transfusions. Finally, leukodepletion proved significantly cost-beneficial, with a 37% cost reduction. CONCLUSIONS: Although hospital outcomes were similar in terms of mortality and length of stay, the improvements in pulmonary, renal, and myocardial function, in association with the cost benefit, justify the use of leukocyte-depletion filters in the clinical practice.