Two cases of hemodynamic improvement by modulation of atrioventricular delay in cardiac operations.

BACKGROUND: Symptomatic sick sinus syndrome is one of the indications for pacemaker implantation, and we have to consider to program the pacemaker to an asynchronous pacing mode during an operation. CASE PRESENTATION: We reported two cases with a pacemaker implanted for sick sinus syndrome undergoing cardiac operation. We changed programming of the pacemaker to an asynchronous pacing mode (DOO) and modulated the programmed atrioventricular delay to avoid ventricular pacing, resulting in better hemodynamic condition. Although we observed premature ventricular contraction, no lethal arrhythmias induced by the R-on-T phenomenon were noted. CONCLUSION: Programming of the pacemaker to an asynchronous pacing mode and modulation of the programmed atrioventricular delay to avoid ventricular pacing may be an option for pacemaker management during an operation.

Articulation of postsurgical patient discharges: coordinating care transitions from hospital to home.

BACKGROUND: Cardiac surgery patients are at high risk for readmissions after hospital discharge- few of these readmissions are preventable by mitigating barriers underlying discharge care transitions. An in-depth evaluation of the nuances underpinning the discharge process and the use of tools to support the process, along with insights on patient and clinician experiences, can inform the design of evidence-based strategies to reduce preventable readmissions. OBJECTIVE: The study objectives are 3-fold: elucidate perceived factors affecting the postsurgical discharge care transitions of cardiac surgery patients going home; highlight differences among clinician and patient perceptions of the postsurgical discharge experiences, and ascertain the impact of these transitions on patient recovery at home. METHODS: We conducted a prospective multi-stakeholder study using mixed methods, including general observations, patient shadowing, chart reviews, clinician interviews, and follow-up telephone patient and caregiver surveys/interviews. We followed thematic and content analyses. FINDINGS: Participants included 49 patients, 6 caregivers, and 27 clinicians. We identified interdependencies between the predischarge preparation, discharge education, and postdischarge follow-up care phases that must be coordinated for effective discharge care transitions. We identified several factors that could lead to fragmented discharges, including limited preoperative preparation, ill-defined discharge education, and postoperative plans. To address these, clinicians often performed behind-the-scenes work, including offering informal preoperative preparation, tailoring discharge education, and personalizing postdischarge follow-up plans. As a result, majority of patients reported high satisfaction with care transitions and their positive impact on their home recovery. DISCUSSION AND CONCLUSIONS: Articulation work by clinicians (ie, behind the scenes work) is critical for ensuring safety, care continuity, and overall patient experience during care transitions. We discuss key evidence-based considerations for re-engineering postsurgical discharge workflows and re-designing discharge interventions.

Mean platelet volume-to-platelet count ratio after elective cardiac surgical procedures is superior in reflecting platelets metabolic hyperactivity compared to other routine morphological platelet indices: A preliminary report.

BACKGROUND: Excessive metabolic excitation of platelets after cardiac procedures may be related to some adverse events but assessment of their metabolic activity is not routine. The purpose of this study was to evaluate which of the basic platelet morphological parameters best reflects their metabolic status. METHODS: The blood samples of 22cardiac surgical patients (mean age of 62.3 ± 10.3 years) were taken before surgery (BS), and 1, 24 and 48 hours after the operation. Correlations between morphological platelet parameters (platelet count [PLT], mean platelet volume [MPV], platelet distribution width [PDW] and MPV/PLT) and their metabolic activity (total concentration of malondialdehyde [MDA] and MDA/PLT) were estimated. RESULTS: Significant decline in PLT after operation (from 223 ± 44 × 10¹²/L to 166 ± 57 × 10¹²/L) was accompanied by marked increase in MPV (from 8.4 ± 0.9 fL to 9.1 ± 1.2 fL) and no change of PDW. Consequently, MPV/PLT index increased significantly after procedures from (median with IQR) 0.038 (0.030-0.043) to 0.053 (0.043-0.078). Simultaneously, a significant increase in total platelet MDA content and MDA/PLT was noted reaching peak levels soon after operation. The strongest correlation was observed between MPV/PLT and MDA/PLT (r = 0.56; p < 0.001), although the others were also found to be significant (MDA/PLT vs. MPV; r = 0.35; MDA/PLT vs. PDW; r = 0.34). CONCLUSIONS: Among basic morphological parameters and indices, the MPV-to-PLT ratio reflects the best metabolic status of platelets in cardiac surgical patients.

Feasibility of coronary CT angiography for guidance of CABG.

OBJECTIVE: To assess the clinical safety and effectiveness of coronary revascularization in patients who underwent coronary artery bypass grafting (CABG) based exclusively on coronary computed tomography angiography (CCTA) results. METHODS: 53 patients (62.3 ± 7.1 years) underwent CCTA before a CABG surgery without prior invasive coronary angiography (ICA). Primary endpoints were all-cause mortality and major adverse cardiovascular events (MACE). The secondary endpoint was quality of life (QoL) assessed with the Minnesota Living with Heart Failure Questionnaire (MLHFQ). All were collected one year after the surgery. RESULTS: CCTA revealed multivessel coronary artery disease (CAD) in 52 patients. Indication for bypass surgery was made exclusively based on CCTA results. 136 distal anastomoses were performed. Assessment at 1 year (13.3 ± 1.4 months) was completed in 98.1% of the patients. MACE and mortality rates were 0%. The MLHFQ total score was 21.8 ± 8.7, and active lifestyle was maintained in all patients. CONCLUSIONS: In this proof of concept prospective pilot study, we observed that non-invasive coronary angiography may provide adequate anatomic detail to guide CABG surgery. Further study of this concept is warranted.

Flexible Textile-Based Pressure Sensing System Applied in the Operating Room for Pressure Injury Monitoring of Cardiac Operation Patients.

Pressure injury is the most important issue facing paralysis patients and the elderly, especially in long-term care or nursing. A new interfacial pressure sensing system combined with a flexible textile-based pressure sensor array and a real-time readout system improved by the Kalman filter is proposed to monitor interfacial pressure progress in the cardiac operation. With the design of the Kalman filter and parameter optimization, noise immunity can be improved by approximately 72%. Additionally, cardiac operation patients were selected to test this developed system for the direct correlation between pressure injury and interfacial pressure for the first time. The pressure progress of the operation time was recorded and presented with the visible data by time- and 2-dimension-dependent characteristics. In the data for 47 cardiac operation patients, an extreme body mass index (BMI) and significantly increased pressure after 2 h are the top 2 factors associated with the occurrence of pressure injury. This methodology can be used to prevent high interfacial pressure in high-risk patients before and during operation. It can be suggested that this system, integrated with air mattresses, can improve the quality of care and reduce the burden of the workforce and medical cost, especially for pressure injury.

Cardiac operation under cardiopulmonary bypass during pregnancy.

BACKGROUND: Certain pregnant women suffer from cardiac pathology,and a few of them need cardiac operations under cardiopulmonary bypass during pregnancy. Feto-neonatal and maternal outcomes have not been sufficiently described. METHODS: We conducted a retrospective review of 22 cases of women undergoing cardiac operations under cardiopulmonary bypass during pregnancy in our hospital from Jan.2014 to Mar.2019. RESULTS: All 22 patients were alive after treatment. The types of cardiac disorders included congenital heart defects, rheumatic heart disease,infective endocarditis,aortic dissection, obstruction and/or thrombosis of a prosthetic valve. Only one case was a twin pregnancy,and the other 21 cases were singletons. Four fetuses died in the utero after surgery. Three patients chose termination of the pregnancy after the cardiac operations: one fetus was detected abnormity of the brain and the other two patients abandoned pregnancy. Fourteen fetuses were alive and born without any abnormity. Two fetuses suffered from neonatal intracranial hemorrhage and died after birth. CONCLUSIONS: Cardiac operation under cardiopulmonary bypass during pregnancy is a challenge for physicians in multidisciplinary teams. Strictly evaluating the indication is vital. On the other hand, some patients can benefit from this management.

Prenatal echocardiographic diagnosis and differential diagnosis of fetal double outlet ventricle / 中华超声影像学杂志

Objective To investigate the clinical value of prenatal diagnosis of fetal double outlet ventricle . Methods T he data of double outlet ventricle from fetal echocardiography in Second Xiangya Hospital of Central South University and Changde Women and Children Health Hospital of Hunan Province from January 2000 to August 2018 were collected . T he statistical method was used to analyze characteristics of echocardiography ,related‐intracardiac and extracardiac abnormalities ,postnatal echocardiography ,surgery and autopsy findings . Results Ninety‐four fetuses were diagnosed with double outlet ventricle ,including 84 cases of double outlet right ventricle ( DORV ) and 10 cases of double outlet left ventricle ( DOLV ) . T he pregnancy was terminated in 45 cases . Autopsy was offered to all patients after termination of pregnancy ,42 cases were consistent with prenatal diagnosis ,1 case was tetralogy of fallot ,2 cases were transposition of great artery . Forty‐nine cases were decided to continue the pregnancy ,32 cases of them were confirmed by postpartum surgery ,17 cases were confirmed by postnatal echocardiography . Echocardiographic findings of fetal double outlet ventricle was characterized by the origin of the both great arteries arising predominantly or completely( ＞50% ) from the same ventricle . Conclusions Prenatal ultrasound diagnosis of double outlet ventricular has important clinical value ,facilitate appropriate prenatal counseling and postnatal management and it should be differentiated with transposition of the great arteries ,tetralogy of fallot and ventricular septal defect .

Effect of goal-directed therapy bundle based on PiCCO parameters to the prevention and treatment of acute kidney injury in patients after cardiopulmonary bypass cardiac operation: a prospective observational study / 中华危重病急救医学

Objective To explore the effect of goal-directed therapy bundle based on pulse-indicated continuous cardiac output (PiCCO) parameters to the prevention and treatment of acute kidney injury (AKI) in patients after cardiopulmonary bypass cardiac operation. Methods A prospective observational study was conducted. The adult patients with selective cardiopulmonary bypass cardiac operation admitted to the Third People's Hospital of Chengdu from December 2015 to January 2018 were enrolled. All patients were divided into two groups based on informed consent for PiCCO monitor at the time of admission to the intensive care unit (ICU): regular monitoring and treatment group (group A) and goal-directed therapy group based on PiCCO parameters (group B). In group A, the restrictive capacity management strategy was implemented to maintain the mean arterial pressure (MAP) > 65 mmHg (1 mmHg = 0.133 kPa) and the central venous pressure (CVP) between 8 mmHg and 10 mmHg. In group B, volume and hemodynamic status were optimized depending on PiCCO parameters to a goal of cardiac index (CI) > 41.68 mL·s-1·m-2, global end diastolic volume index (GEDVI) > 700 mL/m2 or intrathoracic blood volume index (ITBVI) > 850 mL/m2, extravascular lung water index (EVLWI) < 10 mL/kg, and MAP > 65 mmHg. Then the changes in hemodynamics and different prognosis of the patients in two groups were observed. Risk factors affecting the AKI were analyzed by Logistic regression. Results 171 cases were included, with 68 in group A and 103 in group B. There were no significant differences in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), operation ways, operation time, cardiopulmonary bypass time, intraoperative dominant liquid equilibrium quantity, the use of intra-aortic balloon counterpulsation (IABP) during operation, and serum creatinine (SCr) level at the time of admission to ICU between the two groups. There were no significant differences in CVP within 24 hours after admission to ICU between the two groups. MAP in group B was significantly higher than that in group A at 8 hours and 16 hours after ICU admission (mmHg: 68.9±6.3 vs. 66.7±5.1, 69.0±4.9 vs. 67.0±5.3, both P < 0.05). Sequential organ failure assessment (SOFA) score in group B was significantly lower than that in group A at 24 hours after ICU admission (5.7±2.2 vs. 6.9±2.8, P < 0.05). Dominant liquid equilibrium quantity in group B was significant higher than that in group A at 24 hours after ICU admission (mL/kg: 7.1±6.2 vs. -0.1±8.2, P < 0.01), but there was no significant difference of that between groups at 48 hours and 72 hours after ICU admission. Compared with group A, incidence of combination with AKI during 72 hours after ICU admission was significantly decreased in group B [48.5% vs. 69.1%; odds ratio (OR) =0.422, 95% confidence interval (95%CI) = 0.222-0.802, P < 0.05], and incidence of moderate to severe AKI was also significantly decreased in group B (19.4% vs. 35.3%; OR = 0.442, 95%CI = 0.220-0.887, P < 0.05). There was no significant difference in usage of continuous renal replacement therapy (CRRT) after ICU admission between both groups (group A was 4.4%, group B was 4.9%, P > 0.05). It was shown by correlation analysis that only MAP and CI at 8 hours after ICU admission were significantly negatively correlated with AKI (MAP and AKI: r = -0.697, P = 0.000;CI and AKI: r = -0.664, P = 0.000). It was shown by Logistic regressive analysis that the MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI at 72 hours after ICU admission (MAP:OR = 0.736, 95%CI = 0.636-0.851, P = 0.000; CI: OR = 0.006, 95%CI = 0.001-0.063, P = 0.000). There were no significant differences in the duration of mechanical ventilation, the length of ICU stay, the post-operation complications (except AKI), 7-day and 28-day mortality between the two groups. Conclusions Goal-directed therapy bundle based on PiCCO parameters reduced the incidence of AKI in patients after cardiopulmonary bypass cardiac operation and improved the severity of systemic disease. However, it did not reduce the duration of mechanical ventilation, length of ICU stay, the incidence of complications (except AKI), short-term mortality. The MAP and CI at 8 hours after ICU admission were independent risk factors that influence the incidence of AKI in patients after cardiopulmonary bypass cardiac operation.

Long-Term Results of Surgical Atrial Fibrillation Radiofrequency Ablation: Comparison of Two Methods.

BACKGROUND: This retrospective study aimed to evaluate the long-term results of two kinds of surgical atrial fibrillation radiofrequency ablations in concomitant cardiac operations. METHODS: We enrolled 129 patients from January 2006 to December 2015 and performed cardiac operations concomitantly with surgical atrial fibrillation. The patients were divided into a biatrial MAZE group (94 patients) and a left atrial MAZE group (35 patients). A preoperative baseline was compared with intraoperative and postoperative data. Similarly, complications and follow-up results were compared. A matching process based on propensity-score was performed to equalise the potential prognostic factors in both groups and to formulate a balanced 2:1 matched cohort study. RESULTS: There were four deaths (4.3%) in the biatrial MAZE group and one death in left atrial MAZE group due to multiple organ failures followed by low cardiac output. No permanent pacemaker implantations were used in either group. The sinus rhythm maintenance rates at the 6-month, 1-year, 6-year and 8-year follow-ups between the biatrial MAZE group and the left atrial MAZE group were not significantly different (84.7%, 83.3%, 67.3%, and 58.8% vs. 84.9%, 77.4%, 61.1%, and 50%, p>0.05). Similarly, between the propensity-score matched groups, there were no significant differences. CONCLUSION: The left atrial MAZE ablation for the patients with mitral valve diseases who needed open cardiac operation was safe and effective when compared with the biatrial MAZE ablation group.

Clinical analysis of perioperative application and complications of Intra-aortic Balloon Pump in cardiac surgery / 中国综合临床

Objective To assess the perioperative efficacy and complications of intra-aortic balloon pump(IABP) in patients with cardiac operation.Methods A total of 36 cases with IABP patients from January 2011 to September 2016 were studied in Luhe Hospital of Beijing Affiliated to Capital Medical University,inluding 27 patients with coronary atherosclerotic heart disease(CAD),8 patients with valvular heart diseaseand and 1 patient with left atrial myxoma.The clinical data was collected to analyze IABP efficacy and complications.Results There were 10(27.8%) patients died,the mortality rate of CAD patients was lower than that of non-CAD patients(18.5% vs.55.6%,X2=4.615,P=0.032).The related complications after IABP implantation included:6(16.7%) cases suffered from thrombocytopenia,3(8.3%) cases with lower limb ischemia,2(5.6%) cases with lower extremity arterial thromboembolism,2(5.6%) cases with femoral artery pseudoaneurysm,2(5.6%) cases with acute pancreatitis,1(2.8%) cases with intestinal necrosis by mesenteric ischemia,2(5.6%) cases with gastrointestinal bleeding,3(8.3%) cases with hemorrhage in puncture site,4(11.1%) cases of fever,1(2.8%) case with pipeline leak,and 1(2.8%) case no pressure lumen data.After treatment with IABP,in 26 cases survival patients,the hemodynamic indexes(mean arterial pressure,heart rate,central venous pressure,urine volume) were significantly improved and the amount of dopamine and epinephrine decreased(t=-22.35,64.41,53.31,-23.82,26.07,14.15 respectively,P<0.05).Conclusion IABP can significantly improve the perioperative efficacy.The active treatment on complications is important to reduce the death induced by IABP.

The value of end-tidal carbon dioxide partial pressure combined passive leg raising test on volume responsiveness assessment in shocked patients post cardiac operation / 中华危重病急救医学

Objective To assess the value of end-tidal carbon dioxide partial pressure (PETCO2) combined passive leg raising (PLR) test on volume responsiveness assessment in shocked patients post cardiac operation.Methods A prospective,self-controlled,and observational study was conducted.The shocked patients post cardiac operation undergoing complete mechanical ventilation admitted to Department of Critical Care Medicine of First Affiliated Hospital of College of Medicine,Zhejiang University from June 2014 to October 2015 were enrolled.PETCO2 and hemodynamic parameters including stroke volume variation (SVV),cardiac index (CI),mean arterial pressure (MAP) monitored by a pulse indicator continuous cardiac output (PiCCO) were determined before and after PLR and volume expansion (VE).Volume responsiveness was defined as an increase in CI (△ CI) of 15％ or greater after VE,namely response group (△ CI ≥ 15％) and non-response group (△ CI ＜ 15％).The value of PLR-induced PETCO2 change (△PETCO2 PLH) to predict volume responsiveness was evaluated by receiver operating.characteristic curves (ROC).Results Among the 41 patients enrolled,21 had volume responsiveness (response group),and 20 had no responsiveness (non-response group).After PLR,the changes in CI and PETCO2 were both significantly increased in the response group compared with non-response group [△ CI:(13.5 ± 4.6)％ vs.(3.6± 3.5)％,△ PETCO2:(7.4 ± 3.4)％ vs.(2.8 ± 2.5)％,both P ＜ 0.05].△ PETCO2 PLR and baseline SVV were positively correlated with PLR-induced CI change (△ CI PLR) (r1 =0.50,r2 =0.38,both P ＜ 0.05).VE-induced PETCO2 change (△ PETCO2 VE),baseline SVV and △ CI PLR were positively correlated with VE-induced CI (△ CI VE) (r1 =0.58,r2 =0.56 and r3 =0.84,all P ＜ 0.01).The area under ROC curve (AUC) of △ PETCO2 PLR was 0.875±0.054 [95％ confidence interval (95％CI) =0.769-0.981,P ＜ 0.05].△ PETCO2 PLR ≥ 5.8％ predicted volume responsiveness with sensitivity of 76.2％ and specificity of 90.0％.AUC of △CI PLR was 0.933±0.036 (95％CI =0.862-1.000,P ＜ 0.05).△CI PLR ≥ 10.4％ predicted volume responsiveness with sensitivity of 81.0％ and specificity of 90.0％.AUC of baseline SVV was 0.831 ±0.066 (95％CI =0.702-0.960,P ＜ 0.05).Baseline SVV ≥ 12.5％ predicted volume responsiveness with sensitivity of 85.7％ and specificity of 75.0％.Conclusion The change in PETCO2 induced by PLR is a convenient,reliable and non-invasive indicator to predict volume responsiveness in shocked patients post cardiac operation with mechanical ventilation.

Effect of stage 1 acute kidney injury on the prognosis of patients underwent cardiopulmonary bypass cardiac operation：an analysis results from 5 823 patients / 中华危重病急救医学

Objective To investigate the effect of stage 1 acute kidney injury (AKI) on the prognosis of patients underwent cardiopulmonary bypass (CPB) cardiac operation. Methods A retrospective analysis was conducted. All patients aged ≥ 18 years who underwent cardiac operation with CPB admitted to Beijing Anzhen Hospital from July 1st, 2013 to December 31st, 2015 were enrolled. According to the standard of serum creatinice (SCr) of Kidney Disease Improving Global Outcomes (KDIGO) criteria, the AKI patients with stage 1 and non-AKI patients were served as the research objects. Perioperative clinical data of two groups were collected, and the prognosis was recorded during follow up to draw the Kaplan-Meier survival curve. Cox regression model was used to analyze the risk factors of prognosis in patients with stage 1 AKI experienced CPB during cardiac operation. Results A total of 5 823 patients were enrolled, of which 1 285 patients with AKI, and those in stage 1 was 998, accounting for 77.67% of total AKI patients; and 4 538 in non-AKI group. The mean follow-up period among survivors was (23.13±12.28) months. Compared with non-AKI patients, 30-day mortality of patients with stage 1 AKI was significantly increased [4.00% (40/998) vs. 0.40% (18/4 538), P < 0.01]. It was showed by Kaplan-Meier survival analysis that the cumulative survival rate of patients with stage 1 AKI was significantly lower than that of non-AKI patients (log-rank = 51.989, P < 0.001). It was showed by further subgroup analysis that the cumulative survival rate of patients with stage 1 AKI without serum creatinine (SCr) recovery was significantly lower than that of patients with SCr recovery from stage 1 AKI (log-rank = 43.580, P = 0.000). It was showed by Cox multivariate analysis that stage 1 AKI [hazard ratio (HR) = 2.725, 95% confidence interval (95%CI) = 1.810-4.230, P = 0.000] and prolonged CPB in patients undergoing cardiac operation (HR = 1.013, 95%CI = 1.001-1.017, P = 0.000), combined with coronary heart disease (HR = 1.046, 95%CI = 1.010-1.063, P = 0.005) and diabetes mellitus (HR = 1.060, 95%CI = 1.010-1.090, P = 0.002) were independent risk factors of death in patients undergoing CPB during cardiac operation. Conclusion Stage 1 AKI is the main stage of AKI and it is independently related to all-cause mortality in patients underwent cardiovascular operation using CPB.

Effect of intraoperative fluid overload on prognosis of patients after cardiopulmonary bypass cardiac operation：a prospective observational study / 中华危重病急救医学

Objective To explore the clinic values of intraoperative fluid overload in evaluating the perioperative prognosis of patients after cardiopulmonary bypass cardiac operation. Methods A prospective observational study was conducted. The adult patients admitted to the Third People's Hospital of Chengdu from April 2014 to March 2016 for selective cardiopulmonary bypass cardiac operation monitored by pulmonary artery catheter or pulse-indicated continuous cardiac output (PiCCO) were selected. All patients received therapy with restrictive fluid management strategy after admission to the intensive care unit (ICU) and were divided into two groups based on the value of intraoperative fluid accumulation ratio at the time of admission to the ICU: group A with intraoperative fluid accumulation ratio of less than 10% and group B with equal to or more than 10%. Then the changes and different prognosis of the patients in groups were observed. Risk factors affecting the prognosis were analyzed using logistic regression, and the predictive values of various parameters on prognosis were analyzed using receiver operating characteristic curve (ROC). Results 224 cases were included, with 172 in group A and 52 in group B. No significant differences were found between both groups in gender, age, pre-operative scores by European system for cardiac operative risk evaluation (EuroScore), acute physiology and chronic health evaluation Ⅱ (APACHE Ⅱ) and sequential organ failure assessment (SOFA), operation ways, operation time, cardiopulmonary bypass time and blood loss (all P > 0.05). Both APACHE Ⅱ score and SOFA score in group B were significantly higher than those in group A at admission and 24, 48 and 72 hours after ICU admission (APACHE Ⅱ: 24.5±4.1 vs. 21.8±3.5, 14.8±6.5 vs. 9.9±3.9, 12.3±5.4 vs. 9.4±3.7, 10.9±5.0 vs. 8.9±3.3, SOFA: 12.3±2.9 vs. 10.6±2.1, 8.8±2.8 vs. 5.7±1.7, 7.2±3.0 vs. 5.0±2.0, 6.4±3.6 vs. 5.2±1.7, all P < 0.05). Compared with group A, incidence of combination with acute kidney injury (AKI) was significantly increased in group B (92.3% vs. 68.6%, P < 0.01), the level of post operation cardiac index (CI) was significantly lower in group B (mL·s-1·m-2: 40.67±4.00 vs. 49.84±7.50, P < 0.01). Both the duration of mechanical ventilation and the length of stay in the ICU in group B were significant longer than those in group A (days: 3.2±2.1 vs. 1.8±1.3, 5.0±1.7 vs. 3.6±1.2, both P < 0.01). The post-operation complications, 7-day and 28-day mortality in group B were all significantly higher than those in group A (65.4% vs 30.2%, 19.2% vs. 1.7%, 26.9% vs. 3.5%, all P < 0.01). Logistic regressive analysis showed that after controlling the influence of postoperative AKI and CI on mortality, the intraoperative fluid accumulation ratio at ICU admission was still an independent risk factor [odds ratio (OR) of 7-day mortality = 1.380, 95% confidence interval (95%CI) = 1.019-1.869, P = 0.037; OR of 28-day mortality = 1.302, 95%CI = 1.026-1.654, P = 0.030]. The area under the curve of ROC (AUC) in predicting the 28-day mortality of patients after operation using intraoperative fluid accumulation ratio was 0.874 (P = 0.000), with a sensitivity of 95.0 % and a specificity of 78.4% at the optimal threshold value of 7.5%. Conclusions Intraoperative fluid overload in patients admitted to the ICU would aggravate their condition, prolong the duration of mechanical ventilation and the length of ICU stay, and increase post-operative complications morbidity and mortality. After controlling the influence of AKI and cardiac insufficiency on mortality, the fluid overload was still an independent risk factor for the death of patients after cardiopulmonary bypass cardiac operation.

Clinical therapy for blood culture-negative infective endocarditis / 中国综合临床

Objective To summarize the clinical treatment experience of blood culture-negative infective endocarditis,and to explore the surgery chance and therapeutic strategy of blood culture-negative endocarditis. Methods One hundred and sixty-six patients who were diagnosed blood culture-negative endocarditis in the Aisa Heart Hospital of Wuhan from Jul. 2008 to Dec. 2012 were recruited in the study. Broad-spectrum antibiotics including cefuroxime axetil and levofloxacin were used before the result of blood culture,and sensitive antibiotics were selected to control patient's condition when getting the result of blood culture. But broad-spectrum antibiotics were continuously used to the blood culture-negative endocarditis until stable condition. When the conditions were stable,active preparation before surgery should be carried out. Thoroughly clear the vegetation and protect the cardiorespiratory function during operating. Kata-step antibiotics were used to control patient's condition until normal temperature,as well as the number of leukocytes decreased,blood sedimentation normalized and C-reaction protein decreased. Then,the narrow-spectrum antibiotics were selected including cephalosporin until discharged from hospital,and continued treatment of antibiotics for 4 - 6 weeks. Results Five patients died after the operation,including 1 case died of low cardiac output syndrome,2 cases died of multiple organ failure,1 case died of septicemia and the 1 case died of cerebral embolism. All the other patients discharged from hospital successfully. Conclusion The patients with blood culture-negative IE should be controlled rapidly. The duration and dose of antibiotics should be enough. Active operative preparation should be taken and then surgery timely. Thus,the hospital mortality could decrease and prompt the long-term outcome.

A Comparison of the Performance of Myocardial Videodensitometry, Tissue Velocity Imaging and Tissue Tracking in Discrimination Between ST-Segment Elevation Ischemic Reperfusion Injury and Normal Reperfusion State After Non-Beating Cardiac Operation.

BACKGROUND: The timely diagnosis of presence or absence of reperfusion injury after cardiac operation is critical for the patient's outcome. Whether transesophageal echocardiography (TEE) acquisition of regional grayscale intensity (TI), velocity, and displacement (D) after cardiac operation can discriminate between patients with ST-segment elevation ischemic reperfusion injury (STEIRI) and normal reperfusion state remains unknown. OBJECTIVES: In this study, we investigated whether these parameters can effectively reflect the situation of ST-segment elevation ischemic reperfusion injury (STEIRI) in patients after cardiac operation and which has a higher performance of discrimination between patients with and without STEIRI. PATIENTS AND METHODS: The maximal and minimal grayscale intensity in the cardiac cycle [TI (max), TI (min)], the difference of TI (max) and TI (min) [TI (max-min)], the cyclic variation index of TI [TI (CVI)], the systolic velocity (Vs), the early diastolic velocity (Ve), the late diastolic velocity (Va) and the peak displacement in the cardiac cycle (D) at the lateral side of the mitral annulus were measured and compared between patients with and without STEIRI. The performance of these parameters in discriminating between patients with and without STEIRI was analyzed. RESULTS: Compared with the patients without STEIRI, the patients with STEIRI had significantly smaller TI (max-min), TI (CVI), Vs, Ve, Va and D (P<0.05). With the use of these parameters as the criteria to distinguish patients with STEIRI from patients without STEIRI, the areas under the receiver operating characteristic curve were 0.86 for TI (max-min), 0.99 for TI (CVI), 0.89 for Vs, 0.71 for Ve, 0.85 for Va and 0.82 for D. For the best cut-off value of TI (CVI) of less than 34.45%, the sensitivity, specificity and accuracy for the prediction of patients with STEIRI were 94.74%, 97.05%, and 96.22%, respectively. CONCLUSION: The myocardial grayscale intensity, velocity and displacement can effectively reflect the situation of STEIRI in patients after cardiac operation, and TI (CVI) has a higher performance in discriminating between patients with and without STEIRI.

Procalcitonin for the differential diagnosis of infectious and non-infectious systemic inflammatory response syndrome after cardiac operation / 中华危重病急救医学

Objective To assess the value of procalcitonin (PCT) for the differential diagnosis between infectious and non-infectious systemic inflammatory response syndrome (SIRS) after cardiac operation.Methods Patients diagnosed with SIRS after cardiac surgery and admitted to Department of Cardiovascular Surgery of Tokyo Medical and Dental University Graduate School between April 1st,2011 and March 31st,2013 were retrospectively studied.A total of 142 patients with SIRS were included,and they were divided into infectious group (n =47) or non-infectious group (n =95) according to the diagnostic criteria of the Surviving Sepsis Campaign Guidelines for Management of Severe Sepsis and Septic Shock:2012 (SSCG2012).The patients with infectious SIRS were included,and there were 11 with sepsis,12 with severe sepsis without shock,and 24 with septic shock respectively.The clinical data of patients were compared,and the receiver operating characteristic curve (ROC curve) was plotted to assess the diagnostic value of infection and non-infectious diseases for PCT,C-reactive protein (CRP) and white blood cell count (WBC),as well as the diagnosis of the severity of sepsis.Results PCT,CRP,and WBC were significantly higher in the infectious SIRS group than those in the non-infectious SIRS group [PCT (μg/L):2.80 (1.24,10.20) vs.0.10 (0.06,0.21),Z=-9.020,P=0.001; CRP (mg/L):158.0 (120.0,199.0) vs.58.0 (25.0,89.0),Z=-7.264,P=0.001; WBC (× 109/L):15.5 (11.0,22.6) vs.9.3 (7.2,12.6),Z=-5.792,P=0.001].PCT had the highest sensitivity (91.5％) and specificity (93.7％) for differential diagnosis,with a cut-off value for infectious SIRS of 0.47 μg/L,and the cut-offvalue of CRP and WBC were 119.5 mg/L and 10.85 × 109/L,respectively.There was no significant difference in WBC among sepsis group,severe sepsis group,and septic shock group [× 109/L:12.40 (9.10,24.20),13.30 (9.93,16.93),20.40 (13.45,28.6),x2=5.638,P=0.060],while PCT,CRP had significant difference [PCT(μg/L):1.37 (0.72,1.85),3.16 (0.48,13.24),3.68 (1.67,20.96),x2=7.422,P=0.024; CRP (mg/L):120.0(74.0,180.0),135.7 (81.7,181.3),171.1 (151.5,306.0),x2=9.524,P=0.009].PCT was more reliable than CRP in diagnosing severe sepsis without shock,but it was ineffective for diagnosing septic shock.The cut-off value of PCT for diagnosing severe sepsis without shock was 2.28 μg/L,and the sensitivity was 66.7％,specificity was 90.9％.Cut-off value of CRP for the diagnosis of septic shock was 149.5 mg/L,with the sensitivity of 83.3％,and the specificity of 66.7％.Conclusions PCT was a useful marker for the diagnosis of infectious SIRS after cardiac operation as compared with WBC and CRP.The optimal PCT cut-off value for diagnosing infectious SIRS was 0.47 μg/L.

Values of mixed venous oxygen saturation and difference of mixed venous-arterial partial pressure of carbon dioxide in monitoring of oxygen metabolism and treatment after open-heart operation / 中华危重病急救医学

Objective To explore the clinic values of early goal directed treatment (EGDT)with the target of mixed venous oxygen saturation (SvO2)and difference of mixed venous-arterial partial pressure of carbon dioxide (Pv-aCO2) in monitoring of oxygen metabolism and treatment for patients post open-heart operation. Methods A prospective study was conducted. The adult patients admitted to Third People's Hospital of Chengdu from December 2011 to March 2014 with SvO22 mmol/L when admitted in intensive care unit(ICU)were selected on whom elective open-heart operation and pulmonary artery catheter examination were done. All patients received EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg (1 mmHg=0.133 kPa)and were divided into three groups by the values of SvO2 and Pv-aCO2 at 6-hour after ICU admission:A group with SvO2≥0.65 and Pv-aCO2<6 mmHg,B group with SvO2≥0.65 and Pv-aCO2≥6 mmHg,and C group with SvO2<0.65. Then the changes and prognosis of the patients in different groups were observed. Results 103 cases were included,44 in A group,31 in B group and 28 in C group. The acute physiology and chronic health evaluationⅡ (APACHEⅡ)score in group A were significantly lower than that in group B or C at 6,24,48 and 72 hours (T6,T24,T48,T72)of ICU admission (T6:11.4±5.8 vs. 13.9±5.4,13.7±6.4;T24:8.8±3.7 vs. 10.8±4.8,11.8±5.4;T48:8.7±4.1 vs. 9.6 ±4.2,10.2 ±5.1;T72:7.5 ±3.4 vs. 8.6 ±2.9,9.2 ±4.2,all P<0.05),and the sequential organ failure assessment (SOFA)showed the same tendency (T6:6.5±4.3 vs. 8.0±3.8,9.1±4.5;T24:6.6±3.6 vs. 8.6±3.9, 8.5±3.3;T48:5.2±3.4 vs. 7.0±3.6,7.6±5.1;T72:4.6±2.4 vs. 5.8±2.5,6.8±3.5,all P<0.05). The values of blood lactic acid (mmol/L)in group A and B were significant lower than that in group C at T6,T24,T48 and T72 (T6:1.60 ±0.95,2.20 ±1.02 vs. 2.55 ±1.39;T24:2.26 ±1.26,2.70 ±1.36 vs. 3.34 ±2.36;T48:2.01 ±1.15, 2.17 ±1.51 vs. 2.42 ±1.63;T72:1.62 ±1.14,1.64 ±0.75 vs. 2.11 ±1.29,all P<0.05). The time of machine ventilation(days)in group A or B was significantly shorter than that in group C(2.8±2.0,3.6±2.3 vs. 5.0±3.1,both P<0.05). ICU day (days)in group A was significant shorter than that in group C (4.6±2.5 vs. 6.5±3.7,P<0.05). The 7-day mortalities after operation in three groups were significantly different. Compared with group A (2.3%),the odds ratio (OR)in group B (22.6%)was 12.5 (P<0.05),group C (25.0%)14.3 (P<0.05). The morbidity and 28-day mortality in three groups were not significantly different. Pv-aCO2 negatively correlated with cardiac index(CI, r=-0.685,P=0.000),but not correlated with blood lactic acid(r=0.187,P=0.080). Conclusions EGDT with the target of SvO2≥0.65 and Pv-aCO2<6 mmHg improved the general condition and tissue hypoxia,shortened the time of machine ventilation and duration of hospitalization in ICU,and decrease the 7-day mortality.

Effect of topical N-acetylcysteine in the prevention of postoperative pericardial adhesion formation in a rabbit model.

BACKGROUND: N-acetylcysteine (NAC), a precursor of reduced glutathione, has been in clinical use primarily as a mucolytic. In addition, NAC is well known for their free radical scavenging and antioxidant properties. Increasing of reactive oxygen products occurring during cardiac surgery can play an important role in postoperative adhesion formation. We investigated to the efficacy of the NAC for postoperative pericardial adhesions. METHODS: Sixteen New Zealand white rabbits (2.5-3 kg) were used and categorized into two groups including study (use of NAC) and control groups. In both groups, the pericardium was opened longitudinally, and the exposed epicardial surfaces were abraded with dry gauze. The rabbits were divided into two groups: Group 1 was treated with the sponge, which impregnated with NAC solution, (10%, 300 mg/3 ml) and applied over the abraded epicardium for 5 min (n=8). Group 2 was the control, and the sponge, which was impregnated with 3-ml isotonic NaCl solution (0.9%), was applied onto the surface of the abraded epicardium for 5 min (n=8). After a period of 2 weeks, the animals were sacrificed. The scores of adhesion were graded by macroscopic examination, and the pericardial tissues were analyzed microscopically in point of inflammation and fibrosis. RESULTS: In Group 1, the adhesion scores were significantly lower compared with the control group [Group 1 vs. 2; 1 (1-2) vs. 3 (2-3), P<.001]. No significant difference was found between the groups in terms of the severity of inflammation [Group 1 vs. 2; 1.5 (1-3) vs. 2.5 (1-3), P=.083]. There was a difference between groups in terms of the degree of fibrosis [Group 1 vs. 2; 2 (1-2) vs. 3 (2-3), P=.007]. CONCLUSIONS: The use of NAC for preventing postoperative pericardial adhesions was reduced to adhesion and fibrosis scores in an experimental rabbit model. There was no statistically significant difference between groups in terms of inflammatory scores. The NAC effectively prevented the formation of pericardial adhesion.

Preoperative assessment value of treadmill experimental Duke score of coronary artery disease in patients with non-cardiac surgery / 中国综合临床

Objective To analysis of treadmill exercise test Duke score(DTS) in patients with coronary heart disease than the evaluation functions of heart operation perioperative cardiac events.Methods One hundred and eighty-four patients with coronary heart disease,45 ～ 75 years of medium-sized non cardiac operation,were chose from May,2010 to May,2011 in our hospital,Cardiac ultrasound,treadmill exercise test were taken before operation,preoperative examination department of internal medicine disease history and physical examinations.According to the Duke score,they were divided into DTS in low risk group (5 ≤ Duke ≤ 15,n =124),medium risk group DTS(DTS:(-10≤Duke≤5,n =60),the exclusions of patients with high-risk DTS group,and the high-risk group of patients were excluded.Comparative analysis of operations,the main type of Department of internal medicine disease history,intraoperative and postoperative major cardiovascular complications.Results In the two groups of operation type and the type of anesthesia and cardiovascular disease,there is no significant difference (P ＞ 0.05) ; in DTS low risk group the age (59.2 ± 4.1) years,preoperative cardiac dysfunction were 2 cases,left ventricular ejection fraction ＜ 0.50 were 2 case (1.6％),diabetes history 12 case(9.6％),with angina pectoris symptoms of 51 case(41.1％),ECG ischemic changes in 55 (44.3 ％),in the medium DTS risk group,the age(65.2 ± 2.6)years,preoperative cardiac dysfunction were 8 cases(13.3％),left ventricular ejection fraction of ＜ 0.50 was 5 case (8.3％),diabetes history 23 case (38.3 ％),angina pectoris and 60 case (100％),ECG ischemic changes in 40 case (66.7 ％) (t =2.98,P =0.042,x2 values were 4.93,3.84,4.67,5.24,3.58,P ＜0.05).The low risk group of patients with arrhythmia,hypertension incidence rate were 6.5％ (8/124) and 22.5％ (28/124),medium risk group of patients with arrhythmia,hypertension incidence rate were 11.6％ (7/60) and 18.3％ (11/60),compared with DTS in low risk group,DTS medium risk group of arrhythmia and hypertension odds ratio(Odds Ratio,OR) and 95％ confidence intervals were 1.7 (0.8-3.3),0.8 (0.4-1.4),the P values were 0.062,0.074,has no significant difference.Controlling for age and sex DTS in low risk group postoperative myocardial infarction,cardiogenic pulmonary edema rate were 0.8％ (1/124) and 2.4％ (3/124),medium risk group after DTS myocardial infarction,cardiogenic pulmonary edema rate were 10％ (6/60) and 11.7％ (7/60),compared with DTS in low risk group,DTS medium risk group after myocardial infarction and heart pulmonary edema ratios (Odds Ratio,OR) and 95％ confidence intervals were 19.3 (5.6-66.2),5.7 (2.5-12.9),the P values were 0.002,0.003,had significant diflerence.Conclusion DTS medium risk group patients undergoing non cardiac operation preoperative heart failure,diabetes,angina symptoms,peri operation period of cardiac event rate is high and heavy.