Quantitative and functional changes in platelets and fibrinogen following cardiopulmonary by-pass in children.

Introduction: Cardiopulmonary bypass (CPB) causes coagulopathy, increasing the risk of postoperative bleeding and mortality. The underlying causes of post-CPB coagulopathy and the factors associated with its occurrence are not yet fully understood. This study assesses platelet and fibrinogen concentration and function following CPB in children with congenital heart diseases (CHD). Methods: We analyzed prospective data from 104 patients aged 0-16 years who underwent CPB surgery for CHD. Blood samples were collected before surgery and within 30 min of CPB completion. In addition to usual coagulation tests, functional analyses were performed using point of care systems with thromboelastometry and impedance aggregometry. Results: Platelet count, fibrinogen concentration, and platelet and fibrinogen activities significantly decreased after CPB. The duration of CPB was directly associated with a reduction in platelet count and fibrinogen level (r = -0.38, p < 0.001; r = -0.21, p = 0.03, respectively), but not with their measured activity. Postoperative percentages of baseline values for platelet count (58.36% [43.34-74.44] vs. 37.44% [29.81-54.17], p < 0.001) and fibrinogen concentration (73.68% [66.67-82.35] vs. 65.22% [57.89-70.83], p < 0.001) were significantly higher in patients who did not experience hypothermia during surgery. Age was inversely associated with the decrease in platelet count (r = 0.63, p < 0.001), TRAPTEM AUC (r = 0.43, p < 0.001), fibrinogen concentration (r = 0.44, p < 0.001) and FIBTEM MCF (r = 0.57, p < 0.001). Conclusion: Post-CPB coagulopathy is multifactorial and not solely attributed to hemodilution. It also involves functional changes in coagulation cascade components, which can be demonstrated by thromboelastometry and impedance aggregometry. Young children, patients requiring prolonged CPB surgery, or those experiencing hypothermia are particularly affected.

Airway management for right thoracoscopic tracheal tumour resection after left pneumonectomy assisted by cardiopulmonary bypass: a case report.

BACKGROUND: The incidence of secondary tracheal tumours following lung cancer surgery is notably low. Patients with tracheal tumours typically present with symptoms such as coughing, sputum production, haemoptysis, wheezing, stridor, and dyspnoea. In cases of peripheral structure invasion, symptoms may further extend to hoarseness and dysphagia. Initial symptoms may be notably non-distinct. However, the development of pronounced airway symptoms often signifies a critical condition. CASE PRESENTATION: A 70-year-old male with severe chest tightness and asthma was transferred to our hospital for emergency treatment. He had undergone left pneumonectomy for non-small cell carcinoma of the left upper lobe of the lung 3 years prior. The examination confirmed that a secondary tumour originated from the left main bronchus and extended to the carina, occupying 90% of the diameter of the tracheal lumen. To relieve the patient's emergency airway, we chose right thoracoscopic resection of the tracheal tumour assisted by cardiopulmonary bypass (CPB), which provides extracorporeal lung support and a good surgical field. CONCLUSION: In patients with secondary tracheal tumours after left pneumonectomy for lung cancer, perioperative airway management is challenging for anaesthesiologists, and patients' oxygenation should receive close attention. This article describes the airway management process of this patient for reference.

Association of Weight-indexed Conventional Ultrafiltration Volume with Post-operative Lactate in Patients Undergoing Cardiopulmonary Bypass.

Background: Conventional ultrafiltration (CUF) during cardiopulmonary bypass (CPB) is utilized to minimize hemodilution. However, removing high volumes leads to tissue hypoperfusion by activating the anaerobic glycolysis pathways. This study aimed to determine the association between weight-indexed CUF volumes and lactate in patients who underwent coronary artery bypass grafting (CABG). Methods: In this single-center retrospective study, 641 CABG patients, who were referred to Al-Zahra Hospital (Shiraz, Iran) and underwent CPB, during 2019-2021, were recruited. Peri-operative parameters were extracted from the patient's records. The patients with non-elective status, pre-existing liver and renal diseases, ejection fraction<35%, and repeated sternotomy were excluded from the study. An increase in post-operative lactate level≥4 mmol/L after 6 hours was defined as hyperlactatemia (HL). To predict HL, univariable and multiple logistic regression modeling, while controlling confounding factors, were employed. Results: The patients' mean age was 58.8±11.1 years, and 39.2% were women. The incidence of HL was 14.5% (93 patients). There was a significant association between weight-indexed CUF volume and HL. The volume removed in the HL patients was almost doubled (43.37±11.32 vs. 21.41±8.15 mL/Kg, P<0.001), and the higher the weight-indexed CUF volume, the more likely to develop an HL at a rate of 1.38 (Odds ratio=1.38 [1.27-1.49], 95% CI, P<0.001). Furthermore, the multiple logistic regression model showed that HL was associated with the lowest mean arterial pressure (MAP) during CPB. Conclusion: A higher volume of ultrafiltration was associated with increased post-operative serum lactate levels.

Predictive role of cardiopulmonary bypass exposure indexed to body surface area on postoperative organ dysfunction: a retrospective cohort study.

OBJECTIVES: Long cardiopulmonary bypass times are associated with adverse postoperative outcomes and increased healthcare resources use. It is likely that this effect is pronounced in smaller patients. Previous studies have been criticized for not taking into consideration that prolonged bypass times are often due to higher complexity. The purpose of this study was to investigate the relationship between bypass index (bypass time/body surface area) and adverse postoperative events. METHODS: Single-centre, retrospective cohort study including 2413 patients undergoing cardiac surgery on cardiopulmonary bypass from June 2018 to April 2020. Length of hospital stay, as surrogate marker of post-operative morbidity, was selected as primary outcome. The strength of association between BI and the primary outcome was assessed with linear regression analysis. Secondary outcomes included new onset renal, pulmonary or cardiac rhythm dysfunction. The predictive value of bypass index was assessed with linear regression analysis; univariate and multiple regression were used to assess the strength of association between Bi and the secondary outcomes. RESULTS: Bypass index was predictive for length of stay at univariate (RR 1.004, p < 0.001) and at multivariable (RR 1.003, p < 0.001) analysis. The association between bypass index and new renal (mean difference 14.1 min/m2, p < 0.001) and cardiac rhythm dysfunction (mean difference 12.6 min/m2) was significant. This was not true of postoperative lung dysfunction (mean difference -1.5 min/m2, p = 0.293). CONCLUSIONS: Bypass index, calculated as total bypass time/patient body surface area, is predictive of postoperative morbidity and resource utilization after cardiac surgery on pump.

Colchicine prevents perioperative myocardial injury in cardiac surgery by inhibiting the formation of neutrophil extracellular traps: evidence from rat models.

OBJECTIVES: Colchicine, an anti-inflammatory agent, has been reported to improve myocardial infarction prognosis by inhibiting neutrophil extracellular traps release. However, its role in cardiac surgery and the mechanisms behind neutrophil extracellular traps suppression remain unclear. This study aimed to explore colchicine's cardioprotective effects against perioperative myocardial injury in cardiac surgery, focusing on neutrophil extracellular traps inhibition as a novel therapeutic strategy. METHODS: Male Sprague-Dawley rats were pre-treated with colchicine (0.1 mg/kg/day) or CI-amidine (10 mg/kg/day) for seven days before undergoing cardiopulmonary bypass and myocardial ischaemia/reperfusion injury. The model was created by subjecting the rats to cardiopulmonary bypass and myocardial ischaemia/reperfusion injury. Under 4.0% sevoflurane anaesthesia, cardiopulmonary bypass was initiated by cannulating the tail artery and right atrium, and perfusion was maintained for 4 hours. Immunofluorescence detected neutrophil extracellular traps, and Hematoxylin and Eosin staining assessed inflammatory cell. RESULTS: We found colchicine treatment significantly reduced perioperative myocardial injury in rats. Furthermore, we observed a notable elevation of neutrophil extracellular traps in the myocardial tissue of animal models. Moreover, suppressing peptidylarginine deiminase 4(PAD-4) was found to markedly diminish perioperative myocardial injury in rats. Additionally, colchicine can mitigate the release of neutrophil extracellular traps by inhibiting PAD-4. CONCLUSIONS: NETs were significantly elevated during the perioperative period of cardiac surgery. Colchicine significantly mitigated myocardial injury in cardiac surgery by inhibiting neutrophil extracellular traps formation, with PAD-4 inhibition being one of its mechanisms.

The life and work of Judson T. Chesterman, pioneering cardiac surgeon.

Judson Chesterman (1903-1987) was a surgeon working in Sheffield, United Kingdom in the mid-20th century. Born in Bath, Somerset, he attended Bristol Medical School before completing junior doctor positions around England. He developed his skills in thoracic surgery during a Fellowship with Evarts Graham (1883-1957) at Barnes Hospital, St Louis, Missouri and by the mid-1950s was also performing a large number of closed cardiac procedures. In 1955, he performed the first mitral valve replacement in the world, using a prosthesis of his own design, but the patient only survived for around 18 hours. Recognising the limitations of off-pump surgery, he visited the University of Minneapolis before building his own bypass machine and used it in two patients, the first in February 1957, one of the earliest outside the United States of America to do so. In retirement he established an osteoarchaeology laboratory and made additional contributions to that field.

Assessment of the frequency and risk factors of gastrointestinal bleeding after cardiopulmonary bypass in paediatric cases.

INTRODUCTION AND AIM: Gastrointestinal bleeding is a potential complication in paediatric patients undergoing cardiopulmonary bypass, as it develops secondary to low gastrointestinal perfusion. This study aimed to examine the incidence of gastrointestinal bleeding and identify its risk factors in these patients. METHOD: This retrospective study was undertaken to examine the demographic features, clinical findings, and operative data of paediatric patients under years old who had undergone congenital heart surgery with cardiopulmonary bypass between November 1, 2021, and November 1, 2023. The study aimed to investigate the incidence of gastrointestinal bleeding associated with cardiopulmonary bypass and to identify potential risk factors for gastrointestinal bleeding. The obtained results were statistically evaluated. RESULTS: The study period included 1100 patients who underwent congenital heart surgery with cardiopulmonary bypass. Fifty-two percent of the total participants were male. The median weight of the patients was 4.4 kg, with an interquartile range of 3.5-5.8 kg. The patients were categorised by age, revealing that 62% were newborns, 24% were infants, and 14% were children. Forty-four (4.2%) of the total number of patients experienced gastrointestinal bleeding. Newborns had a significantly higher incidence of bleeding (6% or 34 patients) compared to infants (3% or 8 patients) and children (1.5% or 2 patients) (p < 0.05). Patients who experienced gastrointestinal bleeding had a longer median hospital stay of 24 days compared to those who did not, with a median hospital stay of 14 days. Moreover, patients who suffered from bleeding had a significantly higher mortality rate (30%) in comparison to those who did not (9.9%) (p < 0.05). The incidence of gastrointestinal bleeding was found to be associated with several risk factors, such as low operative age and weight, high surgical score, presence of low cardiac output syndrome, extracorporeal membrane oxygenation (ECMO) usage, high lactate levels, and low platelet count. CONCLUSION: Gastrointestinal bleeding is a potential complication for patients who undergo cardiopulmonary bypass. It is particularly relevant for newborns who have undergone prolonged surgery, have a high surgical complexity score, exhibit high lactate levels, display low cardiac output, utilise ECMO, and possess low platelet counts. In such cases, there may be a heightened incidence of gastrointestinal bleeding. It is important to consider this possibility in order to ensure the best possible patient outcomes.

Open Heart Dual Valve Surgery Without Blood Transfusion: A Case Report.

In Nepal, rheumatic heart disease (RHD) is alarmingly prevalent, marked by presentations like migratory joint arthritis, carditis, subcutaneous nodules, erythema marginatum, and Sydenham chorea. This condition can progress to instigate valvular defects. Although these patients are first approached medically, they may require surgery for severe cases. Refusal for blood transfusion might not be a major issue for other general surgeries; however, in cardiac surgery, where there is massive blood loss, it's quite a challenge. This challenge becomes even more pronounced in a developing country that lacks advanced facilities like a cell saver for autotransfusion. Herein, we report a case of a 22-year-old female, a Jehovah's Witness, suffering from RHD, severe mitral regurgitation, severe tricuspid regurgitation, and severe pulmonary artery hypertension. She underwent mitral valve replacement and tricuspid repair surgery (modified DeVega) by avoiding any form of blood product transfusion.

Factors associated with acute kidney injury after on-pump coronary artery bypass grafting.

BACKGROUND: Acute kidney injury (AKI) frequently occurs as a complication of cardiac surgery and cardiopulmonary bypass (CPB). Its prevalence and severity are determined by various preoperative and intraoperative factors. The aim of this study was to examine the risk factors for AKI following on-pump coronary artery bypass grafting (CABG). METHODS: A retrospective analysis of clinical records from a single medical center was performed. The primary determinant for AKI analysis was the creatinine-level changes within the first 48 h after surgery. Records of 120 patients from a prospective cohort study were examined. RESULTS: An AKI incidence of 26% occurred in the study cohort. The univariate analysis revealed that patients who developed AKI had notably higher EuroSCORE II values (2.00 ± 0.98 vs. 1.49 ± 0.74, p = 0.006) and higher initial levels of urea (7.62 ± 2.94 vs. 6.12 ± 1.71, p = 0.002) and creatinine (0.108 ± 0.039 vs. 0.091 ± 0.016, p = 0.003). Additionally, they exhibited a more frequent occurrence of initial albumin levels below 40 g/l (9 (34.6%) vs. 11 (14.9%) cases, p = 0.030) and a lower initial hemoglobin level (137.8 ± 13.2 g/l vs. 146.6 ± 13.6 g/l, p = 0.005) in comparison to patients without this complication. Moreover, those with AKI had a significantly longer hospital stay duration (14.3 ± 5.45 days vs. 12.6 ± 3.05 days, p = 0.048). Logistic regression indicated one risk factor, oxygen delivery during CPB, that correlated with the onset of AKI in the early postoperative period. CONCLUSION: The prevalence of AKI was higher among patients with a higher EuroSCORE II, lower preoperative hemoglobin, increased preoperative levels of creatinine and urea, infrequent albumin levels below 40 g/L, diminished oxygen delivery during CPB, and greater need for RBC transfusion and furosemide, but it did not correlate with the duration of CPB.

Sanguineous cardiopulmonary bypass prime accelerates the inflammatory response during pediatric cardiac surgery.

BACKGROUND: The inflammatory response to cardiopulmonary bypass (CPB) in pediatric patients remains an unresolved challenge. Sanguineous CPB prime, composed of allogenic blood products, is one potentially important stimulus. This study aims to identify specific inflammatory mediators active in sanguineous CPB prime and their impact on the inflammatory response at CPB initiation. METHODS: In a post-hoc analysis of a prospective observational cohort study (NCT05154864), where pediatric patients undergoing cardiac surgery with CPB were enrolled after informed consent, patients were grouped by CPB prime type (sanguineous vs crystalloid). Arterial samples were collected post-sternotomy as a baseline and again at CPB initiation from all patients. In the sanguineous group, CPB prime samples were also collected after buffered ultrafiltration but before CPB initiation. Luminex® measured concentrations of 24 inflammatory mediators for comparison between groups. Statistical analyses were by Mann-Whitney test and Wilcoxon signed-rank test. Data are presented as median [IQR]. RESULTS: Forty consecutive pediatric patients participated. The sanguineous group (n = 26) was younger (4.0 [0.2 - 6.0] vs 48.5 [39.0 - 69.5] months; p = 2.6 × 10-7) and smaller (4.9 [34 - 6.6] vs 17.2 [14.9 - 19.6] kg; p = 2.6 × 10-7) than the crystalloid group (n = 14). Despite this, baseline concentrations of 20 complement and cytokine concentrations were comparable between groups (p > 0.05) while four showed differences between groups (p < 0.05). The sanguineous prime contained supraphysiologic concentrations of complement mediators: C2, C3, C3a, C3b, and C5a. Correspondingly, upon CPB initiation, patients receiving sanguineous prime exhibited a significantly larger burden of C2, C3, C3b, C5, and C5a (p < 0.001) relative to the crystalloid group. Cytokine and chemokine mediators were present at trace levels in the sanguineous prime. CONCLUSIONS: Sanguineous prime contains activated complement that accelerates the inflammatory response at CPB initiation in neonates and infants. Immunomodulatory interventions targeting complement during CPB prime preparation could offer substantial benefits for these vulnerable patients.

Comparable bleeding and inflammation outcomes between heparin-coated and uncoated minimal invasive extracorporeal circuits in isolated coronary artery bypass surgery - A double-blinded randomized control trial.

OBJECTIVE: Minimally invasive extracorporeal circulation has been shown to be non-inferior or even superior to conventional cardiopulmonary bypass circuits in isolated coronary artery bypass grafting, but there is little evidence whether the addition of a heparin-coated circuit can further reduce the inflammatory response and amount of bleeding in these patients. METHODS: A single-center randomized control trial enrolled 49 adult patients scheduled to undergo isolated coronary artery bypass grafting with minimally invasive extracorporeal circulation (MiECC) between January 2015 and December 2018. Patients were randomized 1:1 to either the heparin-coated circuit group, or the uncoated (control) circuit group. The primary outcome was chest tube output 18 h after weaning from MiECC, and secondary outcomes included inflammatory (TNF-α, IL-6, IL-8, IL-10) and complement (C3a, C4d, C5a, sC5b-9) biomarkers, platelet count and function (D2D, TAT, SDC1, PF4), number of transfused blood products, and 30-day survival. RESULTS: Patients were randomized to undergo myocardial revascularization using heparin-coated circuits (n = 25), and to the uncoated MiECC circuit (n = 24), with comparable baseline demographics. No significant difference was observed in chest tube output and for all secondary outcomes. IL-6 and IL-8 were increased from baseline at 18 h after weaning (effect size 0.29 and 0.05, respectively) and sC5b-9 was lower (effect size 0.11) in the heparin-coated than in the uncoated MiECC, although not significantly different. CONCLUSIONS: Compared with an uncoated MiECC circuit, heparin-coated MiECC circuit was not associated with a reduction in postoperative bleeding, transfusion, inflammation, complement activation, and platelet biomarkers, following isolated coronary artery bypass grafting.

Efficacy of Therapeutic Plasma Exchange or Cangrelor as an Adjunctive Strategy to Facilitate Cardiopulmonary Bypass in Patients with Heparin-Induced Thrombocytopenia: A Systematic Review and Meta-Analysis.

OBJECTIVE: Conduct a systematic review and meta-analysis of the efficacy of therapeutic plasma exchange (TPE) or intravenous cangrelor to prevent thromboembolism in patients with heparin-induced thrombocytopenia (HIT) who undergo cardiopulmonary bypass (CPB) with heparin. DESIGN: Systematic review and meta-analysis. SETTING: N/A. PARTICIPANTS: Adults having cardiac surgery with a history of HIT who received preoperative or intraoperative TPE or intravenous cangrelor as an adjunct to CPB with heparin. INTERVENTIONS: None MEASUREMENTS AND MAIN RESULTS: A systematic review was performed using MEDLINE, PubMed, and Google Scholar. The primary outcome was avoidance of thromboembolism (venous or arterial) during or after CPB. Proportional meta-analysis with a random effects model was used to calculate a weighted-pooled proportion/efficacy for the study's primary outcome. Fifty-seven patients in 17 reports received TPE as an adjunctive treatment to prevent HIT-related thrombosis related to heparinization during CPB and 3 (5.3%) experienced thrombosis. Proportional meta-analysis suggested a weighted-pooled freedom from perioperative thromboembolism rate of 91.0% (95% CI 82.6%-96.9%). Fifteen patients in 6 reports received intravenous cangrelor as an adjunctive treatment to prevent HIT-related thrombosis related to heparinization during CPB and 2 (13.3%) experienced thrombosis. Proportional meta-analysis suggested a weighted-pooled freedom from perioperative thromboembolism rate of 83.0% (95% CI 61.2%- 97.6%). CONCLUSIONS: TPE and cangrelor are feasible strategies to prevent thromboembolism in adults with HIT who require CPB with heparin. Given the relatively small number of cases in the published literature and a high likelihood for publication and detection biases, prudence remains warranted when using these strategies.

Comparative outcomes of cardioplegic arrest versus beating heart in pediatric undergoing extracardiac total cavopulmonary connection.

BACKGROUND: Total cavopulmonary connection (TCPC) is a definitive palliative procedure for functionally univentricular congenital heart disease. The study aims to compare the impact of on-pump cardioplegic arrest and on-pump beating heart cardiopulmonary bypass (CPB) on the prognosis of pediatric patients undergoing extracardiac TCPC. METHODS: The medical data of patients (< 18 years) who underwent extracardiac TCPC with CPB between January 2008 and December 2020 in the cardiac surgery center were retrospectively analyzed. Depending on CPB strategies, the patients were assigned to the beating-heart (BH) and cardioplegic arrest (CA) groups. Data including baseline characteristics, intra/postoperative variables, and clinical outcomes were collected for analysis with 1:1 propensity score matching and multivariable stepwise logistic regressions. RESULTS: Fifty-seven matched patient pairs were obtained. No significant difference existed between the two groups in the in-hospital mortality (3.5% vs. 1.8%, P = 1) and one-year survival rate (100% vs. 96.4%, P = 0.484). The BH group had significantly less intraoperative platelet transfusion (10 mL vs. 150 mL, P = 0.019) and blood loss (100 mL vs. 150 mL, P = 0.033) than the CA group. The CA group had significantly higher vasoactive-inotropic scores (P < 0.05) and longer postoperative ICU stays (2.0 d vs. 3.7 d, P = 0.017). No significant difference existed between the two groups in the incidence of postoperative adverse events. CONCLUSION: Although both CPB strategies are safe and feasible for extracardiac TCPC, the BH technique would cause less intraoperative platelet transfusion and blood loss, and achieve faster early-term postoperative recovery.

Strategy and Outcomes of Cardiac Surgery in Patients With Cirrhosis: Comprehensive Approach With Liver Transplant Program.

BACKGROUND: Cardiac surgery is considered a contraindication in patients with advanced liver cirrhosis (LC) due to increased mortality and morbidity. There are limited data on the treatment strategy and management of this population. We aimed to present our strategy and evaluate the clinical outcome of cardiac surgery in patients with LC. METHODS: Our strategy was (i) to list patients for liver transplant (LT) at the time of cardiac surgery; (ii) to maintain high cardiopulmonary bypass (CPB) flow (index up to 3.0 L/min/m2) based on hyper-dynamic states due to LC; and (iii) to proceed to LT if patients' liver function deteriorated with an increasing model for end-stage liver disease Na (MELD-Na) score after cardiac surgery. Thirteen patients (12 male and 1 female [mean age, 63.0]) with LC who underwent cardiac surgery between 2017 and 2024 were retrospectively analyzed. RESULTS: Six patients were listed for LT. Indications for cardiac surgery included coronary artery disease (N = 7), endocarditis (N = 2), and tricuspid regurgitation (N = 1), tricuspid stenosis (N = 1), mitral regurgitation (N = 1), and hypertrophic obstructive cardiomyopathy (N = 1). The Child-Pugh score was A in five, B in six, and C in one patient. The procedure included coronary artery bypass grafting (N = 6), single valve surgery (mitral valve [N = 2] and tricuspid valve [N = 1]), concomitant aortic and tricuspid valve surgery (N = 2), and septal myectomy (N = 1). Two patients had a history of previous sternotomy. The perfusion index during CPB was 3.1 ± 0.5 L/min/m2. Postoperative complications include pleural effusion (N = 6), bleeding events (N = 3), acute kidney injury (N = 1), respiratory failure requiring tracheostomy (N = 2), tamponade (N = 1), and sternal infection (N = 1). There was no in-hospital death. There was one remote death due to COVID-19 complication. Preoperative and postoperative highest MELD-Na score among listed patients was 15.8 ± 5.1 and 19.3 ± 5.3, respectively. Five patients underwent LT (1, 5, 8, 16, and 24 months following cardiac surgery) and one patient remains on the list. Survival rates at 1 and 3 years are 100% and 75.0%, respectively. CONCLUSION: Cardiac surgery maintaining high CPB flow with LT backup is a feasible strategy in an otherwise inoperable patient population with an acceptable early and midterm survival when performed in a center with an experienced cardiac surgery and LT program.

Highlights of the 18th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion.

The 18th International Conference on Pediatric Mechanical Circulatory Support Systems and Pediatric Cardiopulmonary Perfusion was held in Milwaukee, WI, USA, on May 9 and 10, 2024. The conference was hosted by the Herma Heart Institute of Children's Wisconsin at the Pfister Hotel in downtown Milwaukee. This communication provides the highlights of the proceedings.

Anticoagulation management for cardiopulmonary bypass using TEG® 6 s in a patient receiving both heparin and dabigatran.

BACKGROUND: It is difficult to evaluate adequate dose of heparin for cardiopulmonary bypass (CPB) by activated clotting time (ACT) in a patient receiving both heparin and dabigatran because dabigatran can also prolong ACT. We evaluated the effect of dabigatran by thromboelastography (TEG) to determine adequate heparin dose for CPB. CASE PRESENTATION: An 81-year-old woman receiving both heparin and dabigatran was scheduled for an emergency surgical repair of iatrogenic atrial septal perforation. Although ACT was prolonged to 419 s, we performed TEG to distinguish anticoagulation by dabigatran from heparin comparing R in CK and CHK. As the results of TEG indicated residual effect of dabigatran, we reversed dabigatran by idarucizumab and then dosed 200 U/kg of heparin to achieve adequate anticoagulation for CPB by heparin. CONCLUSIONS: TEG could help physicians to determine need for idarucizumab and also an adequate dose of heparin to establish appropriate anticoagulation for CPB.

Effect of perioperative sigh ventilation on postoperative hypoxemia and pulmonary complications after on-pump cardiac surgery (E-SIGHT): study protocol for a randomized controlled trial.

BACKGROUND: Postoperative hypoxemia and pulmonary complications remain a frequent event after on-pump cardiac surgery and mostly characterized by pulmonary atelectasis. Surfactant dysfunction or hyposecretion happens prior to atelectasis formation, and sigh represents the strongest stimulus for surfactant secretion. The role of sigh breaths added to conventional lung protective ventilation in reducing postoperative hypoxemia and pulmonary complications among cardiac surgery is unknown. METHODS: The perioperative sigh ventilation in cardiac surgery (E-SIGHT) trial is a single-center, two-arm, randomized controlled trial. In total, 192 patients scheduled for elective cardiac surgery with cardiopulmonary bypass (CPB) and aortic cross-clamp will be randomized into one of the two treatment arms. In the experimental group, besides conventional lung protective ventilation, sigh volumes producing plateau pressures of 35 cmH2O (or 40 cmH2O for patients with body mass index > 35 kg/m2) delivered once every 6 min from intubation to extubation. In the control group, conventional lung protective ventilation without preplanned recruitment maneuvers is used. Lung protective ventilation (LPV) consists of low tidal volumes (6-8 mL/kg of predicted body weight) and positive end-expiratory pressure (PEEP) setting according to low PEEP/FiO2 table for acute respiratory distress syndrome (ARDS). The primary endpoint is time-weighted average SpO2/FiO2 ratio during the initial post-extubation hour. Main secondary endpoint is the severity of postoperative pulmonary complications (PPCs) computed by postoperative day 7. DISCUSSION: The E-SIGHT trial will be the first randomized controlled trial to evaluate the impact of perioperative sigh ventilation on the postoperative outcomes after on-pump cardiac surgery. The trial will introduce and assess a novel perioperative ventilation approach to mitigate the risk of postoperative hypoxemia and PPCs in patients undergoing cardiac surgery. Also provide the basis for a future larger trial aiming at verifying the impact of sigh ventilation on postoperative pulmonary complications. TRIAL REGISTRATION: ClinicalTrials.gov NCT06248320. Registered on January 30, 2024. Last updated February 26, 2024.

Perioperative management of hemophilia A during coronary artery bypass grafting with patent foramen ovale repair.

Factor VIII deficiency, also known as hemophilia A, is the most common inherited bleeding disorder. Deficiency of Factor VIII results in dysfunction of platelet aggregation due to decreased activation of Factor X to Xa. We present the case of a 68-year-old male with mild hemophilia A (Factor VIII activity, 16%) who underwent a three-vessel coronary artery bypass graft and patent foramen ovale repair, with no increased bleeding utilizing a recombinant Factor VIII (kogenate) preoperative bolus and continuous infusion. His postoperative course was complicated by a sternal wound dehiscence requiring washout, sternal wire removal and omental flap coverage on postoperative Day 21. However, he required no postoperative blood transfusions.

Extravascular lung water assessment by lung ultrasound in infants following pediatric cardiac surgery.

BACKGROUND: Lung edema is a significant factor in prolonged mechanical ventilation and extubation failure after cardiac surgery. This study assessed the predictive capability of point-of-care Lung Ultrasound (LUS) for the duration of mechanical ventilation and extubation failure in infants following cardiac procedures. METHODS: We conducted a prospective observational trial on infants under 1 year, excluding those with pre-existing conditions or requiring extracorporeal membrane oxygenation. LUS was performed upon intensive care unit (ICU) admission and prior to extubation attempts. B-line density was scored by two independent observers. The primary outcomes included the duration of mechanical ventilation and extubation failure, the latter defined as the need for reintubation or non-invasive ventilation within 48 h post-extubation. RESULTS: The study included 42 infants, with findings indicating no correlation between initial LUS scores and extubation timing. Extubation failure occurred in 21% of the patients, with higher LUS scores observed in these cases (p = 0.046). However, interobserver variability was high, impacting the reliability of LUS scores to predict extubation readiness. CONCLUSIONS: LUS was ineffective in determining the length of postoperative ventilation and extubation readiness, highlighting the need for further research and enhanced training in LUS interpretation.

An evaluation of the empirical vancomycin dosing guide in pediatric cardiology.

BACKGROUND: Higher doses of vancomycin are currently prescribed due to the emergence of bacterial tolerance and resistance. This study aimed to evaluate the efficacy and safety of the currently adopted vancomycin dosing guide in pediatric cardiology. METHODS: This was a single-center prospective cohort study with pediatric cardiac patients, younger than 14 years, from June 2020 to March 2021. The patients received intravenous vancomycin (40 mg/kg/day divided every 6-8 h) according to the department's vancomycin medication administration guide (MAG) for at least three days. RESULTS: In total, 88 cardiac patients were included, with a median age of 0.82 years (IQR: 0.25-2.9), and 51 (58%) received cardiopulmonary bypass surgery (CPB). The majority (71.6%, n = 61) achieved a serum vancomycin level within the therapeutic range (7-20 mg/L). Infants, young children, and children exposed to CPB surgery had an increased incidence of subtherapeutic vancomycin levels, [7 (29.2%); P = 0.033], [13 (54.2%); P = 0.01], and [21 (87.5%); P = 0.009] respectively. After the treatment, 8 (10%) patients had an elevated Serum creatinine (SCr) and 2 (2.5%) developed acute kidney injury (AKI). However, no significant difference was found between the patients developing AKI or an elevated SCr and the group who did not, in terms of clinical, therapeutic, and demographic characteristics, except for the decreased incidence of SCr elevation in patients receiving an ACE inhibitor, [4 (36.4%); P = 0.036]. CONCLUSION: Our institution followed MAG recommendations; however, subtherapeutic serum concentrations were evident in infants, young children, and CPB patients. Strategies to prevent AKI should be investigated, as the possible causes have not been identified in this study.