Intravenous amino acid therapy for kidney protection in cardiac surgery patients: A pilot randomized controlled trial.

OBJECTIVE: To determine whether a continuous intravenous infusion of standard amino acids could preserve kidney function after on-pump cardiac surgery. METHODS: Adult patients scheduled to receive cardiac surgery lasting longer than 1 hour on-pump were randomized to standard care (n = 36) or an infusion of amino acids initiated immediately after induction of anesthesia (n = 33). The study's primary outcome measurements assessed renal function. These assessments included duration of renal dysfunction, duration and severity of acute kidney injury (AKI), estimated glomerular filtration rate (eGFR) over time, urine output, and use of renal-replacement therapy. Complications and other measures of morbidity were also assessed. RESULTS: Sixty-nine patients (mean age 71.5 [standard deviation 9.2] years; 19 of 69 women) were enrolled and randomized. Patients received coronary artery bypass graft surgery (37/69), valve surgery (24/69), coronary artery bypass graft and valve surgery (6/69), or other procedures (2/69). Mean on-pump time was 268 [standard deviation 136] minutes. Duration of renal dysfunction did not differ between the groups (relative risk, 0.86; 95% confidence interval [CI], 0.19-3.79, P = .84). However, patients who received the amino acid infusion had a reduced duration of AKI (relative risk, 0.02; 95% CI, 0.005-0.11, P < .0001) and greater eGFR (+10.8%; 95% CI, 1.0%-20.8%, P = .033). Daily mean urine output was also significantly greater in patients who received the amino acid infusion (1.4 ± 0.5 vs 1.7 ± 0.9 L/d; P = .046). CONCLUSIONS: Commencing an infusion of standard amino acids immediately after the induction of anesthesia did not alter duration of renal dysfunction; however, other key measures of renal function (duration of AKI, eGFR and urine output) were significantly improved. These results warrant replication in multicenter clinical trials.

Recombinant activated factor VII in cardiac surgery: experience from the Australian and New Zealand Haemostasis Registry.

BACKGROUND: Data from the Australian and New Zealand Haemostasis Registry (ANZHR) were used to report on the efficacy, mortality, and outcomes of a cohort of cardiac surgical cases receiving recombinant activated factor VII (rFVIIa). METHODS: The ANZHR collects retrospective and contemporaneous data on the use of rFVIIa in patients with critical bleeding from hospitals throughout Australia and New Zealand. Participating centers commit to the collection of data on all patients without hemophilia treated with rFVIIa, which limits bias and prevents the reporting of only positive or anecdotal experiences. RESULTS: At September 2006, the cardiac surgical cohort comprised 304 patients (43%) of a total of 695 cases reported to the ANZHR from 46 hospitals. The 304 cases date from January 2001. The median patient age was 66 years (interquartile range [IQR], 53 to 75 years), and 73% were men. After administration of rFVIIa, all blood product usage was significantly reduced. Patients received a median dose of 93 mug/kg (IQR, 82 to 102), and 85% of patients received a single dose. The documented response rate to a single dose of rFVIIa was 84%, of which 23% reported cessation of bleeding and 61% reported a reduction in bleeding. Patients received a median volume of 6 U of red blood cells before rFVIIa treatment. The median reduction in red blood cells after the rFVIIa dose compared with before was 4 U. Response was reduced in patients with a lower baseline hemoglobin, coagulopathy (determined by international normalized ratio, fibrinogen, and platelets), the number of red blood cell units transfused before rFVIIa, advanced age, more complex operations, hypothermia, and acidosis. Responders had a significantly reduced mortality (p < 0.001). The percentage of patients alive at 28 days was 95% if bleeding ceased after rFVIIa, 86% if bleeding reduced, and 60% for nonresponders. A 7% adverse event rate attributed as "probably" or "possibly" associated with rFVIIa was reported with a 4% reported thromboembolic event rate. CONCLUSIONS: Recombinant FVIIa is a potential rescue therapy in severe uncontrollable critical bleeding after cardiac operations. The observed response rate was high, and response was associated with improved mortality. There was an observed reduction in blood product usage after rFVIIa. The adverse event rate reported was similar to documented adverse event rates in complex cardiac surgical patients. In the absence of randomized controlled trials, this registry provides a basis for understanding current clinical practice with rFVIIa in cardiac surgical procedures.

Recurrent spontaneous coronary artery dissection: A case report and review of the literature.

Spontaneous coronary artery dissection is a rare cause of acute coronary syndrome. Recurrent spontaneous dissection is even more rare. A case of recurrent coronary artery dissection is reported and the literature is reviewed.