Prothrombin Complex Concentrate in Cardiac Surgery: A Systematic Review and Meta-Analysis.

BACKGROUND: Prothrombin complex concentrate (PCC) has recently emerged as an effective alternative to fresh frozen plasma (FFP) in treating excessive perioperative bleeding. This systematic review and meta-analysis evaluated the safety and efficacy of PCC administration as first-line treatment for coagulopathy after adult cardiac surgery. METHODS: PubMed/MEDLINE, EMBASE, and the Cochrane Library were searched from inception to the end of March 2018 to identify eligible articles. Adult patients undergoing cardiac surgery and receiving perioperative PCC were compared with patients receiving FFP. RESULTS: A total of 861 adult patients from four studies were retrieved. No randomized studies were identified. Pooled odds ratios (ORs) showed that the PCC cohort was associated with a significant reduction in the risk of RBC transfusion (OR, 2.22; 95% confidence interval [CI], 1.45 to 3.40) and units of RBC received (OR, 1.34; 95% CI, 0.78 to 1.90). No differences were observed between the groups for reexploration for bleeding (OR, 1.09; 95% CI, 0.66 to 1.82), chest drain output at 24 hours (OR, 66.36; 95% CI, -82.40 to 216.11), hospital mortality (OR, 0.94; 95% CI, 0.59 to 1.49), stroke (OR, 0.80; 95% CI, 0.41 to 1.56), and occurrence of acute kidney injury (OR, 0.80; 95% CI, 0.58 to 1.12). A trend toward increased risk of renal replacement therapy was observed in the PCC group (OR, 0.41; 95% CI, 0.16 to 1.02). CONCLUSIONS: In patients with significant bleeding after cardiac surgery, PCC administration seems to be more effective than FFP in reducing perioperative blood transfusions. No additional risks of thromboembolic events or other adverse reactions were observed. Randomized controlled trials are needed to establish the safety of PCC in cardiac surgery definitively.

Edge-to-edge repair with mitral annuloplasty for Barlow's disease.

BACKGROUND: The purpose of this study was to define the early and midterm results obtained after the use of edge-to-edge repair with mitral annuloplasty in the setting of Barlow's disease. METHODS: Between 1998 and 2004, 41 patients having Barlow's disease had an edge-to-edge repair creating a double-lumen mitral valve orifice in our unit. In 38 patients (93%), an annuloplasty band was also inserted. RESULTS: Preoperatively, all patients had severe mitral regurgitation (MR), 12 were in New York Heart Association (NYHA) class I, 15 in class II, and 14 in class III. One patient died in hospital (2.4%) and 5 experienced complications (12.5%). There were no late deaths. At follow-up, 2 patients had severe MR and underwent valve replacement, 1 exhibited moderate MR, and 5 had mild MR. Kaplan-Meier 5-year survival, freedom from reoperation and recurrent moderate-severe MR was 97.6% +/- 2.4%, 94% +/- 4.4%, and 90.6% +/- 5.1%, respectively. At latest echocardiographic evaluation (mean 35 +/- 12 months) the mean left ventricular end-systolic and end-diastolic diameters, and the mitral valve area decreased (p = 0.0001) compared with baseline. The mean mitral valve gradient increased (p = 0.001) without clinical evidence of mitral stenosis whereas ejection fraction did not change. Currently, 35 patients are in NYHA class I and 5 are in class II. CONCLUSIONS: In the setting of Barlow's disease, use of edge-to-edge repair with mitral annuloplasty is safe and provides lasting restoration of mitral valve competence with measurable hemodynamic and clinical benefits. In our unit, it is the procedure of choice for correction of MR in patients having Barlow's disease.

Effect of training in mitral valve repair surgery on the early and late outcome.

BACKGROUND: Preservation of the native mitral valve provides important advantages over valve replacement. The aim of this study was to evaluate the effect of training for mitral valve repair on the outcome. METHODS: Between 1997 and 2004, 471 patients underwent mitral valve repair procedures in a single firm. Of these procedures, 300 (64%) were performed by a consultant (TJS) (consultant group) and 171 (36%) by trainees supervised by the same consultant (trainees group). RESULTS: Atrial fibrillation was more prevalent in the consultant group (p = 0.02) but there were no significant differences in the demographics, etiology of mitral regurgitation, and other comorbidity between the groups. Posterior leaflet prolapse was more prevalent in the trainees group (p < 0.0001) and anterior leaflet prolapse (p < 0.0001), bileaflet prolapse (p = 0.003), and Barlow's syndrome (p = 0.0003) in the consultant group. The consultant performed a higher proportion of concomitant coronary artery bypass grafting (p = 0.04), aortic valve replacement (p = 0.02), procedures, and nonelective cases (p = 0.03) with shorter bypass (p = 0.01) and ischemic times (p = 0.0004) than trainees. The complication rate was similar in the two groups (26% vs 22%), but the consultant had a higher operative mortality than the trainees (5% vs 0.6%) (p = 0.01). A similar proportion in the two groups exhibited recurrent mitral regurgitation (8% vs 9%). Kaplan-Meier five-year freedom from reoperation (95.6 +/- 1.6 vs 95.7 +/- 2.2%) (p = 0.7) and survival (82 +/- 4% vs 88 +/- 4%) (p = 0.09) were similar in the two groups. CONCLUSIONS: With appropriate patient selection, cardiothoracic trainees can be taught mitral valve repair surgery without a negative effect on the early or late outcome.

Prospective venox feasibility study.

Venox is a propriety Venous Oximetry system, capable of measuring peripheral venous oximetry. In this ongoing study, Venox is being compared against mixed central venous oximetry during human cardiac surgery, with Fibre optic reflectance spectrophotometry being used as the gold standard, placed in the pulmonary artery. A background review of the Pulse oximetry, current venous oximetry techniques and the potential advantage of the VENOX system are discussed. Lessons learnt, Preliminary results, and future plans are included in discussion.

Early changes in plasma antioxidant and lipid peroxidation levels following coronary artery bypass surgery: a complex response.

OBJECTIVE: Total plasma antioxidant capacity (TPAC) quantitatively defines extracellular fluid antioxidant capacity, the mechanism of which is different from the intracellular mechanism. Patients undergoing surgery for congenital heart defects have suppressed TPAC in the early postoperative periods. Our aim was to study the early changes of TPAC following coronary artery bypass grafting (CABG), in relation to lipid peroxidation, and to identify clinical factors affecting these changes. METHODS: We studied 28 consecutive patients undergoing routine uncomplicated CABG with cardiopulmonary bypass (CPB). Patients taking known antioxidants, such as captopril and allopurinol, and those receiving transfusion of blood or blood products at operation or during the first 72 postoperative hours were excluded. Serial blood samples were obtained for TPAC and lipid hydroperoxide concentration (LPX). RESULTS: TPAC was suppressed for 72 h after the operation, while LPX exhibited a significant increase only 1 h post-operatively. TPAC time changes resulted from a simultaneous depression (50% of the baseline occurring approximately 6 h after the operation) and production (18% of the baseline occurring approximately 6 h after the operation) of plasma antioxidants. The earlier the peak of plasma antioxidant production the later and the less the plasma antioxidant depression. Plasma antioxidant depression was inversely related to LPX (r=-0.37, P=0.05 and r=-0.40, P=0.04 at 1 and 6 h respectively). Ejection fraction and operative myocardial ischaemic times significantly influenced plasma antioxidant depression. CONCLUSIONS: TPAC is suppressed for 72 h following CABG. TPAC depression may be involved in the mechanism of lipid peroxidation and is influenced by clinical factors known to be related to post CABG morbidity and mortality, like low ejection fraction and long ischaemic times.