Protamine titration to optimize heparin antagonization after cardiopulmonary bypass.

OBJECTIVES: To optimize protamine titration for heparin antagonization after weaning from cardiopulmonary bypass (CPB). DESIGN: A prospective, observational trial. SETTING: Single-center, non-university teaching hospital. PARTICIPANTS: Forty patients presenting for elective on-pump coronary artery bypass grafting with or without single valve surgery. INTERVENTIONS: At the end of CPB, the residual amount of heparin in the patient was estimated using a Bull-curve. The total protamine dose was calculated as 1 unit of protamine for 1 unit of heparin. Protamine was administered as 5 aliquots containing 20% of the total protamine dose each, with 2-min intervals. MEASUREMENTS AND MAIN RESULTS: Activated Clotting Time (ACT) values were measured 2 min after administration of each aliquot. ROTEM(®)-analysis was performed after the full dose of protamine had been administered. After 60% of the total protamine dose had been administered, ACT values were normalized in 86.5% of patients. After the complete dose of protamine had been administered, 61.1% of patients displayed signs of protamine overdose on ROTEM(®)-analysis. CONCLUSIONS: In patients who present for on-pump coronary artery bypass grafting with or without single valve surgery, a 0.6-to-1 ratio of protamine-to-heparin to antagonize heparin may be sufficient and beneficial for patients.

Endoaortic Clamping Does Not Increase the Risk of Stroke in Minimal Access Mitral Valve Surgery: A Multicenter Experience.

BACKGROUND: Some controversy exists regarding the safety of endoaortic balloon clamping in minimal access isolated mitral valve surgery (MIMVS). The aim of this European multicenter study was to analyze the results in 10 experienced centers and compare the outcomes with published data. METHODS: The most recent 50 consecutive MIMVS cases from 10 European surgeons who had performed at least 100 procedures were prospectively collected and retrospectively analyzed. All procedures were performed through right minithoracotomy with femoral cannulation and endoaortic balloon occlusion. In-hospital and 30-day outcomes were studied. Mortality and stroke rates were compared with published median sternotomy and MIMVS outcomes. RESULTS: Mean age was 63.2 ± 12.5 years, 289 (57.8%) were male, mean logistic European system for cardiac operative risk evaluation was 6.1 ± 6.2, and 53 (10.6%) procedures had cardiac reoperations. Concomitant procedures were performed in 126 (25.9%) cases. Three patients (0.6%) required conversion to full sternotomy. Ten patients (2.0%) necessitated endoaortic balloon clamping conversion (8 to external clamping), and re-exploration for bleeding was necessary in 24 (4.8%) cases. Mean aortic cross-clamp and cardiopulmonary bypass times were 85.6 ± 30.1 and 129.5 ± 40.2 min, respectively, and were significantly longer for concomitant procedures (p < 0.001). There were no aortic dissections and no deep venous thromboses. Operative mortality (none neurologic) and major stroke occurred in 7 (1.4%) and 4 (0.8%) patients, respectively. These rates compared favorably with the published literature on isolated primary mitral valve surgery (MVS) through sternotomy or minithoracotomy (mortality rates 0.2% to 11.6%, stroke rates 0.6% to 4.4%). CONCLUSIONS: Once procedural proficiency is acquired, endoaortic balloon clamping in MIMVS is a safe and effective technique. Despite the fact that this patient cohort also includes combined and redo procedures, the observed mortality and stroke rate compared favorably with the existing literature on primary isolated mitral valve surgery irrespective of the approach.

Right atrial tumor: a contraindication to minimally invasive surgery?

Cardiac tumors are rarely observed. The incidence of primary cardiac tumors in autopsy series ranges from 0.0017% to 0.19%. Surgical resection is the main therapy for the majority of the cardiac tumors. Surgical treatment of these tumors carries an operative mortality rate of 3% or less. In this article, we present our experience with a female patient, who had a right sided atrial tumor mimicking a myxoma. Port access surgery was performed through a small right sided "key-hole" working port in the fourth intercostal space. Extracorporeal circulation was conducted by femoro-femoral bypass and a kinetic assisted venous drainage system. Although, the safety and efficacy of port access approach have been well documented for resection of left atrial tumors in some series, use of this technique for right atrial tumor resection can be detrimental.

Endoscopic correction of the adult form of scimitar syndrome and mitral regurgitation: anatomic and technical considerations.

Scimitar syndrome is a congenital cardiac anomaly characterized by anomalous venous drainage of the right lung into the inferior vena cava. We report the combination of scimitar syndrome and mitral regurgitation and describe port-access correction for the adult form by means of an intraatrial baffle combined with mitral valve repair. Related considerations and modifications required in the standard Heartport (Cardiovations, Somerville, NJ) technique are discussed.

Avoiding vascular complications during minimally invasive, totally endoscopic intracardiac surgery.

OBJECTIVE: The introduction of minimally invasive valve surgery has been associated with an increased use of peripheral vessel cannulation in cardiopulmonary bypass. These techniques are associated with potential problems at the aorta or cannulation sites. The goal of this study was to review and describe our current practice to avoid vascular problems during cannulation of peripheral vessels. METHOD: Data collection for this study was done retrospectively by reviewing the files of all patients who underwent a minimally invasive mitral and/or tricuspid surgery in our institution from 1997 to the end of 2005. RESULTS: Our cohort of 978 patients revealed an overall rate of peripheral vascular complication of 1.0% with 44.4% presenting at the time of the surgery and 63.6% at long-term follow-up. Acute peripheral vascular problems were treated by simple graft replacement of the diseased segment in most cases. All aortic complications happened at the time of the surgery (complication rate of 0.9%) with 60% of them associated with cannulation problems. Most patients were treated by replacement of the ascending aorta. CONCLUSIONS: A systematic and careful approach is associated with a low risk of vascular problems. Prevention and planning with precise surgical technique remain the main conditions to safely use peripheral cannulation and perfusion for minimally invasive mitral valve surgery.