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1.
Cochrane Database Syst Rev ; 10: CD013101, 2020 10 12.
Artigo em Inglês | MEDLINE | ID: mdl-33045104

RESUMO

BACKGROUND: Corticosteroids are routinely given to children undergoing cardiac surgery with cardiopulmonary bypass (CPB) in an attempt to ameliorate the inflammatory response. Their use is still controversial and the decision to administer the intervention can vary by centre and/or by individual doctors within that centre. OBJECTIVES: This review is designed to assess the benefits and harms of prophylactic corticosteroids in children between birth and 18 years of age undergoing cardiac surgery with CPB. SEARCH METHODS: We searched CENTRAL, MEDLINE, Embase and Conference Proceedings Citation Index-Science in June 2020. We also searched four clinical trials registers and conducted backward and forward citation searching of relevant articles. SELECTION CRITERIA: We included studies of prophylactic administration of corticosteroids, including single and multiple doses, and all types of corticosteroids administered via any route and at any time-point in the perioperative period. We excluded studies if steroids were administered therapeutically. We included individually randomised controlled trials (RCTs), with two or more groups (e.g. multi-drug or dose comparisons with a control group) but not 'head-to-head' trials without a placebo or a group that did not receive corticosteroids. We included studies in children, from birth up to 18 years of age, including preterm infants, undergoing cardiac surgery with the use of CPB. We also excluded studies in patients undergoing heart or lung transplantation, or both; studies in patients already receiving corticosteroids; in patients with abnormalities of the hypothalamic-pituitary-adrenal axis; and in patients given steroids at the time of cardiac surgery for indications other than cardiac surgery. DATA COLLECTION AND ANALYSIS: We used the Covidence systematic review manager to extract and manage data for the review. Two review authors independently assessed studies for inclusion, extracted data, and assessed risks of bias. We resolved disagreements by consensus or by consultation with a third review author. We assessed the certainty of evidence with GRADE. MAIN RESULTS: We found 3748 studies, of which 888 were duplicate records. Two studies had the same clinical trial registration number, but reported different populations and interventions. We therefore included them as separate studies. We screened titles and abstracts of 2868 records and reviewed full text reports for 84 studies to determine eligibility. We extracted data for 13 studies. Pooled analyses are based on eight studies. We reported the remaining five studies narratively due to zero events for both intervention and placebo in the outcomes of interest. Therefore, the final meta-analysis included eight studies with a combined population of 478 participants. There was a low or unclear risk of bias across the domains. There was moderate certainty of evidence that corticosteroids do not change the risk of in-hospital mortality (five RCTs; 313 participants; risk ratio (RR) 0.83, 95% confidence interval (CI) 0.33 to 2.07) for children undergoing cardiac surgery with CPB. There was high certainty of evidence that corticosteroids reduce the duration of mechanical ventilation (six RCTs; 421 participants; mean difference (MD) 11.37 hours lower, 95% CI -20.29 to -2.45) after the surgery. There was high-certainty evidence that the intervention probably made little to no difference to the length of postoperative intensive care unit (ICU) stay (six RCTs; 421 participants; MD 0.28 days lower, 95% CI -0.79 to 0.24) and moderate-certainty evidence that the intervention probably made little to no difference to the length of the postoperative hospital stay (one RCT; 176 participants; mean length of stay 22 days; MD -0.70 days, 95% CI -2.62 to 1.22). There was moderate certainty of evidence for no effect of the intervention on all-cause mortality at the longest follow-up (five RCTs; 313 participants; RR 0.83, 95% CI 0.33 to 2.07) or cardiovascular mortality at the longest follow-up (three RCTs; 109 participants; RR 0.40, 95% CI 0.07 to 2.46). There was low certainty of evidence that corticosteroids probably make little to no difference to children separating from CPB (one RCT; 40 participants; RR 0.20, 95% CI 0.01 to 3.92). We were unable to report information regarding adverse events of the intervention due to the heterogeneity of reporting of outcomes. We downgraded the certainty of evidence for several reasons, including imprecision due to small sample sizes, a single study providing data for an individual outcome, the inclusion of both appreciable benefit and harm in the confidence interval, and publication bias. AUTHORS' CONCLUSIONS: Corticosteroids  probably do not change the risk of mortality for children having heart surgery using CPB at any time point. They probably reduce the duration of postoperative ventilation in this context, but have little or no effect on the total length of postoperative ICU stay or total postoperative hospital stay. There was inconsistency in the adverse event outcomes reported which, consequently, could not be pooled. It is therefore impossible to provide any implications and policy-makers will be unable to make any recommendations for practice without evidence about adverse effects. The review highlighted the need for well-conducted RCTs powered for clinical outcomes to confirm or refute the effect of corticosteroids versus placebo in children having cardiac surgery with CPB. A core outcome set for adverse event reporting in the paediatric major surgery and intensive care setting is required.


Assuntos
Corticosteroides/uso terapêutico , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte Cardiopulmonar/efeitos adversos , Inflamação/prevenção & controle , Adolescente , Corticosteroides/efeitos adversos , Viés , Procedimentos Cirúrgicos Cardíacos/mortalidade , Ponte Cardiopulmonar/mortalidade , Causas de Morte , Criança , Pré-Escolar , Dexametasona/uso terapêutico , Máquina Coração-Pulmão/efeitos adversos , Mortalidade Hospitalar , Humanos , Hidrocortisona/uso terapêutico , Lactente , Recém-Nascido , Inflamação/etiologia , Unidades de Terapia Intensiva Pediátrica/estatística & dados numéricos , Tempo de Internação , Metilprednisolona/uso terapêutico , Ensaios Clínicos Controlados Aleatórios como Assunto , Respiração Artificial/estatística & dados numéricos
2.
J Card Surg ; 35(10): 2821-2824, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-33043655

RESUMO

A patient with acute pulmonary embolism suffered cardiac arrest, received manual and mechanical cardiopulmonary resuscitation and tissue plasminogen activator before extracorporeal cardiopulmonary resuscitation was initiated. She suffered a type B aortic dissection and retroperitoneal hemorrhage secondary to resuscitation measures. This case report describes high-risk anticoagulation management for contradicting treatment goals in preparation for pulmonary embolectomy on cardiopulmonary bypass.


Assuntos
Aneurisma Dissecante/etiologia , Aneurisma Aórtico/etiologia , Reanimação Cardiopulmonar/efeitos adversos , Oxigenação por Membrana Extracorpórea/efeitos adversos , Hemorragia/etiologia , Embolia Pulmonar/etiologia , Espaço Retroperitoneal , Ponte Cardiopulmonar/efeitos adversos , Reanimação Cardiopulmonar/métodos , Contraindicações , Embolectomia , Feminino , Parada Cardíaca/etiologia , Humanos , Pessoa de Meia-Idade , Ativadores de Plasminogênio/administração & dosagem , Ativadores de Plasminogênio/efeitos adversos
3.
Ann Thorac Cardiovasc Surg ; 26(5): 276-285, 2020 Oct 21.
Artigo em Inglês | MEDLINE | ID: mdl-32893224

RESUMO

PURPOSE: Benefits of off-pump coronary bypass (OPCAB) over on-pump (ONCAB) remain controversial. We aimed to evaluate the early impacts of OPCAB vs ONCAB for varying left ventricular (LV) function baselines by applying the non-invasive myocardial work (MW) analysis, which enables further insights in cardiac mechanics, contractility, and efficacy. METHODS: We retrospectively analyzed 98 patients (55 ONCAB vs 43 OPCAB). Transthoracic echocardiography (TTE) and concurrent arterial blood pressure measurements taken at rest, prior to, and early after surgery were performed. Global myocardial work index (GMWI), global constructive work (GCW), and global work efficiency (GWE), inter alia, were quantified. RESULTS: Preoperatively, OPCAB patients had significantly lower values than ONCAB patients in terms of GMWI (1404.33 ± 585.41 mmHg% vs 1619.07 ± 535.42 mmHg%, p = 0.039), GWE (90% (60%, 96%) vs 93% (74%, 98%), p = 0.028). After surgery, GMWI was reduced in both groups. However, a more significant GMWI impairment occurred early after ONCAB than after OPCAB (-343.14 ± 35.20 mmHg%, p <0.001 vs -224.04 ± 120.91 mmHg%, p = 0.042). CONCLUSION: Despite lower preoperative LV function in OPCAB patients, GMWIs after OPCAB were superior to ONCAB, indicating better preservation of systolic LV function early after OPCAB by means of contractility compared to ONCAB. Further studies should investigate the long-term course of MW response and their clinical impact.


Assuntos
Ponte Cardiopulmonar , Ponte de Artéria Coronária sem Circulação Extracorpórea , Ponte de Artéria Coronária , Doença da Artéria Coronariana/cirurgia , Contração Miocárdica , Função Ventricular Esquerda , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária sem Circulação Extracorpórea/efeitos adversos , Doença da Artéria Coronariana/diagnóstico por imagem , Doença da Artéria Coronariana/fisiopatologia , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Estudos Retrospectivos , Resultado do Tratamento , Disfunção Ventricular Esquerda/etiologia , Disfunção Ventricular Esquerda/fisiopatologia
5.
J Card Surg ; 35(10): 2469-2476, 2020 Oct.
Artigo em Inglês | MEDLINE | ID: mdl-32789962

RESUMO

BACKGROUND: Pulmonary artery perfusion during cardiopulmonary bypass (CPB) is a known but rarely used technique in adult cardiac surgery. In this study, we aimed to investigate biochemical and histopathological effects of pulmonary artery perfusion during CPB on lung functions. METHODS: Between May 2014 and August 2014, all patients (n = 24) who gave informed consent for participating this study with inclusion criteria were included. Patients undergoing isolated coronary artery bypass grafting were sequentially randomized to conventional CPB (control group, n = 12) and conventional CPB with selective pulmonary artery perfusion (study group, n = 12). Lung functions were monitored using PF ratio, alveolar-arterial oxygen gradient, and lactate levels. A small sample tissue from the left lung was excised for histopathologic examination. Immunocytochemistry analysis was performed using anti-rabbit polyclonal vascular endothelial growth factor (VEGF), rabbit polyclonal inducible nitric oxide synthase (i-NOS), and BCL-2 antibodies. RESULTS: Postoperative course of the patients were uneventful without any clinical outcome differences in terms of cardiopulmonary complications, ventilation time and hospital stay. Pulmonary perfusion group had significantly better oxygenation values after extubation and at postoperative 24-hour. Electron microscopy examinations revealed better preservation of the alveolar wall integrity with pulmonary perfusion. The intensity of VEGF, i-NOS, and BCL-2 antibody expressions in bronchial epithelial cells were more prominent in the pulmonary perfusion group. CONCLUSIONS: Pulmonary artery perfusion during aortic cross-clamping provides better oxygenation and preservation of the wall alveolar integrity after coronary artery bypass grafting surgery. This technique can be used as a protective strategy to minimize CPB-induced lung injury in adult cardiac surgery.


Assuntos
Lesão Pulmonar Aguda/etiologia , Lesão Pulmonar Aguda/prevenção & controle , Ponte Cardiopulmonar/efeitos adversos , Perfusão/métodos , Complicações Pós-Operatórias/etiologia , Complicações Pós-Operatórias/prevenção & controle , Artéria Pulmonar , Lesão Pulmonar Aguda/diagnóstico , Lesão Pulmonar Aguda/patologia , Adulto , Idoso , Biomarcadores/análise , Biomarcadores/sangue , Contagem de Células Sanguíneas , Proteína C-Reativa , Ponte de Artéria Coronária/métodos , Feminino , Hemoglobinas , Humanos , Inflamação , Pulmão/patologia , Pulmão/ultraestrutura , Masculino , Pessoa de Meia-Idade , Óxido Nítrico Sintase Tipo II/análise , Recuperação de Função Fisiológica , Esternotomia , Fator A de Crescimento do Endotélio Vascular/análise
6.
J Card Surg ; 35(8): 1920-1926, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32652793

RESUMO

BACKGROUND: Redo cardiac surgery carries an inherent risk for adverse short-term outcomes and worse long-term survival. Strategies to mitigate these risks have been numerous, including initiation of cardiopulmonary bypass via peripheral cannulation before resternotomy. This study evaluated the impact of central versus peripheral cannulation on long-term survival after redo cardiac surgery. METHODS: This was an observational study of open cardiac surgeries between 2010 and 2018. Patients undergoing open cardiac surgery that utilized cardiopulmonary bypass, who also had more than equal to 1 prior cardiac surgery, were identified. Kaplan-Meier survival estimation and multivariable Cox regression analysis were performed to assess the impact of peripheral cannulation on survival. To isolate long-term survival, patients with operative mortality were excluded and survival time was counted from the date of discharge until the date of death. RESULTS: Of the 1660 patients with more than equal to 1 prior cardiac surgery, 91 (5.5%) received peripheral cannulation. After excluding patients with operative mortality and after multivariable risk-adjustment, the peripheral cannulation group had significantly increased hazard of death, as compared to the central cannulation group (HR 1.53, 95% CI: 1.01, 2.30, P = .044). Yet, there were no relevant differences for other postoperative outcomes, including blood product requirement, prolonged ventilation (>24 hours), pneumonia, reoperation for bleeding, stroke, sepsis, and new dialysis requirement. CONCLUSIONS: This is the first study reporting the long-term impact of peripheral cannulation for redo cardiac surgery after excluding patients with operative mortality. These data suggest that central cannulation may to be the preferred approach to redo cardiac surgery whenever safe and possible.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Procedimentos Cirúrgicos Cardíacos/mortalidade , Procedimentos Cirúrgicos Cardíacos/métodos , Cateterismo Venoso Central/efeitos adversos , Cateterismo Venoso Central/mortalidade , Reoperação/efeitos adversos , Reoperação/mortalidade , Idoso , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Feminino , Humanos , Masculino , Pessoa de Meia-Idade , Risco , Segurança , Taxa de Sobrevida , Fatores de Tempo
8.
PLoS One ; 15(7): e0235604, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32645079

RESUMO

BACKGROUND: Cardiopulmonary bypass (CPB) induces a systemic inflammatory response (SIRS) and affects the organ vascular bed. Experimentally, the lack of pulsatility alters myogenic tone of resistance arteries and increases the parietal inflammatory response. The purpose of this study was to compare the vascular reactivity of the internal thoracic arteries (ITAs) due to the inflammatory response between patients undergoing coronary artery bypass grafting (CABG) under CPB with a roller pump or with a centrifugal pump. METHODS: Eighty elective male patients undergoing CABG were selected using one or two internal thoracic arteries under CPB with a roller pump (RP group) or centrifugal pump (CFP group). ITA samples were collected before starting CPB (Time 1) and before the last coronary anastomosis during aortic cross clamping (Time 2). The primary endpoint was the endothelium-dependent relaxation of ITAs investigated using wire-myography. The secondary endpoint was the parietal inflammatory response of arteries defined by the measurements of superoxide levels, leukocytes and lymphocytes rate and gene expression of inflammatory proteins using. Terminal complement complex activation (SC5b-9) and neutrophil activation (elastase) analysis were performed on arterial blood at the same times. RESULTS: Exposure time of ITAs to the pump flow was respectively 43.3 minutes in the RP group and 45.7 minutes in the CFP group. Acetylcholine-dependent relaxation was conserved in the two groups whatever the time. Gene expression of C3 and C4a in the artery wall decreased from Time 1 to Time 2. No oxidative stress was observed in the graft. There was no difference between the groups concerning the leukocytes and lymphocytes rate. SC5b-9 and elastase increased between Time 1 and Time 2. CONCLUSION: Endothelium-dependent relaxation of the internal thoracic arteries was preserved during CPB whatever the type of pump used. The inflammatory response observed in the blood was not found in the graft wall within this time frame. TRIAL REGISTRATION: Name of trial study protocol: IPITA Registration number (ClinicalTrials.gov): NCT04168853.


Assuntos
Ponte Cardiopulmonar/instrumentação , Ponte de Artéria Coronária/métodos , Coração Auxiliar/efeitos adversos , Artéria Torácica Interna/cirurgia , Complicações Pós-Operatórias/etiologia , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/efeitos adversos , Ponte Cardiopulmonar/métodos , Ponte de Artéria Coronária/efeitos adversos , Ponte de Artéria Coronária/instrumentação , Endotélio Vascular/metabolismo , Endotélio Vascular/fisiologia , Feminino , Humanos , Elastase de Leucócito/metabolismo , Masculino , Pessoa de Meia-Idade , Estresse Oxidativo , Complicações Pós-Operatórias/epidemiologia , Transplantes/fisiologia , Transplantes/cirurgia , Vasoconstrição , Vasodilatação
9.
J Cardiothorac Surg ; 15(1): 134, 2020 Jun 10.
Artigo em Inglês | MEDLINE | ID: mdl-32522213

RESUMO

BACKGROUND: In a rabbit model of cardiopulmonary bypass (CPB) and cardioplegic arrest, we previously showed that hyperoxic myocardial reperfusion was associated with increased left ventricular (LV) systolic dysfunction and myocardial injury compared with normoxic reperfusion. The aim of this study was to evaluate in our experimental model the impact of post-CPB reperfusion conditions on other organs potentially vulnerable to ischemic injury such as the brain and kidney. METHODS: After 60 min of CPB, aortic cross-clamp, and cold cardioplegic arrest, rabbits were reperfused under hyperoxic or normoxic conditions for 120 min. Left ventricular systolic contractility (LV + dP/dt) and diastolic relaxation (LV -dP/dt) were continuously recorded, and end-organ injury was assessed by measuring circulating biomarkers specific for kidney (cystatin C and creatinine) and brain injury [S100B and neuron specific enolase (NSE)]. At completion of the protocol, kidney and brain tissues were harvested for measuring oxidant stress (OS), inflammation and apoptosis. RESULTS: Following aortic cross-clamp removal, rabbits exposed to normoxic reperfusion demonstrated preserved LV systolic and diastolic function compared with hyperoxic reperfusion (LV + dP/dt: 70 ± 14% of pre-CPB vs. 36 ± 21%, p = 0.018; LV -dP/dt: 72 ± 36% of pre-CPB vs. 33 ± 20%, p = 0.023). Similarly, CPB increased plasma creatinine, S100B and NSE that were significantly attenuated by normoxic reperfusion compared with hyperoxic reperfusion (creatinine: 4.0 ± 0.5 vs. 7.1 ± 0.8 mg/dL, p = 0.004; S100B: 4.0 ± 0.8 vs. 6.7 ± 1.0 ng/mL, p = 0.047; NSE: 57.7 ± 6.8 vs. 101.3 ± 16.1 pg/mL, p = 0.040). Furthermore, both kidney and brain tissues showed increased mRNA expression and activation of pathways for OS, inflammation, and apoptosis, that were reduced under normoxic compared with hyperoxic conditions. CONCLUSIONS: Normoxic reperfusion ameliorates cardiac, renal and neural injury compared with hyperoxic reperfusion in an in vivo animal model of CPB and cardioplegic arrest. This protective effect of normoxic reperfusion may be due to a reduction in signaling pathways for OS, inflammation, and apoptosis.


Assuntos
Isquemia Encefálica/sangue , Ponte Cardiopulmonar/efeitos adversos , Parada Cardíaca Induzida/efeitos adversos , Nefropatias/sangue , Oxigênio/administração & dosagem , Traumatismo por Reperfusão/sangue , Animais , Apoptose , Biomarcadores/sangue , Encéfalo/fisiopatologia , Isquemia Encefálica/etiologia , Isquemia Encefálica/fisiopatologia , Creatinina/sangue , Cistatina C/sangue , Inflamação/metabolismo , Rim/fisiopatologia , Nefropatias/etiologia , Nefropatias/fisiopatologia , Masculino , Estresse Oxidativo/genética , Fosfopiruvato Hidratase/sangue , RNA Mensageiro/metabolismo , Coelhos , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/fisiopatologia , Subunidade beta da Proteína Ligante de Cálcio S100/sangue , Função Ventricular Esquerda
10.
J Cardiothorac Surg ; 15(1): 137, 2020 Jun 11.
Artigo em Inglês | MEDLINE | ID: mdl-32527277

RESUMO

OBJECTIVES: Cardiac surgery can lead to post-operative end-organ complications secondary to activation of systemic inflammatory response. We hypothesize that surgical trauma or cardiopulmonary bypass (CPB) may initiate systemic inflammatory response via release of mitochondrial DNA (mtDNA) signaling Toll-like receptor 9 (TLR9) and interleukin-6 production (IL-6). MATERIALS AND METHODS: The role of TLR9 in systemic inflammatory response in cardiac surgery was studied using a murine model of sternotomy and a porcine model of sternotomy and CPB. mtDNA and IL-6 were measured with and without TLR9-antagonist treatment. To study ischemia-reperfusion injury, we utilized an ex-vivo porcine kidney model. RESULTS: In the rodent model (n = 15), circulating mtDNA increased 19-fold (19.29 ± 3.31, p < 0.001) and plasma IL-6 levels increased 59-fold (59.06 ± 14.98) at 1-min post-sternotomy compared to pre-sternotomy. In the murine model (n = 11), administration of TLR-9 antagonists lowered IL-6 expression post-sternotomy when compared to controls (59.06 ± 14.98 vs. 5.25 ± 1.08) indicating that TLR-9 is a positive regulator of IL-6 after sternotomy. Using porcine models (n = 10), a significant increase in circulating mtDNA was observed after CPB (Fold change 29.9 ± 4.8, p = 0.005) and along with IL-6 following renal ischaemia-reperfusion. Addition of the antioxidant sulforaphane reduced circulating mtDNA when compared to controls (FC 7.36 ± 0.61 vs. 32.0 ± 4.17 at 60 min post-CPB). CONCLUSION: CPB, surgical trauma and ischemic perfusion injury trigger the release of circulating mtDNA that activates TLR-9, in turn stimulating a release of IL-6. Therefore, TLR-9 antagonists may attenuate this response and may provide a future therapeutic target whereby the systemic inflammatory response to cardiac surgery may be manipulated to improve clinical outcomes.


Assuntos
Ponte Cardiopulmonar/efeitos adversos , DNA Mitocondrial/sangue , Interleucina-6/sangue , Esternotomia/efeitos adversos , Receptor Toll-Like 9/sangue , Animais , Procedimentos Cirúrgicos Cardíacos , Feminino , Inflamação/sangue , Masculino , Camundongos , Mitocôndrias , Complicações Pós-Operatórias , Ratos , Transdução de Sinais , Suínos , Receptor Toll-Like 9/antagonistas & inibidores
11.
Asian Cardiovasc Thorac Ann ; 28(6): 336-338, 2020 Jul.
Artigo em Inglês | MEDLINE | ID: mdl-32539424

RESUMO

Rapidly progressive epicardial hemorrhagic blebs during weaning from cardiopulmonary bypass after perimembranous ventricular septal defect closure has not been reported previously. Here, we describe the case of a 3-month-old baby with life-threatening epicardial hemorrhagic blebs and an interventricular septal hematoma after perimembranous ventricular septal defect patch closure.


Assuntos
Vesícula/etiologia , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Comunicação Interventricular/cirurgia , Hematoma/etiologia , Pericárdio/transplante , Vesícula/diagnóstico por imagem , Evolução Fatal , Comunicação Interventricular/diagnóstico por imagem , Hematoma/diagnóstico por imagem , Humanos , Lactente , Masculino
12.
Adv Gerontol ; 33(2): 319-324, 2020.
Artigo em Russo | MEDLINE | ID: mdl-32593247

RESUMO

To identify predictors of neurological complications in the hospital period after coronary artery bypass grafting (CABG), 92 patients with coronary heart disease aged 70 years and over were analyzed. Intraoperative monitoring of cerebral oxygenation (rSO2, %) was carried out. At the stage of induction anesthesia, the average level of rSO2 for left and right hemispheres was 64-65% without significant changes during the operation. A decrease in rSO2 during cardiopulmonary bypass (CPB) was associated with increased risk of neurological complications. The risk of neurological complications increase 7-fold and 9-fold with a decrease in rSO2 by 20% or more during CPB relative to baseline for left and right hemispheres, respectively. A history of two or more myocardial infarctions increases 3-fold the risk of neurological complications after CABG.


Assuntos
Ponte de Artéria Coronária/efeitos adversos , Doença das Coronárias/cirurgia , Doenças do Sistema Nervoso/diagnóstico , Doenças do Sistema Nervoso/etiologia , Complicações Pós-Operatórias/diagnóstico , Idoso , Idoso de 80 Anos ou mais , Ponte Cardiopulmonar/efeitos adversos , Doença das Coronárias/complicações , Humanos , Infarto do Miocárdio/complicações , Infarto do Miocárdio/cirurgia , Complicações Pós-Operatórias/etiologia
13.
Medicine (Baltimore) ; 99(21): e20007, 2020 May 22.
Artigo em Inglês | MEDLINE | ID: mdl-32481266

RESUMO

To investigate the changes in the concentrations of interleukin-6 (IL-6), interleukin-8 (IL-8), tumor necrosis factor-α (TNF-α), and 8-iso-prostaglandin F2α (8-isoPGF2α) in exhaled breath condensate (EBC) in patients undergoing cardiac valve replacement under cardiopulmonary bypass (CPB) and its relationship with postoperative acute respiratory distress syndrome (ARDS).A prospective, case-control study was performed on 55 patients undergoing elective cardiac valve replacement under cardiopulmonary bypass, between November 2017 and May 2019. According to the diagnosis of postoperative ARDS, the patients were divided into ARDS group and control group. We compared the clinical characteristics, outcomes, respiratory mechanics, oxygenation parameters, and mediators in the 2 groups immediately after tracheal intubation (T1), at the end of CPB (T2), and 2 hours (T3) and 6 hours (T4) after CPB, and calculated the receiver operating characteristic curve (ROC), sensitivity, and specificity of the corresponding mediators.ARDS occurred in 29 patients after CPB. The ARDS group exhibited prolonged postoperative ventilator support, time to extubation, length of stay in the ICU, and postoperative length of stay. The peak airway pressure (Ppeak) and plat airway pressure (Pplat) at T4 were higher in the ARDS group compared with the control group. The alveolar-arterial oxygen partial pressure [P(A-a)O2] and respiratory index (RI) were higher and PaO2/FiO2 was lower in the ARDS group at T2-4 compared with the control group. The levels of EBC and serum mediators in the ARDS group were significantly higher at T2-4 compared with those in the control group. All the mediators in EBC were correlated significantly with those in the serum in the ARDS group (r = 0.7314, 0.898, 0.8386, 0.792) and control group (r = 0.6093, 0.8524, r = 0.7828, r = 0.6575) (P < .001). Meanwhile, the area under the curve (AUC) of IL-8 in EBC was significantly lower at T2 and the AUC of IL-6 in EBC was significantly higher at T4 than in serum (P < .05). In addition, all of the mediators in EBC had a certain accuracy in diagnose of postoperative ARDS.EBC analysis could be used to predict the high incidence of ARDS after cardiac valve replacement under CPB.


Assuntos
Ponte Cardiopulmonar/efeitos adversos , Expiração , Implante de Prótese de Valva Cardíaca/efeitos adversos , Síndrome do Desconforto Respiratório do Adulto/etiologia , Adulto , Idoso , Idoso de 80 Anos ou mais , Estudos de Casos e Controles , Feminino , Humanos , Interleucina-6 , Interleucina-8 , Tempo de Internação , Masculino , Pessoa de Meia-Idade , Período Pós-Operatório , Estudos Prospectivos , Fator de Necrose Tumoral alfa
14.
Clin Hemorheol Microcirc ; 76(1): 43-49, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32417764

RESUMO

BACKGROUND: Tranexamic acid (TXA) reduces perioperative bleeding among patients undergoing heart surgery. It is uncertain whether its postoperative administration, after prior administration before cardiopulmonary bypass (CPB), has an additional benefit. OBJECTIVE: Our study aimed to evaluate whether the postoperative administration of TXA reduces the blood loss after heart surgery. METHODS: In a retrospective cohort study at the University Heart Center Dresden, patients who underwent on-pump open-heart surgery and received 1 g TXA before CPB were included. Patients with postoperative administration of 1 g TXA were compared to patients without. Primary endpoint was the postoperative blood loss within 24 hours. RESULTS: Among 2,179 patients undergoing heart surgery between 1 July 2013 and 31 October 2014, 92 (4.2%) received TXA postoperatively. After matching, 71 patients with postoperative administration of TXA were compared to 71 without (n = 142). Postoperative administration of TXA did not result in decreased blood loss (MD 146.7 mL; p = 0.064). There was no evidence of an increased risk for thromboembolic complications. CONCLUSIONS: The postoperative administration of TXA did not reduce blood loss. The use of TXA was shown to be safe in terms of thromboembolic events and hospital mortality. Unless there is no clear evidence, the postoperative administration of TXA should be restricted to patients with massive blood loss and signs of hyperfibrinolysis only.


Assuntos
Antifibrinolíticos/uso terapêutico , Ponte Cardiopulmonar/efeitos adversos , Hemorragia Pós-Operatória/tratamento farmacológico , Ácido Tranexâmico/uso terapêutico , Idoso , Antifibrinolíticos/farmacologia , Feminino , Humanos , Masculino , Estudos Retrospectivos , Ácido Tranexâmico/farmacologia , Resultado do Tratamento
15.
Pediatr Cardiol ; 41(6): 1145-1152, 2020 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-32424719

RESUMO

Patients with congenital heart disease (CHD) are surviving longer thanks to improved surgical techniques and increasing knowledge of natural history. Pleural effusions continue to be a complication that affect many surgical patients and are associated with increased morbidity, many times requiring readmission and additional invasive procedures. The risks for development of pleural effusion after hospital discharge are ill-defined, which leads to uncertainty related to strategies for prevention. Our primary objective was to determine, in patients with CHD requiring cardiopulmonary bypass, the prevalence of post-surgical pleural effusions leading to readmission. The secondary objective was to identify risk factors associated with post-surgical pleural effusions requiring readmission. We identified 4417 citations; 10 full-text articles were included in the final review. Of the included studies, eight focused on single-ventricle palliation, one looked at Tetralogy of Fallot patients, and another on pleural effusion in the setting of post-pericardiotomy syndrome. Using a random-effect model, the overall prevalence of pleural effusion requiring readmission was 10.2% (95% CI 4.6; 17.6). Heterogeneity was high (I2 = 91%). In a subpopulation of patients after single-ventricle palliation, the prevalence was 13.0% (95% CI 6.0;21.0), whereas it was 3.0% (95% CI 0.4;6.75) in patients mostly with biventricular physiology. We were unable to accurately assess risk factors. A better understanding of this complication with a focus on single-ventricle physiology will allow for improved risk stratification, family counseling, and earlier recognition of pleural effusion in this patient population.


Assuntos
Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Readmissão do Paciente , Derrame Pleural/etiologia , Adolescente , Adulto , Criança , Pré-Escolar , Feminino , Cardiopatias Congênitas/cirurgia , Humanos , Lactente , Masculino , Fatores de Risco , Adulto Jovem
16.
Cardiovasc Ther ; 2020: 7834173, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-32292492

RESUMO

Extracorporeal hemadsorption may reduce inflammatory reaction in cardiopulmonary bypass (CPB) surgery. Glucocorticoids have been used during open-heart surgery for alleviation of systemic inflammation after CPB. We compared intraoperative hemadsorption and methylprednisolone, with usual care, during complex cardiac surgery on CPB, for inflammatory responses, hemodynamics, and perioperative course. Seventy-six patients with prolonged CPB were recruited and randomized, with 60 included in final analysis. Allocation was into three groups: Methylprednisolone (n = 20), Cytosorb (n = 20), and Control group (usual care, n = 20). Proinflammatory (TNF-α, IL-1ß, IL-6, and IL-8) and anti-inflammatory (IL-10) cytokines which complement C5a, CD64, and CD163 expression by immune cells were analyzed within the first five postoperative days, in addition to hemodynamic and clinical outcome parameters. Methylprednisolone group, compared to Cytosorb and Control had significantly lower levels of TNF-α (until the end of surgery, p < 0.001), IL-6 (until 48 h after surgery, p < 0.001), and IL-8 (until 24 h after surgery, p < 0.016). CD64 expression on monocytes was the highest in the Cytosorb group and lasted until the 5th postoperative day (p < 0.016). IL-10 concentration (until the end of surgery) and CD163 expression on monocytes (until 48 h after surgery) were the highest in the Methylprednisolone group (p < 0.016, for all measurements between three groups). No differences between groups in the cardiac index or clinical outcome parameters were found. Methylprednisolone more effectively ameliorates inflammatory responses after CPB surgery compared to hemadsorption and usual care. Hemadsorption compared with usual care causes higher prolonged expression of CD64 on monocytes but short lasting expression of CD163 on granulocytes. Hemadsorption with CytoSorb® was safe and well tolerated. This trial is registered with clinicaltrials.gov (NCT02666703).


Assuntos
Anti-Inflamatórios/administração & dosagem , Procedimentos Cirúrgicos Cardíacos , Ponte Cardiopulmonar , Glucocorticoides/administração & dosagem , Hemadsorção , Inflamação/prevenção & controle , Metilprednisolona/administração & dosagem , Adulto , Idoso , Idoso de 80 Anos ou mais , Anti-Inflamatórios/efeitos adversos , Biomarcadores/sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Citocinas/sangue , Feminino , Glucocorticoides/efeitos adversos , Granulócitos/efeitos dos fármacos , Granulócitos/imunologia , Granulócitos/metabolismo , Humanos , Inflamação/sangue , Inflamação/diagnóstico , Inflamação/imunologia , Mediadores da Inflamação/sangue , Masculino , Metilprednisolona/efeitos adversos , Pessoa de Meia-Idade , Monócitos/efeitos dos fármacos , Monócitos/imunologia , Monócitos/metabolismo , Estudos Prospectivos , Eslovênia , Fatores de Tempo , Resultado do Tratamento
17.
J Surg Res ; 253: 8-17, 2020 09.
Artigo em Inglês | MEDLINE | ID: mdl-32305498

RESUMO

BACKGROUND: Cytochrome P450 epoxygenase 2J2 (CYP2J2) metabolizes arachidonic acid to epoxyeicosatrienoic acids, which exert anti-inflammatory effects and alleviate oxidative stress in the cardiovascular system. Our previous work revealed that CYP2J2 is expressed in pulmonary artery endothelial cells. It was therefore hypothesized that CYP2J2 overexpression may prevent lung ischemia/reperfusion injury (LIRI) in 3-week-old C57BL/6 mice during deep hypothermic low flow (DHLF). This study aimed to establish whether CYP2J2 protects against LIRI and the mechanisms of CYP2J2 overexpression during DHLF in mice. The aim of this study was to explore the effects of DHLF on lung tissue in mice and to find out the regularity of this process, so as to provide theoretical data for lung tissue protection in children undergoing this process in clinic. METHODS: A 3-week-old C57BL/6 mouse model was used to mimic LIRI conditions during DHLF by clamping the left pulmonary artery and left main bronchus for 120 min, followed by reperfusion for 2 h. The body temperature of the mice was maintained between 18°C and 19°C to induce DHLF. RESULTS: During DHLF, lung ischemia/reperfusion increased the left lung wet/dry weight, the left lung weight/body weight ratio, the protein concentration in bronchoalveolar lavage fluid, and the concentration of proinflammatory mediators in the lungs, including interleukin (IL)-1, IL-8, and necrosis factor (NF)-α, and decreased the concentration of the anti-inflammatory mediator IL-10. Furthermore, activation of NF-κB p65 and degradation of IKBα were remarkably increased in lung tissues after ischemia/reperfusion. The CYP2J2 overexpression group showed the opposite results (P < 0.05), and p-Akt1 and p-GSK-3ß expression were significantly higher in the CYP2J2 overexpression group (P < 0.05). Moreover, the changes in IL-1, IL-8, tumor necrosis factor-α, IL-10, p-Akt1, p-GSK-3ß, NF-κB p65, and IKBα were reversed in the Akt1 gene heterozygous knockout group, and lung damage was significantly higher in the Akt1 gene heterozygous knockout group than in the CYP2J2 overexpression group. CYP2J2 overexpression can protect against LIRI, whereas Akt1 gene heterozygous knockout in mice can abolish this protective effect. CONCLUSIONS: CYP2J2 overexpression can protect against LIRI by activating the P13K/Akt/GSK-3ß/NF-kB signaling pathway during DHLF. Thus, changing CYP2J2 expression can be a novel strategy for the prevention and treatment of LIRI during DHLF.


Assuntos
Ponte Cardiopulmonar/efeitos adversos , Sistema Enzimático do Citocromo P-450/metabolismo , Terapia Genética/métodos , Lesão Pulmonar/terapia , Traumatismo por Reperfusão/terapia , Animais , Ponte Cardiopulmonar/métodos , China , Sistema Enzimático do Citocromo P-450/genética , Modelos Animais de Doenças , Glicogênio Sintase Quinase 3 beta/metabolismo , Cardiopatias Congênitas/cirurgia , Humanos , Pulmão , Lesão Pulmonar/etiologia , Lesão Pulmonar/patologia , Camundongos , Camundongos Transgênicos , Estresse Oxidativo , Fosfatidilinositol 3-Quinases/metabolismo , Proteínas Proto-Oncogênicas c-akt/metabolismo , Proteínas Recombinantes/genética , Proteínas Recombinantes/metabolismo , Traumatismo por Reperfusão/etiologia , Traumatismo por Reperfusão/patologia , Transdução de Sinais , Fator de Transcrição RelA/metabolismo , Transfecção
18.
J Cardiovasc Pharmacol Ther ; 25(4): 338-345, 2020 07.
Artigo em Inglês | MEDLINE | ID: mdl-32323557

RESUMO

BACKGROUND: Vitamin D plays an important role in immune system and in the regulation of inflammatory cytokines. Coronary artery bypass graft (CABG) with cardiopulmonary bypass (CPB) is associated with an extensive inflammatory response. The aim of this study is to examine the effect of vitamin D treatment on the apoptosis and inflammatory changes developed after CABG. METHODS: This trial was conducted on 70 patients undergoing CABG with CPB. Patients were randomly administered either in placebo or in the group of orally consuming 150 000 IU vitamin D daily for 3 consecutive days before surgery. The right atrium sample was taken to assess caspases 2, 3, and 7 activity using immunohistochemistry method. The serum level of interleukin-10 (IL-10) and insulin-like growth factor 1 (IGF-1) were compared at intervals. RESULTS: The average number of positive cells for caspases 2 and 3 were less in vitamin D group (P = .006 and P < .001, respectively). There was an increase in serum levels of IL-10 after 3 days from vitamin D treatment before surgery (vitamin D group = 4.4 ± 4.9 ng/mL and control group = 1 ± 0.5 ng/mL, P = .001). After operation, IL-10 increased in both groups, higher level in vitamin D group (P < .001). The comparison of serum IGF-1 showed significant difference after 3 days (P = .006) and remained higher in vitamin D group after CPB (P < .001). CONCLUSIONS: These findings suggest the apoptosis rate after CPB can be reduced by vitamin D. Vitamin D treatment may improve the inflammatory status before and after surgery. Further studies are needed to confirm the antiapoptotic property of vitamin D and clinical implication.


Assuntos
Apoptose/efeitos dos fármacos , Ponte Cardiopulmonar/efeitos adversos , Ponte de Artéria Coronária/efeitos adversos , Suplementos Nutricionais , Átrios do Coração/efeitos dos fármacos , Vitamina D/administração & dosagem , Idoso , Biomarcadores/sangue , Caspases/metabolismo , Suplementos Nutricionais/efeitos adversos , Método Duplo-Cego , Feminino , Átrios do Coração/metabolismo , Átrios do Coração/patologia , Humanos , Mediadores da Inflamação/sangue , Fator de Crescimento Insulin-Like I/metabolismo , Interleucina-10/sangue , Irã (Geográfico) , Masculino , Pessoa de Meia-Idade , Fatores de Tempo , Resultado do Tratamento , Vitamina D/efeitos adversos
19.
J Card Surg ; 35(5): 1062-1071, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32237166

RESUMO

BACKGROUND AND AIM OF THE STUDY: Ventricular septal defect (VSD) following myocardial infarction (MI) is a relatively infrequent complication with high mortality. We sought to investigate the effect of concomitant coronary artery bypass graft (CABG) on outcomes following post-MI VSD repair. METHODS: Electronic search was performed to identify all relevant studies published from 2000 to 2018. Sixty-seven studies were selected for the analysis comprising 2174 patients with post-MI VSD. Demographic information, perioperative variables, and outcomes including survival data were extracted and pooled for systematic review and meta-analysis. RESULTS: Single-vessel disease was most common (47%, 95% confidence interval [CI], 42-52), left anterior descending coronary artery was the most commonly involved vessel (55%, 95% CI, 46-63), and anterior wall was the most commonly affected territory (57%, 95% CI, 51-63). Concomitant CABG was performed in 52% (95% CI, 46-57) of patients. Of these, infarcted territory was re-vascularized in 54% (95% CI, 23-82). A residual/recurrent shunt was present in 29% (95% CI, 24-34) of patients. Of these, surgical repair was performed in 35% (95% CI, 28-41) and transcatheter repair in 11% (95% CI, 6-21). Thirty-day mortality was 30% (95% CI, 26-35) in patients who had preoperative coronary angiogram, and 58% (95% CI, 43-71) in those who did not (P < .01). No significant survival difference observed between those who had concomitant CABG vs those without CABG. CONCLUSIONS: Concomitant CABG did not have a significant effect on survival following VSD repair. Revascularization should be weighed against the risks associated with prolonged cardiopulmonary bypass.


Assuntos
Cateterismo Cardíaco/métodos , Procedimentos Cirúrgicos Cardíacos/métodos , Ponte de Artéria Coronária , Comunicação Interventricular/cirurgia , Ponte Cardiopulmonar/efeitos adversos , Feminino , Comunicação Interventricular/etiologia , Comunicação Interventricular/mortalidade , Humanos , Masculino , Infarto do Miocárdio/complicações , Taxa de Sobrevida , Resultado do Tratamento
20.
J Card Surg ; 35(5): 1043-1050, 2020 May.
Artigo em Inglês | MEDLINE | ID: mdl-32248625

RESUMO

BACKGROUND: Patients undergoing cardiac surgery requiring cardiopulmonary bypass (CPB) are at risk for coagulopathy and bleeding requiring blood product transfusion. Acute normovolemic hemodilution (ANH) is a blood conservation technique shown to reduce transfusion and bleeding associated with cardiac surgery. Despite numerous advantages, little is known about the effect of ANH on coagulation testing. METHODS: Prospective observational study, 80 patients (40 controls, 40 ANH) undergoing cardiac surgery requiring CPB. Blood for coagulation testing (hemoglobin, platelet count, prothrombin time/International Normalized Ratio [PT/INR], activated partial thromboplastin time [aPTT], fibrinogen, and kaolin thromboelastography [TEG]) was collected 5 minutes after protamine (Time 1), and following ANH reinfusion (or 30 minutes after Time 1) in controls (Time 2). RESULTS: Patients undergoing ANH had a significantly lower aPTT (-1.4 seconds 95% CI [-2.7, 0.0]; P = .044) and higher fibrinogen (+13 mg/dL [+1, +26]; P = .040) between Time 1 and Time 2 compared to controls. Additionally, the change in hemoglobin between Time 1 and Time 2 was significantly increased in the ANH group (+0.4 [+0.1, +0.8]; P = .024). The study also demonstrated a normalization of the platelet count, PT/INR, aPTT, and TEG values between Time 1 and Time 2 in control patients. CONCLUSIONS: In patients undergoing cardiac surgery requiring CPB, ANH results in significant improvements of aPTT, fibrinogen and hemoglobin values; however, the true clinical significance is questionable. In the absence of ongoing surgical bleeding, there appears to be normalization of coagulation tests (excluding fibrinogen) following CPB.


Assuntos
Transtornos da Coagulação Sanguínea/etiologia , Testes de Coagulação Sanguínea , Transfusão de Sangue , Procedimentos Cirúrgicos Cardíacos/efeitos adversos , Ponte Cardiopulmonar/efeitos adversos , Hemodiluição/métodos , Hemorragia/etiologia , Complicações Pós-Operatórias/etiologia , Idoso , Transtornos da Coagulação Sanguínea/sangue , Transtornos da Coagulação Sanguínea/prevenção & controle , Feminino , Hemorragia/sangue , Hemorragia/prevenção & controle , Humanos , Coeficiente Internacional Normatizado , Masculino , Pessoa de Meia-Idade , Tempo de Tromboplastina Parcial , Contagem de Plaquetas , Complicações Pós-Operatórias/prevenção & controle , Estudos Prospectivos , Risco , Tromboelastografia
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