Effect of Xenon Anesthesia Compared to Sevoflurane and Total Intravenous Anesthesia for Coronary Artery Bypass Graft Surgery on Postoperative Cardiac Troponin Release: An International, Multicenter, Phase 3, Single-blinded, Randomized Noninferiority Trial.

BACKGROUND: Ischemic myocardial damage accompanying coronary artery bypass graft surgery remains a clinical challenge. We investigated whether xenon anesthesia could limit myocardial damage in coronary artery bypass graft surgery patients, as has been reported for animal ischemia models. METHODS: In 17 university hospitals in France, Germany, Italy, and The Netherlands, low-risk elective, on-pump coronary artery bypass graft surgery patients were randomized to receive xenon, sevoflurane, or propofol-based total intravenous anesthesia for anesthesia maintenance. The primary outcome was the cardiac troponin I concentration in the blood 24 h postsurgery. The noninferiority margin for the mean difference in cardiac troponin I release between the xenon and sevoflurane groups was less than 0.15 ng/ml. Secondary outcomes were the safety and feasibility of xenon anesthesia. RESULTS: The first patient included at each center received xenon anesthesia for practical reasons. For all other patients, anesthesia maintenance was randomized (intention-to-treat: n = 492; per-protocol/without major protocol deviation: n = 446). Median 24-h postoperative cardiac troponin I concentrations (ng/ml [interquartile range]) were 1.14 [0.76 to 2.10] with xenon, 1.30 [0.78 to 2.67] with sevoflurane, and 1.48 [0.94 to 2.78] with total intravenous anesthesia [per-protocol]). The mean difference in cardiac troponin I release between xenon and sevoflurane was -0.09 ng/ml (95% CI, -0.30 to 0.11; per-protocol: P = 0.02). Postoperative cardiac troponin I release was significantly less with xenon than with total intravenous anesthesia (intention-to-treat: P = 0.05; per-protocol: P = 0.02). Perioperative variables and postoperative outcomes were comparable across all groups, with no safety concerns. CONCLUSIONS: In postoperative cardiac troponin I release, xenon was noninferior to sevoflurane in low-risk, on-pump coronary artery bypass graft surgery patients. Only with xenon was cardiac troponin I release less than with total intravenous anesthesia. Xenon anesthesia appeared safe and feasible.

Effect of Levosimendan on Low Cardiac Output Syndrome in Patients With Low Ejection Fraction Undergoing Coronary Artery Bypass Grafting With Cardiopulmonary Bypass: The LICORN Randomized Clinical Trial.

Importance: Low cardiac output syndrome after cardiac surgery is associated with high morbidity and mortality in patients with impaired left ventricular function. Objective: To assess the ability of preoperative levosimendan to prevent postoperative low cardiac output syndrome. Design, Setting, and Participants: Randomized, double-blind, placebo-controlled trial conducted in 13 French cardiac surgical centers. Patients with a left ventricular ejection fraction less than or equal to 40% and scheduled for isolated or combined coronary artery bypass grafting with cardiopulmonary bypass were enrolled from June 2013 until May 2015 and followed during 6 months (last follow-up, November 30, 2015). Interventions: Patients were assigned to a 24-hour infusion of levosimendan 0.1 µg/kg/min (n = 167) or placebo (n = 168) initiated after anesthetic induction. Main Outcomes and Measures: Composite end point reflecting low cardiac output syndrome with need for a catecholamine infusion 48 hours after study drug initiation, need for a left ventricular mechanical assist device or failure to wean from it at 96 hours after study drug initiation when the device was inserted preoperatively, or need for renal replacement therapy at any time postoperatively. It was hypothesized that levosimendan would reduce the incidence of this composite end point by 15% in comparison with placebo. Results: Among 336 randomized patients (mean age, 68 years; 16% women), 333 completed the trial. The primary end point occurred in 87 patients (52%) in the levosimendan group and 101 patients (61%) in the placebo group (absolute risk difference taking into account center effect, -7% [95% CI, -17% to 3%]; P = .15). Predefined subgroup analyses found no interaction with ejection fraction less than 30%, type of surgery, and preoperative use of ß-blockers, intra-aortic balloon pump, or catecholamines. The prevalence of hypotension (57% vs 48%), atrial fibrillation (50% vs 40%), and other adverse events did not significantly differ between levosimendan and placebo. Conclusions and Relevance: Among patients with low ejection fraction who were undergoing coronary artery bypass grafting with cardiopulmonary bypass, levosimendan compared with placebo did not result in a significant difference in the composite end point of prolonged catecholamine infusion, use of left ventricular mechanical assist device, or renal replacement therapy. These findings do not support the use of levosimendan for this indication. Trial Registration: EudraCT Number: 2012-000232-25; clinicaltrials.gov Identifier: NCT02184819.

Safety and effectiveness of the transsubclavian approach for transcatheter aortic valve implantation with the 14-F CoreValve Evolut R device.

AIMS: In addition to the transfemoral route, common approaches for transcatheter aortic valve implantation (TAVI) are the transapical and transaortic ones. Yet, these are associated with morbidity. The transsubclavian approach (TSA) is an alternative to minimize invasiveness. METHODS: Fifteen consecutive patients underwent TAVI via TSA using the CoreValve Evolut R. The 14F delivery system without sheath was directly introduced into the artery. RESULTS: Success was 100%; contrast volume was 99.4 ±â€Š29.58 ml. Patients were extubated after 1.66 ±â€Š0.89 h. Hemoglobin drop was 0.64 ±â€Š0.28 g/dl. There were no complications. Hospital stay was 4.53 ±â€Š1.24 days: 11 patients were discharged home, the remainder to rehabilitation. CONCLUSION: TSA is associated with limited morbidity, early patient mobilization, short hospitalization.

Clinical outcomes in patients after extracorporeal membrane oxygenation support for post-cardiotomy cardiogenic shock: a single-centre experience of 92 cases.

OBJECTIVES: Post-cardiotomy cardiogenic shock is a major concern in cardiac surgery. We reviewed our experience of extracorporeal membrane oxygenation (ECMO) as temporary circulatory support in post-cardiotomy cardiogenic shock. METHODS: Between January 2005 and December 2014, adult patients implanted with ECMO after cardiac surgical procedures were included. Indications for ECMO were failure to be withdrawn from cardiopulmonary bypass or refractory cardiogenic shock occurring during postoperative Days 1 and 2. Patients' characteristics and outcomes were prospectively collected in a local ECMO database. RESULTS: Ninety-two patients, median age of 63 years (17-83 years), were supported by ECMO following valvular surgery (66%), acute aortic dissection (10%) and coronary artery bypass grafting (9%). A total of 37% were combined surgical procedures, 24% were redo procedures and 33% were emergent procedures. The median duration of ECMO support was 6 days (1-28 days). The weaning rate from mechanical support was 48%. Overall 1-month and 6-month survival rates were, respectively, 42% and 39%. Survivors were younger (57 vs 63 years old, P = 0.02) and had a higher preoperative left ventricular ejection fraction (52.5 vs 44.1%, P = 0.017). There was a trend for lower serum creatinine levels and total bilirubin rates in the survivors' group 24 h after initiation of ECMO (respectively, 162 vs 212 µmol/l, P = 0.06; 25.3 vs 54.2 mg/dl, P = 0.08). Valvular surgery and peak lactic acid serum level were associated with poor outcomes. The mean health-related quality of life EuroQoL scale was 68 ± 16/100 at 2 years. CONCLUSIONS: Refractory cardiogenic shock requiring ECMO was most frequently observed after redo valvular surgery in the present study. The overall 6-month survival rate was 39% after ECMO support for post-cardiotomy cardiogenic shock with acceptable health-related quality of life. Improved kidney and liver functions after 24 h of support were associated with favourable outcomes.

The accuracy of transcutaneous PCO2 in subjects with severe brain injury: a comparison with end-tidal PCO2.

BACKGROUND: In patients suffering from brain injury, end-tidal PCO2 (PETCO2 ) monitoring is controversial, but transcutaneous PCO2 (PtcCO2 ), which is noninvasive and utilizes immediate display, may be an alternative method. We hypothesized that PtcCO2 would be more accurate than PETCO2 for monitoring PaCO2 in patients with severe brain injury. METHODS: A prospective observational study included consecutive mechanically ventilated adult subjects who had acute brain injury and an arterial catheter in place. When an arterial blood gas analysis was required, the PETCO2 and PtcCO2 values were simultaneously recorded. The agreement between the PETCO2 , PtcCO2 , and PaCO2 measurements (reference) was determined using the Bland-Altman method. The number of outliers defined by the formula ([PETCO2 or PtcCO2 ] - PaCO2 ) > ± 4 mm Hg indicated the proportion of measurements that were considered clinically unacceptable. RESULTS: A total of 25 subjects were included in the study, and 85 simultaneous measurements of PaCO2 , PtcCO2 , and PETCO2 were obtained. The bias and precision between PaCO2 and PtcCO2 were -0.75 and 6.23 mm Hg, respectively. The limits of agreement ranged from -12.97 to 11.47 mm Hg. The bias and precision between PaCO2 and PETCO2 were 0.68 and 5.82 mm Hg, respectively. The limits of agreement ranged from -10.72 to 12.08 mm Hg. There were 34 (40%) outliers for the PtcCO2 sensor and 34 (40%) outliers for the PETCO2 sensor (P > .99). CONCLUSIONS: The accuracy of PtcCO2 was not superior to that of PETCO2 for assessing PCO2 levels and should not be used to monitor these levels in subjects with severe brain injury.