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Ramachandran RV, Subramaniam B. Pro: Individualized Optimal Perfusion Pressure-Maximizing Patient Care During Cardiopulmonary Bypass. J Cardiothorac Vasc Anesth 2024; 38:563-565. [PMID: 38065696 DOI: 10.1053/j.jvca.2023.10.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/15/2023] [Revised: 10/03/2023] [Accepted: 10/21/2023] [Indexed: 01/27/2024]
Abstract
Cardiopulmonary bypass (CPB) has revolutionized cardiac surgery but poses challenges such as hemodynamic instability and adverse clinical outcomes. Achieving optimal perfusion during CPB ensures adequate oxygen delivery to vital organs. Although mean arterial pressure is a key determinant of perfusion pressure, clear guidelines for optimal perfusion have yet to be established. Autoregulation, the organ's ability to maintain consistent blood flow, plays a vital role in perfusion. Individual variability in autoregulation responses and intraoperative factors necessitate an individualized approach to determining the autoregulation range. Continuous assessment of autoregulation during surgery allows for personalized perfusion targets, optimizing organ perfusion. Exploring techniques like multimodal intravenous anesthesia guided by electroencephalogram can enhance perfusion maintenance within the auto-regulatory range. By adopting an individualized approach to perfusion targets on CPB, we can improve outcomes and enhance patient care.
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Rozencwajg S, Wu EL, Heinsar S, Stevens M, Chinchilla J, Fraser JF, Pauls JP. A mock circulation loop to evaluate differential hypoxemia during peripheral venoarterial extracorporeal membrane oxygenation. Perfusion 2024; 39:66-75. [PMID: 35038287 DOI: 10.1177/02676591211056567] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
INTRODUCTION Peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO) creates a retrograde flow along the aorta competing with the left ventricle (LV) in the so-called 'mixing zone' (MZ). Detecting it is essential to understand which of the LV or the ECMO flow perfuses the upper body - particularly the brain and the coronary arteries - in case of differential hypoxemia (DH). METHODS We described a mock circulation loop (MCL) that enabled experimental research on DH. We recreated the three clinical situations relevant to clinicians: where the brain is either totally perfused by the ECMO or the LV or both. In a second step, we used this model to investigate two scenarios to diagnose DH: (i) pulse pressure and (ii) thermodilution via injection of cold saline in the ECMO circuit. RESULTS The presented MCL was able to reproduce the three relevant mixing zones within the aortic arch, thus allowing to study DH. Pulse pressure was unable to detect location of the MZ. However, the thermodilution method was able to detect whether the brain was totally perfused by the ECMO or not. CONCLUSION We validated an in-vitro differential hypoxemia model of cardiogenic shock supported by VA ECMO. This MCL could be used as an alternative to animal studies for research scenarios.
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Affiliation(s)
- Sacha Rozencwajg
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Sorbonne Université, INSERM, UMRS-1166, ICAN Institute of Cardiometabolism and Nutrition, Medical ICU, Pitié-Salpêtrière University Hospital, Paris, France
| | - Eric L Wu
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Silver Heinsar
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - Michael Stevens
- Graduate School of Biomedical Engineering, UNSW Sydney, AU -NSW, Australia
| | - Josh Chinchilla
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- Faculty of Medicine, The University of Queensland, Brisbane, AU-QLD, Australia
| | - Jo P Pauls
- Innovative Cardiovascular Engineering and Technology Laboratory, Critical Care Research Group, The Prince Charles Hospital, Brisbane, AU-QLD, Australia
- School of Engineering and Built Environment, Griffith University, Southport, AU-QLD, Australia
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Lin Z, Chen X, Xu Z, Chen L, Dai X. Comparison of post-operative pain and quality of life between total thoracoscopic surgery and conventional full-sternotomy for aortic valve replacement. BMC Cardiovasc Disord 2023; 23:580. [PMID: 38001480 PMCID: PMC10675860 DOI: 10.1186/s12872-023-03617-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/05/2023] [Accepted: 11/15/2023] [Indexed: 11/26/2023] Open
Abstract
BACKGROUND To compare the post-operative pain and quality of life of patients who underwent total thoracoscopic surgery (TTS) or conventional full-sternotomy (CFS) for aortic valve replacement (AVR). METHODS We reviewed the records of 223 consecutive AVR patients with either TTS or CFS from January 2018 to December 2022. We used a visual analogue scale (VAS) and the Short Form-36 Health Survey (SF-36) to measure the post-operative pain and quality of life, respectively. We also compared the operative data and clinical outcomes between the two groups. RESULTS The TTS group had lower adjusted mean VAS scores than the CFS group at all time points after surgery (at 1 to 3 days and at 3 and 6 months, p < .001 for all comparisons), indicating less pain. The TTS group also had higher mean SF-36 scores than the CFS group up to 6 months after surgery (p < .001 for all comparisons), indicating better quality of life. The operative time was similar between the two groups (p = .224), but the TTS group had longer cardiopulmonary bypass time and aortic cross-clamp time than the CFS group (p < .001). The TTS group had more pulmonary complications than the CFS group (p = .023). However, there were no significant differences in other major complications or mortality between the two groups. CONCLUSIONS TTS is a safe and effective alternative to CFS for AVR. TTS resulted in less pain and better quality of life, especially in the early recovery period. However, further prospective randomized controlled studies are needed to confirm our findings.
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Affiliation(s)
- Zhiqin Lin
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Xinquan Road 29#, Fuzhou, 350001, P. R. China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, P. R. China
| | - Xiujun Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Xinquan Road 29#, Fuzhou, 350001, P. R. China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, P. R. China
| | - Zheng Xu
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Xinquan Road 29#, Fuzhou, 350001, P. R. China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, P. R. China
| | - Liangwan Chen
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Xinquan Road 29#, Fuzhou, 350001, P. R. China
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, P. R. China
| | - Xiaofu Dai
- Department of Cardiovascular Surgery, Union Hospital, Fujian Medical University, Xinquan Road 29#, Fuzhou, 350001, P. R. China.
- Key Laboratory of Cardio-Thoracic Surgery, Fujian Medical University, Fujian Province University, Fuzhou, 350001, P. R. China.
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Shah N, Li X, Shanmugham P, Fan E, Thiagarajan RR, Venkataraman R, Raman L. Early Changes in Arterial Partial Pressure of Carbon Dioxide and Blood Pressure After Starting Extracorporeal Membrane Oxygenation in Children: Extracorporeal Life Support Organization Database Study of Neurologic Complications. Pediatr Crit Care Med 2023; 24:541-550. [PMID: 36877009 DOI: 10.1097/pcc.0000000000003216] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
OBJECTIVE Neurologic complications in pediatric patients supported by extracorporeal membrane oxygenation (ECMO) are common and lead to morbidity and mortality; however, few modifiable factors are known. DESIGN Retrospective study of the Extracorporeal Life Support Organization registry (2010-2019). SETTING Multicenter international database. PATIENTS Pediatric patients receiving ECMO (2010-2019) for all indications and any mode of support. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS We investigated if early relative change in Pa co2 or mean arterial blood pressure (MAP) soon after starting ECMO was associated with neurologic complications. The primary outcome of neurologic complications was defined as a report of seizures, central nervous system infarction or hemorrhage, or brain death. All-cause mortality (including brain death) was used as a secondary outcome.Out of 7,270 patients, 15.6% had neurologic complications. Neurologic complications increased when the relative Pa co2 decreased by greater than 50% (18.4%) or 30-50% (16.5%) versus those who had a minimal change (13.9%, p < 0.01 and p = 0.046). When the relative MAP increased greater than 50%, the rate of neurologic complications was 16.9% versus 13.1% those with minimal change ( p = 0.007). In a multivariable model adjusting for confounders, a relative decrease in Pa co2 greater than 30% was independently associated with greater odds of neurologic complication (odds ratio [OR], 1.25; 95% CI, 1.07-1.46; p = 0.005). Within this group, with a relative decrease in Pa co2 greater than 30%, the effects of increased relative MAP increased neurologic complications (0.05% per BP Percentile; 95% CI, 0.001-0.11; p = 0.05). CONCLUSIONS In pediatric patients, a large decrease in Pa co2 and increase in MAP following ECMO initiation are both associated with neurologic complications. Future research focusing on managing these issues carefully soon after ECMO deployment can potentially help to reduce neurologic complications.
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Affiliation(s)
- Neel Shah
- Department of Pediatrics, Washington University in St. Louis, St. Louis, MO
| | - Xilong Li
- Department of Population and Data Science, University of Texas Southwestern Medical Center, Dallas, TX
| | - Prashanth Shanmugham
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine, Toronto General Hospital, Toronto, ON, Canada
| | | | | | - Lakshmi Raman
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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5
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Mainali S. Neurologic Complications of Cardiac and Pulmonary Disease. Continuum (Minneap Minn) 2023; 29:684-707. [PMID: 37341327 DOI: 10.1212/con.0000000000001284] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/22/2023]
Abstract
OBJECTIVE The heart and lungs work as a functional unit through a complex interplay. The cardiorespiratory system is responsible for the delivery of oxygen and energy substrates to the brain. Therefore, diseases of the heart and lungs can lead to various neurologic illnesses. This article reviews various cardiac and pulmonary pathologies that can lead to neurologic injury and discusses the relevant pathophysiologic mechanisms. LATEST DEVELOPMENTS We have lived through unprecedented times over the past 3 years with the emergence and rapid spread of the COVID-19 pandemic. Given the effects of COVID-19 on the lungs and heart, an increased incidence of hypoxic-ischemic brain injury and stroke associated with cardiorespiratory pathologies has been observed. Newer evidence has questioned the benefit of induced hypothermia in patients with out-of-hospital cardiac arrest. Further, global collaborative initiatives such as the Curing Coma Campaign are underway with the goal of improving the care of patients with coma and disorders of consciousness, including those resulting from cardiac and pulmonary pathologies. ESSENTIAL POINTS The neurologic complications of cardiorespiratory disorders are common and present in various forms such as stroke or hypoxic and anoxic injury related to cardiac or respiratory failure. With the emergence of the COVID-19 pandemic, neurologic complications have increased in recent years. Given the intimate and interdependent dynamics of the heart, lungs, and brain, it is crucial for neurologists to be aware of the interplay between these organs.
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Justice CN, Halperin HR, Vanden Hoek TL, Geocadin RG. Extracorporeal cardiopulmonary resuscitation (eCPR) and cerebral perfusion: A narrative review. Resuscitation 2023; 182:109671. [PMID: 36549433 PMCID: PMC9877198 DOI: 10.1016/j.resuscitation.2022.12.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2022] [Revised: 12/12/2022] [Accepted: 12/13/2022] [Indexed: 12/23/2022]
Abstract
Extracorporeal cardiopulmonary resuscitation (eCPR) is emerging as an effective, lifesaving resuscitation strategy for select patients with prolonged or refractory cardiac arrest. Currently, a paucity of evidence-based recommendations is available to guide clinical management of eCPR patients. Despite promising results from initial clinical trials, neurological injury remains a significant cause of morbidity and mortality. Neuropathology associated with utilization of an extracorporeal circuit may interact significantly with the consequences of a prolonged low-flow state that typically precedes eCPR. In this narrative review, we explore current gaps in knowledge about cerebral perfusion over the course of cardiac arrest and resuscitation with a focus on patients treated with eCPR. We found no studies which investigated regional cerebral blood flow or cerebral autoregulation in human cohorts specific to eCPR. Studies which assessed cerebral perfusion in clinical eCPR were small and limited to near-infrared spectroscopy. Furthermore, no studies prospectively or retrospectively evaluated the relationship between epinephrine and neurological outcomes in eCPR patients. In summary, the field currently lacks a comprehensive understanding of how regional cerebral perfusion and cerebral autoregulation are temporally modified by factors such as pre-eCPR low-flow duration, vasopressors, and circuit flow rate. Elucidating these critical relationships may inform future strategies aimed at improving neurological outcomes in patients treated with lifesaving eCPR.
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Affiliation(s)
- Cody N Justice
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Henry R Halperin
- Departments of Medicine, Radiology and Biomedical Engineering, Johns Hopkins University, Baltimore, MD, USA
| | - Terry L Vanden Hoek
- Center for Advanced Resuscitation Medicine, Department of Emergency Medicine, Center for Cardiovascular Research, University of Illinois at Chicago, Chicago, IL USA
| | - Romergryko G Geocadin
- Departments of Neurology, Anesthesiology-Critical Care Medicine, and Neurosurgery, Johns Hopkins University, Baltimore, MD, USA.
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Santos DPDAD, Thirumala PD, Reddy G, Barros DFD, Faria VNR, Shandal V, Kurtz P. Risk of perioperative stroke and cerebral autoregulation monitoring: a systematic review. ARQUIVOS DE NEURO-PSIQUIATRIA 2022; 80:1196-1203. [PMID: 36580956 PMCID: PMC9800166 DOI: 10.1055/s-0042-1758648] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Perioperative stroke, delirium, and cognitive impairment could be related to management and to variations in blood pressure control, cerebral hypoperfusion and raised blood volume. Cerebral autoregulation (CAR) is a mechanism to maintain cerebral perfusion through the control of the vascular tone and hemodynamic reactions in the circulation. OBJECTIVE The present systematic review addresses the relationship between impaired CAR and perioperative stroke by evaluating the rate of neurological complications after surgery in studies in which perioperative CAR was tested or monitored. METHODS We included randomized clinical trials and prospective observational studies. All studies had adjusted the relative risk, hazard ratio or 95% confidence interval (95%CI) values. These estimation effects were tested using random-effects models. Heterogeneity among the selected studies was assessed using the Higgins and Thompson I2 statistics. RESULTS The Web of Science, PubMed and EMBASE electronic databases were searched to retrieve articles. A total of 4,476 studies published between 1983 and 2019 were analyzed, but only 5 qualified for the data extraction and were included in the final analysis. The combined study cohort comprised 941 patients who underwent CAR monitoring during surgical procedures. All studies provided information about perioperative stroke, which equated to 16% (158 of 941) of the overall patient population. CONCLUSION The present meta-analysis showed evidence of the impact of CAR impairment in the risk of perioperative stroke. On the pooled analysis, blood fluctuations or other brain insults large enough to compromise CAR were associated with the outcome of stroke (odds ratio [OR]: 2.26; 95%CI: 1.54-2.98; p < 0.0001).
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Affiliation(s)
- Daniel Paes de Almeida dos Santos
- Hospital Copa Star, Centro de Terapia Intensiva, Rio de Janeiro RJ, Brazil.,Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Address for correspondence Daniel P. A. Santos
| | | | - Gautama Reddy
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Intraneuro, Rio de Janeiro RJ, Brazil.
| | | | - Vinicius Naves Rezende Faria
- Sinapse Clínica, Rio de Janeiro RJ, Brazil.,Universidade Federal de Uberlândia, Faculdade de Engenharia Elétrica, Uberlândia MG, Brazil.
| | - Varun Shandal
- University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, United States.
| | - Pedro Kurtz
- Instituto D'Or de Pesquisa e Ensino, Departamento de Cuidado Intensivo, São Paulo SP, Brazil.
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8
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Chegondi M, Lin WC, Naqvi S, Sendi P, Totapally BR. The Effect of Electroencephalography Abnormalities on Cerebral Autoregulation in Sedated Ventilated Children. Pediatr Rep 2022; 15:9-15. [PMID: 36649002 PMCID: PMC9844431 DOI: 10.3390/pediatric15010002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2022] [Revised: 12/05/2022] [Accepted: 12/19/2022] [Indexed: 12/24/2022] Open
Abstract
Purpose: To determine the effects of non-ictal electroencephalogram (EEG) changes on cerebrovascular autoregulation (AR) using the cerebral oximetry index (COx). Materials and Methods: Mean arterial blood pressure (MAP), cerebral tissue oxygenation (CrSO2), and EEG were acquired for 96 h. From all of the EEG recordings, 30 min recording segments were extracted using the endotracheal suction events as the guide. EEG recordings were classified as EEG normal and EEG abnormal groups. Each 30 min segment was further divided into six 5 min epochs. Continuous recordings of MAP and CrSO2 by near-infrared spectroscopy (NIRS) were extracted. The COx value was defined as the concordance (R) value of the Pearson correlation between MAP and CrSO2 in a 5 min epoch. Then, an Independent-Samples Mann-Whitney U test was used to analyze the number of epochs within the 30 min segments above various R cutoff values (0.2, 0.3, and 0.4) in normal and abnormal EEG groups. A p-value < 0.05 was considered significant, and all analyses were two-tailed. Results: Among 16 sedated, mechanically ventilated children, 382 EEG recordings of 30 min segments were analyzed. The proportions of epochs in each 30 min segment above the R cutoff values were similar between the EEG normal and EEG abnormal groups (p > 0.05). The median concordance values for CSrO2 and MAP in EEG normal and EEG abnormal groups were similar (0.26 (0.17−0.35) and 0.18 (0.12−0.31); p = 0.09). Conclusions: Abnormal EEG patterns without ictal changes do not affect cerebrovascular autoregulation in sedated and mechanically ventilated children.
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Affiliation(s)
- Madhuradhar Chegondi
- Division of Critical Care Medicine, Stead Family Children’s Hospital, Iowa City, IA 52242, USA
- Department of Pediatrics, Carver College of Medicine, University of Iowa, Iowa City, IA 52242, USA
- Correspondence: ; Tex.: +1-319-356-1615; Fax: +1-319-356-8443
| | - Wei-Chiang Lin
- Department of Biomedical Engineering, Florida International University, Miami, FL 33174, USA
| | - Sayed Naqvi
- Department of Neurology, Nicklaus Children’s Hospital, Miami, FL 33155, USA
| | - Prithvi Sendi
- Division of Critical Care Medicine, Nicklaus Children’s Hospital, Miami, FL 33155, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
| | - Balagangadhar R. Totapally
- Division of Critical Care Medicine, Nicklaus Children’s Hospital, Miami, FL 33155, USA
- Herbert Wertheim College of Medicine, Florida International University, Miami, FL 33199, USA
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El-Chouli M, Meddis A, Christensen DM, Gerds TA, Sehested T, Malmborg M, Phelps M, Bang CN, Ahlehoff O, Torp-Pedersen C, Sindet-Pedersen C, Raunsø J, Idorn L, Gislason G. Lifetime risk of comorbidity in patients with simple congenital heart disease: a Danish nationwide study. Eur Heart J 2022; 44:741-748. [PMID: 36477305 PMCID: PMC9976987 DOI: 10.1093/eurheartj/ehac727] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2022] [Revised: 10/25/2022] [Accepted: 11/23/2022] [Indexed: 12/12/2022] Open
Abstract
AIMS In a continuously ageing population of patients with congenital heart disease (CHD), understanding the long-term risk of morbidity is crucial. The aim of this study was to compare the lifetime risks of developing comorbidities in patients with simple CHD and matched controls. METHODS AND RESULTS Using the Danish nationwide registers spanning from 1977 to 2018, simple CHD cases were defined as isolated atrial septal defect (ASD), ventricular septal defect (VSD), pulmonary stenosis, or patent ductus arteriosus in patients surviving until at least 5 years of age. There were 10 controls identified per case. Reported were absolute lifetime risks and lifetime risk differences (between patients with simple CHD and controls) of incident comorbidities stratified by groups and specific cardiovascular comorbidities. Of the included 17 157 individuals with simple CHD, the largest subgroups were ASD (37.7%) and VSD (33.9%), and 52% were females. The median follow-up time for patients with CHD was 21.2 years (interquartile range: 9.4-39.0) and for controls, 19.8 years (9.0-37.0). The lifetime risks for the investigated comorbidities were higher and appeared overall at younger ages for simple CHD compared with controls, except for neoplasms and chronic kidney disease. The lifetime risk difference among the comorbidity groups was highest for neurological disease (male: 15.2%, female: 11.3%), pulmonary disease (male: 9.1%, female: 11.7%), and among the specific comorbidities for stroke (male: 18.9%, female: 11.4%). The overall risk of stroke in patients with simple CHD was mainly driven by ASD (male: 28.9%, female: 17.5%), while the risks of myocardial infarction and heart failure were driven by VSD. The associated lifetime risks of stroke, myocardial infarction, and heart failure in both sexes were smaller in invasively treated patients compared with untreated patients with simple CHD. CONCLUSION Patients with simple CHD had increased lifetime risks of all comorbidities compared with matched controls, except for neoplasms and chronic kidney disease. These findings highlight the need for increased attention towards early management of comorbidity risk factors.
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Affiliation(s)
| | - Alessandra Meddis
- Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | | | - Thomas A Gerds
- Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark,Section of Biostatistics, University of Copenhagen, Copenhagen, Denmark
| | - Thomas Sehested
- Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark,Department of Cardiology, Roskilde University Hospital, Zealand, Denmark
| | - Morten Malmborg
- Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Matthew Phelps
- Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark
| | - Casper N Bang
- Department of Cardiology, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark
| | - Ole Ahlehoff
- Department of Cardiology, The Heart Centre, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Christian Torp-Pedersen
- Departments of Clinical Investigation and Cardiology, North Zealand University Hospital, Hillerød, Denmark
| | | | - Jakob Raunsø
- Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Herlev, Denmark
| | - Lars Idorn
- Department of Pediatric Cardiology, Rigshospitalet, Copenhagen, Denmark
| | - Gunnar Gislason
- Danish Heart Foundation, Vognmagergade 7, 1120 Copenhagen, Denmark,Department of Cardiology, Copenhagen University Hospital, Herlev and Gentofte, Hellerup, Denmark,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
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10
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Wang D, Le S, Wu J, Xie F, Li X, Wang H, Zhang A, Du X, Huang X. Nomogram for Postoperative Headache in Adult Patients Undergoing Elective Cardiac Surgery. J Am Heart Assoc 2022; 11:e023837. [PMID: 35411784 PMCID: PMC9238448 DOI: 10.1161/jaha.121.023837] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Background Postoperative headache (POH) is frequent after cardiac surgery; however, few studies on risk factors for POH exist. The aims of the current study were to explore risk factors related to POH after elective cardiac surgery and to establish a predictive system. Methods and Results Adult patients undergoing elective open-heart surgery under cardiopulmonary bypass from 2016 to 2020 in 4 cardiac centers were retrospectively included. Two thirds of the patients were randomly allocated to a training set and one third to a validation set. Predictors for POH were selected by univariate and multivariate analysis. POH developed in 3154 of the 13 440 included patients (23.5%) and the overall mortality rate was 2.3%. Eight independent risk factors for POH after elective cardiac surgery were identified, including female sex, younger age, smoking history, chronic headache history, hypertension, lower left ventricular ejection fraction, longer cardiopulmonary bypass time, and more intraoperative transfusion of red blood cells. A nomogram based on the multivariate model was constructed, with reasonable calibration and discrimination, and was well validated. Decision curve analysis revealed good clinical utility. Finally, 3 risk intervals were divided to better facilitate clinical application. Conclusions A nomogram model for POH after elective cardiac surgery was developed and validated using 8 predictors, which may have potential application value in clinical risk assessment, decision-making, and individualized treatment associated with POH.
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Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery Union Hospital Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China.,Department of Cardiovascular Surgery The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Sheng Le
- Department of Cardiovascular Surgery Union Hospital Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China.,Department of Thoracic Surgery Zhongnan Hospital of Wuhan UniversityWuhan University Wuhan China
| | - Jia Wu
- Key Laboratory for Molecular Diagnosis of Hubei Province The Central Hospital of WuhanTongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Fei Xie
- Department of Cardiovascular Surgery The First Affiliated Hospital of Zhengzhou University Zhengzhou China
| | - Ximei Li
- Department of Nursing Huaihe Hospital of Henan University Kaifeng Henan China
| | - Hongfei Wang
- Department of Cardiovascular Surgery Union Hospital Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Anchen Zhang
- Department of Cardiology The Central Hospital of WuhanTongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Xinling Du
- Department of Cardiovascular Surgery Union Hospital Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery Union Hospital Tongji Medical CollegeHuazhong University of Science and Technology Wuhan China
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11
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Continuous Determination of the Optimal Bispectral Index Value Based on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A Retrospective Observational Cohort Study of a Novel Individualized Sedation Target. Crit Care Explor 2022; 4:e0656. [PMID: 35265854 PMCID: PMC8901214 DOI: 10.1097/cce.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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12
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Wang D, Le S, Luo J, Chen X, Li R, Wu J, Song Y, Xie F, Li X, Wang H, Huang X, Ye P, Du X, Zhang A. Incidence, Risk Factors and Outcomes of Postoperative Headache After Stanford Type a Acute Aortic Dissection Surgery. Front Cardiovasc Med 2022; 8:781137. [PMID: 35004895 PMCID: PMC8733002 DOI: 10.3389/fcvm.2021.781137] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2021] [Accepted: 11/30/2021] [Indexed: 01/28/2023] Open
Abstract
Background: Postoperative headache (POH) is common in clinical practice, however, no studies about POH after Stanford type A acute aortic dissection surgery (AADS) exist. This study aims to describe the incidence, risk factors and outcomes of POH after AADS, and to construct two prediction models. Methods: Adults who underwent AADS from 2016 to 2020 in four tertiary hospitals were enrolled. Training and validation sets were randomly assigned according to a 7:3 ratio. Risk factors were identified by univariate and multivariate logistic regression analysis. Nomograms were constructed and validated on the basis of independent predictors. Results: POH developed in 380 of the 1,476 included patients (25.7%). Poorer outcomes were observed in patients with POH. Eight independent predictors for POH after AADS were identified when both preoperative and intraoperative variables were analyzed, including younger age, female sex, smoking history, chronic headache history, cerebrovascular disease, use of deep hypothermic circulatory arrest, more blood transfusion, and longer cardiopulmonary bypass time. White blood cell and platelet count were also identified as significant predictors when intraoperative variables were excluded from the multivariate analysis. A full nomogram and a preoperative nomogram were constructed based on these independent predictors, both demonstrating good discrimination, calibration, clinical usefulness, and were well validated. Risk stratification was performed and three risk intervals were defined based on the full nomogram and clinical practice. Conclusions: POH was common after AADS, portending poorer outcomes. Two nomograms predicting POH were developed and validated, which may have clinical utility in risk evaluation, early prevention, and doctor-patient communication.
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Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jingjing Luo
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xing Chen
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Rui Li
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Jia Wu
- Key Laboratory for Molecular Diagnosis of Hubei Province, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Yu Song
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Fei Xie
- Department of Cardiovascular Surgery, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Ximei Li
- Department of Nursing, Huaihe Hospital of Henan University, Kaifeng, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Ping Ye
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Anchen Zhang
- Department of Cardiology, The Central Hospital of Wuhan, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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13
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Bydén M, Segernäs A, Thulesius H, Vanky F, Ahlgren E, Skoog J, Zachrisson H. Cerebrovascular Reserve Capacity as a Predictor of Postoperative Delirium: A Pilot Study. Front Surg 2022; 8:658849. [PMID: 34993226 PMCID: PMC8724247 DOI: 10.3389/fsurg.2021.658849] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 12/01/2021] [Indexed: 11/13/2022] Open
Abstract
Introduction: Postoperative delirium is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Compromised regulation of the cerebral circulation may be a predisposing factor for delirium. However, the potential relationship between cerebrovascular reserve capacity and delirium is unknown. The aim of this study was to investigate if impaired cerebrovascular reserve capacity was associated with postoperative delirium. Methods: Forty-two patients scheduled for cardiac surgery with CPB were recruited consecutively. All patients underwent preoperative transcranial Doppler (TCD) ultrasound with calculation of breath-hold index (BHI). BHI < 0.69 indicated impaired cerebrovascular reserve capacity. In addition, patients were examined with preoperative neuropsychological tests such as MMSE (Mini Mental State Examination) and AQT (A Quick Test of cognitive speed). Postoperative delirium was assessed using Nursing Delirium Screening Scale (Nu-DESC) in which a score of ≥2 was considered as delirium. Results: Six patients (14%) scored high for postoperative delirium and all demonstrated impaired preoperative cerebrovascular reserve capacity. Median (25th-75th percentile) BHI in patients with postoperative delirium was significantly lower compared to the non-delirium group [0.26 (-0.08-0.44) vs. 0.83 (0.57-1.08), p = 0.002]. Preoperative MMSE score was lower in patients who developed postoperative delirium (median, 25th-75th percentile; 26.5, 24-28 vs. 28.5, 27-29, p = 0.024). Similarly, patients with postoperative delirium also displayed a slower performance during the preoperative cognitive speed test AQT color and form (mean ± SD; 85.8 s ± 19.3 vs. 69.6 s ± 15.8, p = 0.043). Conclusion: The present findings suggest that an extended preoperative ultrasound protocol with TCD evaluation of cerebrovascular reserve capacity and neuropsychological tests may be valuable in identifying patients with increased risk of developing delirium after cardiac surgery.
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Affiliation(s)
- Moa Bydén
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Anna Segernäs
- Primary Health Care Center in Linköping and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Hans Thulesius
- Department of Clinical Sciences, Malmö, Lund University Faculty of Medicine, Lund, Sweden.,Department of Medicine and Optometry, Linnaeus University Faculty of Health Social Work and Behavioral Sciences, Kalmar, Sweden
| | - Farkas Vanky
- Department of Thoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Eva Ahlgren
- Department of Thoracic and Vascular Surgery and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Johan Skoog
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
| | - Helene Zachrisson
- Department of Clinical Physiology and Department of Health, Medicine and Caring Sciences, Linköping University, Linköping, Sweden
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14
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Vu T, Smith JA. An Update on Postoperative Cognitive Dysfunction Following Cardiac Surgery. Front Psychiatry 2022; 13:884907. [PMID: 35782418 PMCID: PMC9240195 DOI: 10.3389/fpsyt.2022.884907] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/27/2022] [Accepted: 05/23/2022] [Indexed: 12/14/2022] Open
Abstract
Postoperative cognitive dysfunction is extremely prevalent following cardiac surgery. The increasing patient age and comorbidity profile increases their susceptibility to cognitive impairment. The underlying pathophysiological mechanisms leading to cognitive impairment are not clearly elucidated. Using the contemporary literature (2015-present), this narrative review has three aims. Firstly, to provide an overview of postoperative cognitive impairment. Secondly, to analyse the predominant pathophysiological mechanisms leading to cognitive dysfunction following cardiac surgery such as inflammation, cerebral hypoperfusion, cerebral microemboli, glycaemic control and anaesthesia induced neurotoxicity. Lastly, to assess the current therapeutic strategies of interest to address these pathophysiological mechanisms, including the administration of dexamethasone, the prevention of prolonged cerebral desaturations and the monitoring of cerebral perfusion using near-infrared spectroscopy, surgical management strategies to reduce the neurological effects of microemboli, intraoperative glycaemic control strategies, the effect of volatile vs. intravenous anaesthesia, and the efficacy of dexmedetomidine.
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Affiliation(s)
- Tony Vu
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
| | - Julian A Smith
- Department of Cardiothoracic Surgery, Monash Health, Melbourne, VIC, Australia.,Department of Surgery, School of Clinical Sciences at Monash Health, Monash University, Melbourne, VIC, Australia
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15
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Stecker MM, Keselman I. Monitoring cardiac and ascending aortic procedures. HANDBOOK OF CLINICAL NEUROLOGY 2022; 186:395-406. [PMID: 35772898 DOI: 10.1016/b978-0-12-819826-1.00009-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/15/2023]
Abstract
Although cardiac and aortic operations have been successfully performed for more than 60 years, the risk of neurologic complications remains high. In particular, the rate of stroke with cardiac operations continues to be significant in the 1%-5% range. Similarly, the risk of stroke with aortic operations remains in the range of 7%-10% despite many years of improving techniques. Because of this persistently high risk, the use of intra-operative neurophysiologic monitoring (IONM) has the potential of improving outcomes. This chapter provides an overview of cardiac/aortic arch procedures from the neurophysiologic standpoint and discusses the roles of different monitoring modalities in detecting injury.
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Affiliation(s)
- Mark M Stecker
- Fresno Institute of Neuroscience, Fresno, CA, United States.
| | - Inna Keselman
- Department of Neurology, University of California Los Angeles, Los Angeles, CA, United States
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16
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Jufar AH, Lankadeva YR, May CN, Cochrane AD, Marino B, Bellomo R, Evans RG. Renal and Cerebral Hypoxia and Inflammation During Cardiopulmonary Bypass. Compr Physiol 2021; 12:2799-2834. [PMID: 34964119 DOI: 10.1002/cphy.c210019] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Cardiac surgery-associated acute kidney injury and brain injury remain common despite ongoing efforts to improve both the equipment and procedures deployed during cardiopulmonary bypass (CPB). The pathophysiology of injury of the kidney and brain during CPB is not completely understood. Nevertheless, renal (particularly in the medulla) and cerebral hypoxia and inflammation likely play critical roles. Multiple practical factors, including depth and mode of anesthesia, hemodilution, pump flow, and arterial pressure can influence oxygenation of the brain and kidney during CPB. Critically, these factors may have differential effects on these two vital organs. Systemic inflammatory pathways are activated during CPB through activation of the complement system, coagulation pathways, leukocytes, and the release of inflammatory cytokines. Local inflammation in the brain and kidney may be aggravated by ischemia (and thus hypoxia) and reperfusion (and thus oxidative stress) and activation of resident and infiltrating inflammatory cells. Various strategies, including manipulating perfusion conditions and administration of pharmacotherapies, could potentially be deployed to avoid or attenuate hypoxia and inflammation during CPB. Regarding manipulating perfusion conditions, based on experimental and clinical data, increasing standard pump flow and arterial pressure during CPB appears to offer the best hope to avoid hypoxia and injury, at least in the kidney. Pharmacological approaches, including use of anti-inflammatory agents such as dexmedetomidine and erythropoietin, have shown promise in preclinical models but have not been adequately tested in human trials. However, evidence for beneficial effects of corticosteroids on renal and neurological outcomes is lacking. © 2021 American Physiological Society. Compr Physiol 11:1-36, 2021.
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Affiliation(s)
- Alemayehu H Jufar
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
| | - Yugeesh R Lankadeva
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Clive N May
- Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia.,Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia
| | - Andrew D Cochrane
- Department of Cardiothoracic Surgery, Monash Health and Department of Surgery (School of Clinical Sciences at Monash Health), Monash University, Melbourne, Victoria, Australia
| | - Bruno Marino
- Cellsaving and Perfusion Resources, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- Department of Critical Care, Faculty of Medicine, Dentistry and Health Sciences, University of Melbourne, Victoria, Australia.,Department of Intensive Care, Austin Health, Heidelberg, Victoria, Australia
| | - Roger G Evans
- Cardiovascular Disease Program, Biomedicine Discovery Institute and Department of Physiology, Monash University, Melbourne, Victoria, Australia.,Pre-Clinical Critical Care Unit, Florey Institute of Neuroscience and Mental Health, University of Melbourne, Melbourne, Victoria, Australia
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17
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Longhitano Y, Iannuzzi F, Bonatti G, Zanza C, Messina A, Godoy D, Dabrowski W, Xiuyun L, Czosnyka M, Pelosi P, Badenes R, Robba C. Cerebral Autoregulation in Non-Brain Injured Patients: A Systematic Review. Front Neurol 2021; 12:732176. [PMID: 34899560 PMCID: PMC8660115 DOI: 10.3389/fneur.2021.732176] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/11/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Cerebral autoregulation (CA) plays a fundamental role in the maintenance of adequate cerebral blood flow (CBF). CA monitoring, through direct and indirect techniques, may guide an appropriate therapeutic approach aimed at improving CBF and reducing neurological complications; so far, the role of CA has been investigated mainly in brain-injured patients. The aim of this study is to investigate the role of CA in non-brain injured patients. Methods: A systematic consultation of literature was carried out. Search terms included: “CA and sepsis,” “CA and surgery,” and “CA and non-brain injury.” Results: Our research individualized 294 studies and after screening, 22 studies were analyzed in this study. Studies were divided in three groups: CA in sepsis and septic shock, CA during surgery, and CA in the pediatric population. Studies in sepsis and intraoperative setting highlighted a relationship between the incidence of sepsis-associated delirium and impaired CA. The most investigated setting in the pediatric population is cardiac surgery, but the role and measurement of CA need to be further elucidated. Conclusion: In non-brain injured patients, impaired CA may result in cognitive dysfunction, neurological damage, worst outcome, and increased mortality. Monitoring CA might be a useful tool for the bedside optimization and individualization of the clinical management in this group of patients.
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Affiliation(s)
- Yaroslava Longhitano
- Department of Anesthesiology and Critical Care, AO St. Antonio, Biagio and Cesare Arrigo, Alessandria, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giulia Bonatti
- Anesthesia and Intensive Care, Gaslini Hospital, Genova, Italy
| | - Christian Zanza
- Foundation of "Nuovo Ospedale Alba-Bra" and Department of Emergency Medicine, Anesthesia and Critical Care Division, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniel Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, 2 Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | | | - Li Xiuyun
- Department of Anesthesiology & Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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18
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Konarik M, Sramko M, Dorazilova Z, Blah M, Netuka I, Ivak P, Maly J, Szarszoi O. Effects of Acute Pump Speed Changes on Cerebral Hemodynamics in Patients With an Implantable Continuous-Flow Left Ventricular Assist Devices. Physiol Res 2021; 70:831-839. [PMID: 34717062 DOI: 10.33549/physiolres.934738] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
Abstract
Mechanical circulatory support (MCS) with an implantable left ventricular assist device (LVAD) is an established therapeutic option for advanced heart failure. Most of the currently used LVADs generate a continuous stream of blood that decreases arterial pulse pressure. This study investigated whether a change of the pulse pressure during different pump speed settings would affect cerebral autoregulation and thereby affect cerebral blood flow (CBF). The study included 21 haemodynamically stable outpatients with a continuous-flow LVAD (HeartMate II, Abbott, USA) implanted a median of 6 months before the study (interquartile range 3 to 14 months). Arterial blood pressure (measured by finger plethysmography) was recorded simultaneously with CBF (measured by transcranial Doppler ultrasound) during baseline pump speed (8900 rpm [IQR 8800; 9200]) and during minimum and maximum tolerated pump speeds (8000 rpm [IQR 8000; 8200] and 9800 rpm [IQR 9800; 10 000]). An increase in LVAD pump speed by 800 rpm [IQR 800; 1000] from the baseline lead to a significant decrease in arterial pulse pressure and cerebral blood flow pulsatility (relative change -24% and -32%, both p < 0.01), but it did not affect mean arterial pressure and mean CBF velocity (relative change 1% and -1.7%, p = 0.1 and 0.7). In stable patients with a continuous-flow LVAD, changes of pump speed settings within a clinically used range did not impair static cerebral autoregulation and cerebral blood flow.
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Affiliation(s)
- M Konarik
- Dept. of Cardiac Surgery, Institute for Clinical and Experimental Medicine, Prague, Czech Republic.
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19
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Wang D, Huang X, Wang H, Le S, Du X. Predictors and nomogram models for postoperative headache in patients undergoing heart valve surgery. J Thorac Dis 2021; 13:4236-4249. [PMID: 34422352 PMCID: PMC8339753 DOI: 10.21037/jtd-21-644] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2021] [Accepted: 06/04/2021] [Indexed: 12/13/2022]
Abstract
Background Headache is a frequent complication after cardiac surgery. However, studies on the risk factors of postoperative headache (POH) are rare. The purpose of this study was to identify independent risk factors for POH in patients undergoing heart valve surgery (HVS) and to develop and validate risk prediction models. Methods Consecutive patients undergoing open HVS from 2016 to 2019 were enrolled in this study. Patients were randomly assigned to training and validation sets at a 2:1 ratio. Univariate and multivariate analysis were applied to identify independent predictors for POH in the training set. A nomogram predicting POH was developed based on these factors, and was validated in the independent validation set. Results POH developed in 1,061 of the 3,853 patients (27.5%). The overall mortality was 2.9%, and it was significantly higher in patients with POH (4.3% versus 2.4%, P<0.001). In the training set, six independent predictors were identified by multivariate analysis, including female, smoking history, hypertension, headache history, left ventricular ejection fraction, and cardiopulmonary bypass time. The model demonstrated good discrimination in both the training (c-index: 0.811) and validation sets (c-index: 0.814), and calibration was assessed by visual inspection. A second nomogram was also constructed including only preoperative predictors, with good discrimination (c-index: 0.792) and calibration. The decision and clinical impact curves of the models showed good clinical utility. Conclusions We developed and validated two risk prediction models for POH in patients undergoing HVS. The models may have clinical utility in individualized risk assessment and preventive interventions.
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Affiliation(s)
- Dashuai Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xiaofan Huang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Hongfei Wang
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Sheng Le
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
| | - Xinling Du
- Department of Cardiovascular Surgery, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, China
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20
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Hugenroth K, Borchardt R, Ritter P, Groß-Hardt S, Meyns B, Verbelen T, Steinseifer U, Kaufmann TAS, Engelmann UM. Optimizing cerebral perfusion and hemodynamics during cardiopulmonary bypass through cannula design combining in silico, in vitro and in vivo input. Sci Rep 2021; 11:16800. [PMID: 34408243 PMCID: PMC8373878 DOI: 10.1038/s41598-021-96397-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2021] [Accepted: 08/03/2021] [Indexed: 11/09/2022] Open
Abstract
Cardiopulmonary bypass (CPB) is a standard technique for cardiac surgery, but comes with the risk of severe neurological complications (e.g. stroke) caused by embolisms and/or reduced cerebral perfusion. We report on an aortic cannula prototype design (optiCAN) with helical outflow and jet-splitting dispersion tip that could reduce the risk of embolic events and restores cerebral perfusion to 97.5% of physiological flow during CPB in vivo, whereas a commercial curved-tip cannula yields 74.6%. In further in vitro comparison, pressure loss and hemolysis parameters of optiCAN remain unaffected. Results are reproducibly confirmed in silico for an exemplary human aortic anatomy via computational fluid dynamics (CFD) simulations. Based on CFD simulations, we firstly show that optiCAN design improves aortic root washout, which reduces the risk of thromboembolism. Secondly, we identify regions of the aortic intima with increased risk of plaque release by correlating areas of enhanced plaque growth and high wall shear stresses (WSS). From this we propose another easy-to-manufacture cannula design (opti2CAN) that decreases areas burdened by high WSS, while preserving physiological cerebral flow and favorable hemodynamics. With this novel cannula design, we propose a cannulation option to reduce neurological complications and the prevalence of stroke in high-risk patients after CPB.
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Affiliation(s)
- Kristin Hugenroth
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany. .,Enmodes GmbH, Aachen, Germany.
| | | | | | - Sascha Groß-Hardt
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.,Enmodes GmbH, Aachen, Germany
| | - Bart Meyns
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Tom Verbelen
- Department of Cardiac Surgery, University Hospitals Leuven, Leuven, Belgium
| | - Ulrich Steinseifer
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany
| | - Tim A S Kaufmann
- Department of Cardiovascular Engineering, Institute of Applied Medical Engineering, Faculty of Medicine, RWTH Aachen University, Aachen, Germany.,Enmodes GmbH, Aachen, Germany
| | - Ulrich M Engelmann
- Enmodes GmbH, Aachen, Germany. .,Department of Medical Engineering and Applied Mathematics, FH Aachen University of Applied Sciences, Jülich, Germany.
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21
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Trans-Ocular Brain Impedance Indices Predict Pressure Reactivity Index Changes in a Porcine Model of Hypotension and Cerebral Autoregulation Perturbation. Neurocrit Care 2021; 36:139-147. [PMID: 34244920 DOI: 10.1007/s12028-021-01272-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 05/06/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND Cerebrovascular autoregulation (CA) is a protective mechanism that enables the cerebral vasculature to automodulate tone in response to changes in cerebral perfusion pressure to ensure constant levels of cerebral blood flow (CBF) and oxygen delivery. CA can be impaired after neurological injury and contributes to secondary brain injury. In this study, we report novel impedance indices using trans-ocular brain impedance (TOBI) during controlled systemic hemorrhage and hypotension to assess CA in comparison with pressure reactivity index (PRx). METHODS Yorkshire swine were instrumented to record intracranial pressure (ICP), mean arterial pressure (MAP), and CBF. TOBI was recorded using electrocardiographic electrodes placed on the closed eyelids. Impedance changes (dz) were recorded in response to introducing an alternating current (0.4 mA) through the electrodes. MAP, ICP, and CBF were also measured. Animals were subjected to a controlled hemorrhage to remove 30-40% of each animal's total blood volume over 25-35 min. Hemorrhage was titrated to reach an MAP of approximately 35 mm Hg and end-tidal carbon dioxide above 28 mm Hg. PRx was calculated as a moving Pearson correlation between MAP and ICP. TOBI indices were calculated as the amplitude of the respiratory-induced changes in dz. DZx was calculated as a moving Pearson correlation between dz and MAP. TOBI indices (dz and DZx) were compared with hemodynamic indicators and PRx. RESULTS dz was shown to be highly correlated with MAP, ICP, cerebral perfusion pressure, and CBF (r = - 0.823, - 0.723, - 0.813, and - 0.726), respectively (p < 0.0001). During hemorrhage, cerebral perfusion pressure and CBF had a mean percent decrease (standard deviation) from baseline of - 54.2% (12.5%) and - 28.3% (14.7%), respectively, whereas dz increased by 277% (268%). Receiver operator characteristics and precision-recall curves demonstrated high predictive performance of DZx when compared with PRx with an area under the curve above 0.82 and 0.89 for receiver operator characteristic and precision-recall curves, respectively, with high sensitivity and positive predictive power. CONCLUSIONS TOBI indices appear to track changes in PRx and hemodynamics that affect CA during hemorrhage-induced hypotension. TOBI may offer a suitable, less invasive surrogate to PRx for monitoring and assessing CA.
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22
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Quick Assessment of the Lower Limit of Autoregulation by Use of Transcranial Doppler Ultrasound During Cardiac Surgery. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839836 DOI: 10.1007/978-3-030-59436-7_30] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
INTRODUCTION Assessment of the individual safest minimal mean arterial pressure (MAP) during cardiac surgery remains empirical. The objective of this study was to evaluate the lower limit of autoregulation (LLA) within a short period (15 min). METHODS After developing autoregulation software (OptiMAP) incorporated into transcranial Doppler ultrasound (Waki-Atys®, Lyon, France), we monitored the mean blood flow velocity (MV) and MAP. Thirty successive values of MV and MAP were automatically analysed to calculate the correlation (Mx) between the two parameters. We compared two methods of Mx sampling during a period of 15 min: Mx10s = long averaging windows (one MAP/MV pair recorded every 10 s), and Mx2s = short averaging windows (one MAP/MV pair recorded every 2 s). The LLA value calculated from the whole recording (Mx10s) was used as the reference. Autoregulation was considered impaired at an Mx value >0.35. RESULTS Five patients were included in the study. The surgery lasted for 138 ± 32 min and cardiopulmonary bypass lasted for 72 ± 33 min. MAP and MV were recorded for 117 ± 24 min. MAP varied from 33 ± 10 to 92 ± 10 mmHg. LLA calculated from the whole recording (Mx10s) was similar to LLA calculated from the 15-min recording (Mx2s): 70 ± 2.5 versus 73 ± 3.5 mmHg. MAP remained below LLA during 48 ± 12% of the recording. During the 15-min recording, Mx10s was not able to calculate the LLA value. CONCLUSION In cases of haemodynamic instability, decreasing the Mx sampling window seems to accurately detect LLA.
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Liu X, Akiyoshi K, Nakano M, Brady K, Bush B, Nadkarni R, Venkataraman A, Koehler RC, Lee JK, Hogue CW, Czosnyka M, Smielewski P, Brown CH. Determining Thresholds for Three Indices of Autoregulation to Identify the Lower Limit of Autoregulation During Cardiac Surgery. Crit Care Med 2021; 49:650-660. [PMID: 33278074 PMCID: PMC7979429 DOI: 10.1097/ccm.0000000000004737] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
OBJECTIVES Monitoring cerebral autoregulation may help identify the lower limit of autoregulation in individual patients. Mean arterial blood pressure below lower limit of autoregulation appears to be a risk factor for postoperative acute kidney injury. Cerebral autoregulation can be monitored in real time using correlation approaches. However, the precise thresholds for different cerebral autoregulation indexes that identify the lower limit of autoregulation are unknown. We identified thresholds for intact autoregulation in patients during cardiopulmonary bypass surgery and examined the relevance of these thresholds to postoperative acute kidney injury. DESIGN A single-center retrospective analysis. SETTING Tertiary academic medical center. PATIENTS Data from 59 patients was used to determine precise cerebral autoregulation thresholds for identification of the lower limit of autoregulation. These thresholds were validated in a larger cohort of 226 patients. METHODS AND MAIN RESULTS Invasive mean arterial blood pressure, cerebral blood flow velocities, regional cortical oxygen saturation, and total hemoglobin were recorded simultaneously. Three cerebral autoregulation indices were calculated, including mean flow index, cerebral oximetry index, and hemoglobin volume index. Cerebral autoregulation curves for the three indices were plotted, and thresholds for each index were used to generate threshold- and index-specific lower limit of autoregulations. A reference lower limit of autoregulation could be identified in 59 patients by plotting cerebral blood flow velocity against mean arterial blood pressure to generate gold-standard Lassen curves. The lower limit of autoregulations defined at each threshold were compared with the gold-standard lower limit of autoregulation determined from Lassen curves. The results identified the following thresholds: mean flow index (0.45), cerebral oximetry index (0.35), and hemoglobin volume index (0.3). We then calculated the product of magnitude and duration of mean arterial blood pressure less than lower limit of autoregulation in a larger cohort of 226 patients. When using the lower limit of autoregulations identified by the optimal thresholds above, mean arterial blood pressure less than lower limit of autoregulation was greater in patients with acute kidney injury than in those without acute kidney injury. CONCLUSIONS This study identified thresholds of intact and impaired cerebral autoregulation for three indices and showed that mean arterial blood pressure below lower limit of autoregulation is a risk factor for acute kidney injury after cardiac surgery.
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Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Kei Akiyoshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Mitsunori Nakano
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
- Saitama Medical Center, Jichi Medical University, Saitama, Japan 330-8503
| | - Ken Brady
- Northwestern University, Ann & Robert H. Lurie Children’s Hospital of Chicago, Department of Anesthesiology, Chicago, Illinois, USA
| | - Brian Bush
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Rohan Nadkarni
- Department of Biomedical Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Archana Venkataraman
- Department of Electrical and Computer Engineering, Whiting School of Engineering, Johns Hopkins University, Baltimore, Maryland, USA
| | - Raymond C. Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Charles W. Hogue
- Department of Anesthesiology, Feinberg School of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgey, Cambridge University Hospitals, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgey, Cambridge University Hospitals, University of Cambridge, Cambridge, UK
| | - Charles H. Brown
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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24
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Xia Q, Cao Y, Xie B, Qiu D, Deng L, Wang M, Han H. Cannulation strategies in type A aortic dissection: a novel insight narrative review. J Thorac Dis 2021; 13:2551-2562. [PMID: 34012600 PMCID: PMC8107572 DOI: 10.21037/jtd-21-411] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
This review highlights vital details that can be easily overlooked and discuss how to identify and fix failed cannulation from another novel insight. Appropriate arterial cannulation strategy during cardiopulmonary bypass (CPB) in Stanford type A aortic dissection (AAD) is highly necessary to reach satisfactory perfusion effects and appreciable clinical outcomes. Despite several previously published reviews on cannulation strategies in AAD, most focus on the advantages and disadvantages by comparing various cannulation strategies. In fact, most of evidence came from retrospective studies. More importantly, however, some important details and novel approaches maybe overlooked due to variety reasons. These overlooked details also make sense in clinical practice. Papers related to cannulation refer to type AAD were retrieved and analyzed from the PubMed and Medline database. The key words such as “aortic dissection”, “cannula”, “cannulation”, “cannulation strategy”, “cerebral perfusion”, “type I aortic dissection” were conducted and analyzed. In addition, we looked at some new and very significant specific perfusion techniques such as anterograde cerebral perfusion combined with retrograde inferior vena caval perfusion (RIVP) and reperfusion via the right carotid artery before surgery. The arterial cannulation site and strategy should be determined individually. Monitoring measures are very necessary in the whole procedure.
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Affiliation(s)
- Qingping Xia
- Department of Science and Education, The People's Hospital of Gaozhou, Gaozhou, China
| | - Yong Cao
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Baodong Xie
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Dongyun Qiu
- Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Li Deng
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China.,Department of Cardiovascular Surgery, The First Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Maosheng Wang
- Department of Cardiovascular Surgery, The People's Hospital of Gaozhou, Gaozhou, China
| | - Hongguang Han
- Department of Cardiovascular Surgery, The General Hospital of Northern Theater Command, Shenyang, China
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25
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Porta A, Fantinato A, Bari V, Gelpi F, Cairo B, De Maria B, Bertoldo EG, Fiolo V, Callus E, De Vincentiis C, Volpe M, Molfetta R, Ranucci M. Evaluation of the impact of surgical aortic valve replacement on short-term cardiovascular and cerebrovascular controls through spontaneous variability analysis. PLoS One 2020; 15:e0243869. [PMID: 33301491 PMCID: PMC7728248 DOI: 10.1371/journal.pone.0243869] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/03/2020] [Accepted: 11/30/2020] [Indexed: 11/25/2022] Open
Abstract
We assessed the effect of surgical aortic valve replacement (SAVR) on cardiovascular and cerebrovascular controls via spontaneous variability analyses of heart period, approximated as the temporal distance between two consecutive R-wave peaks on the electrocardiogram (RR), systolic, diastolic and mean arterial pressure (SAP, DAP and MAP) and mean cerebral blood flow (MCBF). Powers in specific frequency bands, complexity, presence of nonlinear dynamics and markers of cardiac baroreflex and cerebral autoregulation were calculated. Variability series were acquired before (PRE) and after (POST) SAVR in 11 patients (age: 76±5 yrs, 7 males) at supine resting and during active standing. Parametric spectral analysis was performed based on the autoregressive model. Complexity was assessed via a local nonlinear prediction approach exploiting the k-nearest-neighbor strategy. The presence of nonlinear dynamics was checked by comparing the complexity marker computed over the original series with the distribution of the same index assessed over a set of surrogates preserving distribution and power spectral density of the original series. Cardiac baroreflex and cerebral autoregulation were estimated by assessing the transfer function from SAP to RR and from MAP to MCBF and squared coherence function via the bivariate autoregressive approach. We found that: i) orthostatic challenge had no effect on cardiovascular and cerebrovascular control markers in PRE; ii) RR variance was significantly reduced in POST; iii) complexity of SAP, DAP and MAP variabilities increased in POST with a greater likelihood of observing nonlinear dynamics over SAP compared to PRE at supine resting; iv) the amplitude of MCBF variations and MCBF complexity in POST remained similar to PRE; v) cardiac baroreflex sensitivity decreased in POST, while cerebrovascular autoregulation was preserved. SAVR induces important changes of cardiac and vascular autonomic controls and baroreflex regulation in patients exhibiting poor reactivity of cardiovascular regulatory mechanisms, while cerebrovascular autoregulation seems to be less affected.
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Affiliation(s)
- Alberto Porta
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
- * E-mail:
| | - Angela Fantinato
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Vlasta Bari
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Francesca Gelpi
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - Beatrice Cairo
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
| | | | | | - Valentina Fiolo
- Clinical Psychology Service, IRCCS Policlinico San Donato, Milan, Italy
| | - Edward Callus
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy
- Clinical Psychology Service, IRCCS Policlinico San Donato, Milan, Italy
| | | | - Marianna Volpe
- Department of Cardiac Rehabilitation, IRCCS Policlinico San Donato, Milan, Italy
| | - Raffaella Molfetta
- Department of Cardiac Rehabilitation, IRCCS Policlinico San Donato, Milan, Italy
| | - Marco Ranucci
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
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26
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Effects of dobutamine and phenylephrine on cerebral perfusion in patients undergoing cerebral bypass surgery: a randomised crossover trial. Br J Anaesth 2020; 125:539-547. [PMID: 32718724 PMCID: PMC7565906 DOI: 10.1016/j.bja.2020.05.040] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2020] [Revised: 04/20/2020] [Accepted: 05/13/2020] [Indexed: 01/22/2023] Open
Abstract
Background Patients undergoing cerebral bypass surgery are prone to cerebral hypoperfusion. Currently, arterial blood pressure is often increased with vasopressors to prevent cerebral ischaemia. However, this might cause vasoconstriction of the graft and cerebral vasculature and decrease perfusion. We hypothesised that cardiac output, rather than arterial blood pressure, is essential for adequate perfusion and aimed to determine whether dobutamine administration resulted in greater graft perfusion than phenylephrine administration. Methods This randomised crossover study included 10 adult patients undergoing cerebral bypass surgery. Intraoperatively, patients randomly and sequentially received dobutamine to increase cardiac index or phenylephrine to increase mean arterial pressure (MAP). An increase of >10% in cardiac index or >10% in MAP was targeted, respectively. Before both interventions, a reference phase was implemented. The primary outcome was the absolute difference in graft flow between the reference and intervention phase. We compared the absolute flow difference between each intervention and constructed a random-effect linear regression model to explore treatment and carry-over effects. Results Graft flow increased with a median of 4.1 (inter-quartile range [IQR], 1.7–12.0] ml min−1) after dobutamine administration and 3.6 [IQR, 1.3–7.8] ml min−1 after phenylephrine administration (difference –0.6 ml min−1; 95% confidence interval [CI], –14.5 to 5.3; P=0.441). There was no treatment effect (0.9 ml min−1; 95% CI, 0.0–20.1; P=0.944) and no carry-over effect. Conclusions Both dobutamine and phenylephrine increased graft flow during cerebral bypass surgery, without a preference for one method over the other. Clinical trial registration Netherlands Trial Register, NL7077 (https://www.trialregister.nl/trial/7077).
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27
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Liu X, Czosnyka M, Donnelly J, Cardim D, Cabeleira M, Lalou DA, Hu X, Hutchinson PJ, Smielewski P. Assessment of cerebral autoregulation indices - a modelling perspective. Sci Rep 2020; 10:9600. [PMID: 32541858 PMCID: PMC7295753 DOI: 10.1038/s41598-020-66346-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2018] [Accepted: 05/13/2020] [Indexed: 11/09/2022] Open
Abstract
Various methodologies to assess cerebral autoregulation (CA) have been developed, including model - based methods (e.g. autoregulation index, ARI), correlation coefficient - based methods (e.g. mean flow index, Mx), and frequency domain - based methods (e.g. transfer function analysis, TF). Our understanding of relationships among CA indices remains limited, partly due to disagreement of different studies by using real physiological signals, which introduce confounding factors. The influence of exogenous noise on CA parameters needs further investigation. Using a set of artificial cerebral blood flow velocities (CBFV) generated from a well-known CA model, this study aims to cross-validate the relationship among CA indices in a more controlled environment. Real arterial blood pressure (ABP) measurements from 34 traumatic brain injury patients were applied to create artificial CBFVs. Each ABP recording was used to create 10 CBFVs corresponding to 10 CA levels (ARI from 0 to 9). Mx, TF phase, gain and coherence in low frequency (LF) and very low frequency (VLF) were calculated. The influence of exogenous noise was investigated by adding three levels of colored noise to the artificial CBFVs. The result showed a significant negative relationship between Mx and ARI (r = −0.95, p < 0.001), and it became almost purely linear when ARI is between 3 to 6. For transfer function parameters, ARI positively related with phase (r = 0.99 at VLF and 0.93 at LF, p < 0.001) and negatively related with gain_VLF(r = −0.98, p < 0.001). Exogenous noise changed the actual values of the CA parameters and increased the standard deviation. Our results show that different methods can lead to poor correlation between some of the autoregulation parameters even under well controlled situations, undisturbed by unknown confounding factors. They also highlighted the importance of exogenous noise, showing that even the same CA value might correspond to different CA levels under different ‘noise’ conditions.
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Affiliation(s)
- Xiuyun Liu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK. .,Department of Anesthesiology & Critical Care Medicine, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warszawa, Poland
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center, Dallas, USA
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Despina Aphroditi Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Xiao Hu
- School of Nursing, Duke University, Durham, NC, USA
| | - Peter J Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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28
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Neurological complications after cardiac surgery: anesthetic considerations based on outcome evidence. Curr Opin Anaesthesiol 2020; 32:563-567. [PMID: 31145196 PMCID: PMC6735528 DOI: 10.1097/aco.0000000000000755] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Neurological complications after cardiac surgery remain prevalent. This review aims to discuss the modifiable and outcome-relevant risk factors based on an up-to-date literature review, with a focus on interventions that may improve outcomes.
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29
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Efficacy of unilateral cerebral perfusion for brain protection in aortic arch surgery. J Thorac Cardiovasc Surg 2020; 159:365-371.e1. [DOI: 10.1016/j.jtcvs.2019.02.039] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2018] [Revised: 01/16/2019] [Accepted: 02/09/2019] [Indexed: 12/16/2022]
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30
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Kajimoto M, Nuri M, Sleasman JR, Charette KA, Nelson BR, Portman MA. Inhaled nitric oxide reduces injury and microglia activation in porcine hippocampus after deep hypothermic circulatory arrest. J Thorac Cardiovasc Surg 2020; 161:e485-e498. [PMID: 32037238 DOI: 10.1016/j.jtcvs.2019.12.075] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/17/2019] [Revised: 11/15/2019] [Accepted: 12/01/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Dysregulation of local nitric oxide (NO) synthetases occurs during ischemia and reperfusion associated with cardiopulmonary bypass, deep hypothermic circulatory arrest (DHCA), and reperfusion. Rapid fluctuations in local NO occurring in neonates and infants probably contribute to inflammation-induced microglial activation and neuronal degeneration after these procedures, eventually impairing neurodevelopment. We evaluated the anti-inflammatory efficacy of inhaled NO (iNO) in a piglet model emulating conditions during pediatric open-heart surgery with DHCA. METHODS Infant Yorkshire piglets underwent DHCA (18°C) for 30 minutes, followed by reperfusion and rewarming either with or without iNO (20 ppm) in the ventilator at the onset of reperfusion for 3 hours (n = 5 per group, DHCA-iNO and DHCA). Through craniotomy, brains were extracted after perfusion fixation for histology. RESULTS Plasma NO metabolites were elevated 2.5 times baseline data before DHCA by iNO. Fluoro-Jade C staining identified significantly lower number of degenerating neurons in the hippocampus of the DHCA-iNO group (P = .02) compared with the DHCA group. Morphologic analyses of ionized calcium-binding adapter molecule-1 stained microglia, evaluating cell body and dendritic process geometry with Imaris imaging software, revealed subjectively less microglial activation in the hippocampus of pigs receiving iNO. CONCLUSIONS Using DHCA for 30 minutes, consistent with clinical exposure, we noted that iNO reduces neuronal degeneration in the hippocampus. In addition, iNO reduces microglial activation in the hippocampus after DHCA. The data suggest that iNO reduces neuronal degeneration by ameliorating inflammation and may be a practical mode of neuroprotection for infants undergoing DHCA.
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Affiliation(s)
- Masaki Kajimoto
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Wash
| | - Muhammad Nuri
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Wash; Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Justin R Sleasman
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Kevin A Charette
- Division of Pediatric Cardiac Surgery, Seattle Children's Hospital, Seattle, Wash
| | - Branden R Nelson
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Wash
| | - Michael A Portman
- Center for Integrative Brain Research, Seattle Children's Research Institute, Seattle, Wash; Division of Cardiology, University of Washington, Seattle, Wash.
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31
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Lee KF, Wood MD, Maslove DM, Muscedere JG, Boyd JG. Dysfunctional cerebral autoregulation is associated with delirium in critically ill adults. J Cereb Blood Flow Metab 2019; 39:2512-2520. [PMID: 30295556 PMCID: PMC6893984 DOI: 10.1177/0271678x18803081] [Citation(s) in RCA: 21] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Delirium is common during critical illness and is associated with morbidity and mortality, but its pathophysiology is unknown. We tested whether dysfunctional cerebral autoregulation (CA) contributes to the development of delirium. Adult patients (n = 40) with respiratory failure and/or shock were prospectively enrolled. Continuous recordings of regional cerebral oxygen saturation (rSO2) were obtained by near-infrared spectroscopy (NIRS) during the first 72 h of intensive care unit (ICU) admission. CA function was estimated by the cerebral oximetry index (COx), which is the time-varying correlation between rSO2 and mean arterial pressure (MAP). Delirium was assessed daily. The median ICU stay was seven days (IQR 4-13). Twenty-four patients (60%) screened positive for delirium on at least one day during their stay. Taking positive COx values to reflect periods of CA dysfunction, we found that the cumulative duration of CA dysfunction during the first one to three days in the ICU was significantly associated with the subsequent development of delirium. Additionally, we assessed two alternative methods for estimating optimal MAP targets in individual patients. In summary, early disturbances in CA may contribute to delirium, and NIRS-derived rSO2 may be used to identify individual perfusion targets in critically ill patients.
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Affiliation(s)
- Kevin Fh Lee
- School of Medicine, Queen's University, Kingston, ON, Canada
| | - Michael D Wood
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, Kingston, ON, Canada.,Department of Critical Care Medicine, Queen's University, Kingston, ON, Canada.,Department of Medicine, Queen's University, Kingston, ON, Canada
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32
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Caldas JR, Panerai RB, Bor-Seng-Shu E, Ferreira GSR, Camara L, Passos RH, Salinet AM, Azevedo DS, de-Lima-Oliveira M, Galas FRBG, Fukushima JT, Nogueira R, Taccone FS, Landoni G, Almeida JP, Robinson TG, Hajjar LA. Intra-aortic balloon pump does not influence cerebral hemodynamics and neurological outcomes in high-risk cardiac patients undergoing cardiac surgery: an analysis of the IABCS trial. Ann Intensive Care 2019; 9:130. [PMID: 31773324 PMCID: PMC6879692 DOI: 10.1186/s13613-019-0602-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2019] [Accepted: 11/07/2019] [Indexed: 12/24/2022] Open
Abstract
Background The intra-aortic balloon pump (IABP) is often used in high-risk patients undergoing cardiac surgery to improve coronary perfusion and decrease afterload. The effects of the IABP on cerebral hemodynamics are unknown. We therefore assessed the effect of the IABP on cerebral hemodynamics and on neurological complications in patients undergoing cardiac surgery who were randomized to receive or not receive preoperative IABP in the ‘Intra-aortic Balloon Counterpulsation in Patients Undergoing Cardiac Surgery’ (IABCS) trial. Methods This is a prospectively planned analysis of the previously published IABCS trial. Patients undergoing elective coronary artery bypass surgery with ventricular ejection fraction ≤ 40% or EuroSCORE ≥ 6 received preoperative IABP (n = 90) or no IABP (n = 91). Cerebral blood flow velocity (CBFV) of the middle cerebral artery through transcranial Doppler and blood pressure through Finometer or intra-arterial line were recorded preoperatively (T1) and 24 h (T2) and 7 days after surgery (T3) in patients with preoperative IABP (n = 34) and without IABP (n = 33). Cerebral autoregulation was assessed by the autoregulation index that was estimated from the CBFV response to a step change in blood pressure derived by transfer function analysis. Delirium, stroke and cognitive decline 6 months after surgery were recorded. Results There were no differences between the IABP and control patients in the autoregulation index (T1: 5.5 ± 1.9 vs. 5.7 ± 1.7; T2: 4.0 ± 1.9 vs. 4.1 ± 1.6; T3: 5.7 ± 2.0 vs. 5.7 ± 1.6, p = 0.97) or CBFV (T1: 57.3 ± 19.4 vs. 59.3 ± 11.8; T2: 74.0 ± 21.6 vs. 74.7 ± 17.5; T3: 71.1 ± 21.3 vs. 68.1 ± 15.1 cm/s; p = 0.952) at all time points. Groups were not different regarding postoperative rates of delirium (26.5% vs. 24.2%, p = 0.83), stroke (3.0% vs. 2.9%, p = 1.00) or cognitive decline through analysis of the Mini-Mental State Examination (16.7% vs. 40.7%; p = 0.07) and Montreal Cognitive Assessment (79.16% vs. 81.5%; p = 1.00). Conclusions The preoperative use of the IABP in high-risk patients undergoing cardiac surgery did not affect cerebral hemodynamics and was not associated with a higher incidence of neurological complications. Trial registrationhttp://www.clinicaltrials.gov (NCT02143544).
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Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil.,Universidade de Salvador, UNIFACS, Salvador, Bahia, Brazil.,Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil.,Escola Bahiana de Medicina e Saude Púbica, Salvador, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Edson Bor-Seng-Shu
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | - Ligia Camara
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Rogério H Passos
- Critical Care Unit Hospital São Rafael Salvador, Salvador, Brazil
| | - Angela M Salinet
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Daniel S Azevedo
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | | | | | - Julia T Fukushima
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Ricardo Nogueira
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil
| | - Fabio S Taccone
- Department of Intensive Care, Hopital Erasme, Brussels, Belgium
| | - Giovanni Landoni
- Department of Anaesthesia and Intensive Care, IRCCS San Raffaele Scientific Institute and Vita-Salute San Raffaele University of Milan, Milan, Italy
| | - Juliano P Almeida
- Department of Anesthesia, University of São Paulo, São Paulo, São Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Universidade de São Paulo, São Paulo, Brazil. .,Surgical Intensive Care, Heart Institute, University of São Paulo, Av. Dr. Ene´as de Carvalho Aguiar 44, 05403-000, São Paulo, Brazil.
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33
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Vaini E, Bari V, Fantinato A, Pistuddi V, Cairo B, De Maria B, Ranucci M, Porta A. Causality analysis reveals the link between cerebrovascular control and acute kidney dysfunction after coronary artery bypass grafting. Physiol Meas 2019; 40:064006. [PMID: 31091519 DOI: 10.1088/1361-6579/ab21b1] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Patients undergoing coronary artery bypass graft (CABG) surgery might experience postoperative complications and some of them, such as acute kidney dysfunction (AKD), are the likely consequence of hypoperfusion. We hypothesized that an impaired cerebrovascular control is a hallmark of a vascular damage that might favor AKD after CABG. OBJECTIVE Our aim is to characterize cerebrovascular control in CABG patients through the assessment of the relationship between mean arterial pressure (MAP) and mean cerebral blood flow velocity (MCBFV) and to check whether markers describing MCBFV-MAP dynamical interactions could identify subjects at risk to develop postoperative AKD. APPROACH MAP and MCBFV beat-to-beat series were extracted from invasive arterial pressure and transcranial Doppler recordings acquired simultaneously in 23 patients just before CABG after the induction of propofol general anesthesia. Subjects were divided into AKD group (n = 9, age: 68 ± 9, 8 males) and noAKD group (n = 14, age: 65 ± 8, 12 males) according to whether they developed postoperative AKD or not after CABG. We computed MAP and MCBFV time-domain and spectral markers as well as MCBFV-MAP cross-spectral indexes in very-low-frequency (VLF, 0.02-0.07 Hz), low-frequency (LF, 0.07-0.15 Hz) and high-frequency (HF, 0.15-0.30 Hz) bands. We also calculated model-based transfer entropy (TE) to quantify the degree of MCBFV dependence on MAP and vice versa. The null hypothesis of MCBFV-MAP uncoupling was tested via a surrogate approach associating MAP and MCBFV in different patients. MAIN RESULTS Time, spectral and cross-spectral markers had a limited power in separating AKD from noAKD individuals. Conversely, TE from MAP to MCBFV was significantly above the level set by surrogates only in AKD groups and significantly larger than that computed in noAKD. SIGNIFICANCE The reduced cerebrovascular autoregulation in AKD patients suggest a vascular impairment likely making them more at risk of hypoperfusion during CABG and AKD after CABG.
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Affiliation(s)
- Emanuele Vaini
- Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, San Donato Milanese, Milan, Italy
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Why and how to assess cerebral autoregulation? Best Pract Res Clin Anaesthesiol 2019; 33:211-220. [DOI: 10.1016/j.bpa.2019.05.007] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2019] [Revised: 05/13/2019] [Accepted: 05/16/2019] [Indexed: 02/07/2023]
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Thudium M, Ellerkmann RK, Heinze I, Hilbert T. Relative cerebral hyperperfusion during cardiopulmonary bypass is associated with risk for postoperative delirium: a cross-sectional cohort study. BMC Anesthesiol 2019; 19:35. [PMID: 30851736 PMCID: PMC6408763 DOI: 10.1186/s12871-019-0705-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 02/25/2019] [Indexed: 12/19/2022] Open
Abstract
Background Our objective was to evaluate if changes in on-pump cerebral blood flow, relative to the pre-bypass baseline, are associated with the risk for postoperative delirium (POD) following cardiac surgery. Methods In 47 consecutive adult patients, right middle cerebral artery blood flow velocity (MCAV) was assessed using transcranial Doppler sonography. Individual values, measured during cardiopulmonary bypass (CPB), were normalized to the pre-bypass baseline value and termed MCAVrel. An MCAVrel > 100% was defined as cerebral hyperperfusion. Prevalence of POD was assessed using the Confusion Assessment Method for the Intensive Care Unit. Results Overall prevalence of POD was 27%. In the subgroup without POD, 32% of patients had experienced relative cerebral hyperperfusion during CPB, compared to 67% in the subgroup with POD (p < 0.05). The mean averaged MCAVrel was 90 (±21) % in the no-POD group vs. 112 (±32) % in the POD group (p < 0.05), and patients developing delirium experienced cerebral hyperperfusion during CPB for about 39 (±35) min, compared to 6 (±11) min in the group without POD (p < 0.001). In a subcohort with pre-bypass baseline MCAV (MCAVbas) below the median MCAVbas of the whole cohort, prevalence of POD was 17% when MCAVrel during CPB was kept below 100%, but increased to 53% when these patients actually experienced relative cerebral hyperperfusion. Conclusions Our results suggest a critical role for cerebral hyperperfusion in the pathogenesis of POD following on-pump open-heart surgery, recommending a more individualized hemodynamic management, especially in the population at risk. Electronic supplementary material The online version of this article (10.1186/s12871-019-0705-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Marcus Thudium
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Richard K Ellerkmann
- Department of Anesthesiology and Intensive Care Medicine, Dortmund Hospital, Beurhausstrasse 40, 44137, Dortmund, Germany
| | - Ingo Heinze
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany
| | - Tobias Hilbert
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Sigmund-Freud-Strasse 25, 53127, Bonn, Germany.
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Liu X, Xiao R, Gadhoumi K, Tran N, Smielewski P, Czosnykan M, Hetts SW, Ko N, Hu X. Continuous monitoring of cerebrovascular reactivity through pulse transit time and intracranial pressure. Physiol Meas 2019; 40:01LT01. [PMID: 30577032 PMCID: PMC7197410 DOI: 10.1088/1361-6579/aafab1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Cerebrovascular reactivity (CR) is a mechanism that maintains stable blood flow supply to the brain. Pressure reactivity index (PRx), the correlation coefficient between slow waves of invasive arterial blood pressure (ABP) and intracranial pressure (ICP) has been validated for CR assessment. However, in clinical ward, not every subarachnoid hemorrhage (SAH) patient has invasive ABP monitoring. Pulse transit time (PTT), the propagation time of a pulse wave travelling from the heart to peripheral arteries, has been suggested as a surrogate measure of ABP. In this study, we proposed to use PTT instead of invasive ABP to monitor CR. APPROACH Forty-five SAH patients with simultaneous recordings of invasive ABP, ICP, oxygen saturation level (SpO2) and electrocardiograph (ECG) were included. PTT was calculated as the time from the ECG R-wave peak to the onset of SpO2. PTT based pressure reactivity index (tPRx) was calculated as the correlation coefficient between slow waves of PTT and ICP. Wavelet tPRx (wtRx) was calculated as the cosine of wavelet phase shift between PTT and ICP. Meanwhile, PRx and wPRx were also calculated using invasive ABP and ICP as input. MAIN RESULTS The result showed a negative relationship between PTT and ABP (r = -0.58, p < 0.001). tPRx negatively correlated with PRx (r = -0.51, p = 0.003). Wavelet method correlated well with correlation method demonstrated through positive relationship between wPRx and PRx (r = 0.82, p < 0.001) as well as wtPRx and tPRx (r = 0.84, p < 0.001). SIGNIFICANCE PTT demonstrates great potential as a useful tool for CR assessment when invasive ABP is unavailable. Key points • Pulse transit time (PTT), defined as the propagation time of a pulse wave travelling from the heart to the peripheral arteries, has been proposed as a surrogate measure of ABP. The relationship between PTT and ABP in SAH patients remains unknown. • Cerebrovascular reactivity (CR) assessment through PTT has advantages over invasive ABP, as it avoids bleeding and infection risk, and can be used outside of the ICU. • We introduced a new method to assess CR using PTT and ICP through correlation based method and wavelet based method. • We found that beat-to-beat PTT was negatively related with invasive ABP in SAH patients. A significant linear relationship exists between PTT-based CR parameter and a well validated method, PRx. PTT demonstrates great potential as a useful tool for CR assessment when invasive ABP is unavailable in SAH patients.
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Affiliation(s)
- Xiuyun Liu
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Ran Xiao
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Kais Gadhoumi
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Nate Tran
- Department of Physiological Nursing, University of California, San Francisco, USA
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnykan
- Brain Physics Laboratory, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Steve W. Hetts
- Department of Radiology and Biomedical Imaging, University of California, San Francisco, USA
| | - Nerissa Ko
- Department of Neurology, University of California, San Francisco, USA
| | - Xiao Hu
- Department of Physiological Nursing, University of California, San Francisco, USA
- Department of Neurosurgery, School of Medicine, University of California, Los Angeles, USA
- Department of Neurological Surgery, University of California, San Francisco, USA
- Institute of Computational Health Sciences, University of California, San Francisco, USA
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Caldas JR, Panerai RB, Bor-Seng-Shu E, Ferreira GSR, Camara L, Passos RH, de-Lima-Oliveira M, Galas FRBG, Almeida JP, Nogueira RC, Mian N, Gaiotto FA, Robinson TG, Hajjar LA. Dynamic cerebral autoregulation: A marker of post-operative delirium? Clin Neurophysiol 2018; 130:101-108. [PMID: 30503909 PMCID: PMC7106549 DOI: 10.1016/j.clinph.2018.11.008] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/10/2018] [Revised: 09/22/2018] [Accepted: 11/05/2018] [Indexed: 12/17/2022]
Abstract
Dynamic cerebral blood flow autoregulation is impaired on the first day following cardiac surgery. Autoregulation index before and after surgery is predictive of post-operative delirium. Patients with impaired dynamic cerebral autoregulation at 24 h and 7 days after surgery had a higher incidence of delirium.
Objective We investigated the potential association of cerebral autoregulation (CA) with postoperative delirium (PD), a common complication of cardiac surgery with cardiopulmonary bypass (CPB). Methods In patients undergoing coronary artery bypass graft (CABG) surgery with CPB, cerebral blood flow velocity (CBFV) and blood pressure (BP) were continuously recorded during 5-min preoperatively (T1), after 24 h (T2), and 7 days after procedure (T3). Prospective multivariate logistic regression analysis was performed to determine the independent risk factors of PD. Autoregulation index (ARI) was calculated from the CBFV response to a step change in BP derived by transfer function analysis. Results In 67 patients, mean age 64.3 ± 9.5 years, CA was depressed at T2 as shown by values of ARI (3.9 ± 1.7), compared to T1 (5.6 ± 1.7) and T3 (5.5 ± 1.8) (p < 0.001). Impaired CA was found in 37 (55%) patients at T2 and in 7 patients (20%) at T3. Lower ARI at T1 and T2 were predictors of PD (p = 0.003). Conclusion Dynamic CA was impaired after CABG surgery with CPB and was a significant independent risk factor of PD. Significance Assessment of CA before and after surgery could have considerable potential for early identification of patients at risk of PD, thus reducing poor outcomes and length of stay. Clinical trials registration: www.clinicaltrials.gov (NCT02143544, April 30, 2014).
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Affiliation(s)
- Juliana R Caldas
- Department of Anesthesia, University of Sao Paulo, Brazil; Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, Brazil; Critical Care Unit Hospital São Rafael Salvador, Brazil.
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, UK; NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Edson Bor-Seng-Shu
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, Brazil
| | | | - Ligia Camara
- Department of Anesthesia, University of Sao Paulo, Brazil
| | - R H Passos
- Critical Care Unit Hospital São Rafael Salvador, Brazil
| | | | | | | | - Ricardo C Nogueira
- Department of Neurosurgery, Hospital das Clinicas, University of São Paulo, Brazil
| | - Natalia Mian
- Department of Cardiopneumology, University of Sao Paulo, Brazil
| | - Fabio A Gaiotto
- Department of Cardiopneumology, University of Sao Paulo, Brazil
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, UK; NIHR Leicester Biomedical Research Centre, Leicester, UK
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Denault AY, Brassard P, Jacquet-Lagrèze M, Halwagi AE. Targeting optimal blood pressure monitoring: what's next? J Thorac Dis 2018; 10:S3281-S3285. [PMID: 30370138 DOI: 10.21037/jtd.2018.08.115] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- André Y Denault
- Department of Anesthesiology and Division of Critical Care, Montreal Heart Institute, Université de Montréal, Montreal, Canada.,Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Quebec, Canada.,Research Center, Institut universitaire de cardiologie et de pneumologie de Québec, Quebec, Canada
| | - Matthias Jacquet-Lagrèze
- Department of Intensive Care and Anesthesiology, Hôpital Louis Pradel, Hospices civils de Lyon, Lyon, France
| | - Antoine E Halwagi
- Department of Anesthesiology and Division of Critical Care, Centre Hospitalier de l'Université de Montréal, Montreal, Canada
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