Temporary circulatory support with surgically implanted microaxial pumps in postcardiotomy cardiogenic shock following coronary artery bypass surgery

Objectives

Patients with ischemic cardiomyopathy undergoing coronary artery bypass grafting (CABG) surgery may develop postcardiotomy cardiogenic shock. In these cases, implantation of an Impella 5.0 or 5.5 microaxial pump offers full hemodynamic support while simultaneously unloading of the left ventricle.

Methods

Preoperative, perioperative, and postoperative data of all patients receiving postoperative support with an Impella 5.0 or 5.5 after CABG surgery between September 2017 and October 2022 were retrospectively collected. Cohort built-up was performed according to the timing of Impella implantation, either simultaneous during CABG surgery or delayed.

Results

A total of n = 42 patients received postoperative Impella support, of whom 27 patients underwent simultaneous Impella implantation during CABG surgery and 15 patients underwent delayed Impella therapy. Preoperative left ventricular ejection fraction was similarly low in both groups (26.7 ± 0.7% vs 24.8 ± 11.3%; P = .32). In the delayed cohort, Impella implantation was performed after a median of 1 (1; 2) days after CABG surgery. Survival after 30 days (75.6% vs 47.6%, P = .04) and 1 year (69.4% vs 29.8%, P = .03) was better in the cohort receiving simultaneous Impella implantation.

Conclusions

The combined advantages of hemodynamic support and LV unloading with microaxial pumps may lead to a favorable survival in patients with left ventricular failure following CABG surgery. Early implantation during the initial surgery shows a trend toward a more favorable survival as compared with patients receiving delayed support.

Renal Safety of Hydroxyethyl starch 130/0.42 After Cardiac Surgery: A Retrospective Cohort Analysis

Introduction

The risk for renal complications from hydroxyethyl starch 130/0.42 (HES) impacts treatment decisions in patients after cardiac surgery.

Objective

The objective of this study was to determine the impact of postoperatively administered HES on renal function and 90-day mortality compared to sole crystalloid administration in patients after elective cardiac surgery.

Methods

Using electronic health records from a university hospital, confounding-adjusted models analyzed the associations between postoperative HES administration and the occurrence of postoperative acute kidney injury. In addition, 90-day mortality was evaluated. The impact of HES dosage and timing on renal function on trajectories of estimated glomerular filtration rates over the postoperative period was investigated using linear mixed-effects models.

Results

Overall 1009 patients (45.0%) experienced acute kidney injury. Less acute kidney injury occurred in patients receiving HES compared with patients receiving only crystalloids for fluid resuscitation (43.7% vs 51.2%, p = 0.008). In multivariate acute kidney injury models, HES had a protective association (odds ratio: 0.89; 95% confidence interval 0.82–0.96). Crystalloids were not as protective as HES (odds ratio: 0.98; 95% confidence interval 0.95–1.00). There was no association between HES and 90-day mortality (odds ratio: 1.05; 95% confidence interval 0.88–1.25). Renal function trajectories were dose dependent and biphasic, HES appeared to slow down the late postoperative decline.

Conclusions

This study showed no association between HES and the postoperative occurrence of acute kidney injury and thus further closes the evidence gap on HES safety in cardiac surgery patients. Although this was a retrospective cohort study, the results indicated that HES might be safely administered to cardiac surgery patients with regard to renal outcomes, especially if it was administered early and dosed appropriately.

Supplementary Information

The online version contains supplementary material available at 10.1007/s40264-021-01116-5.

Management of biventricular assist device implantation in patients with necrotic pancreatitis

This report describes the management of biventricular assist device (BIVAD) implantation in a patient with necrotic pancreatitis. BIVADs provide mechanical support for ventricular ejection in the failing heart and have become an accepted treatment for end-stage heart failure. They also have proved to be a successful bridge to heart transplantation. As their popularity has grown, the number of patients with BIVADs presenting for noncardiac surgery is increasing. We report the successful management of an implanted extracorporeal BIVAD in a patient with end-stage heart failure and with pancreatic stents in a case of necrotic pancreatitis. Historical, physical, laboratory, and imaging data allowed conservative management leading to a favorable outcome.

Early postoperative delirium after open-heart cardiac surgery is associated with decreased bispectral EEG and increased cortisol and interleukin-6

PURPOSE

It is difficult to substantiate the clinical diagnosis of postoperative delirium with objective parameters in intensive care units (ICU). The purpose of this study was to analyze (1) whether the bilateral bispectral (BIS) index, (2) cortisol as a stress marker, and (3) interleukin-6 as a marker of inflammation were different in delirious patients as compared to nondelirious ones after cardiac surgery.

METHODS

On the first postoperative day, delirium was analyzed in 114 patients by using the confusion assessment method for ICU (CAM-ICU). Bilateral BIS data were determined; immediately thereafter plasma samples were drawn to analyze patients' blood characteristics. The current ICU medication, hemodynamic characteristics, SOFA and APACHE II scores, and artificial ventilation were noted.

RESULTS

Delirium was detected at 19.1 ± 4.8 h after the end of surgery in 32 of 114 patients (28%). Delirious patients were significantly older than nondelirious ones and were artificially ventilated 4.7-fold more often during the testing. In delirious patients, plasma cortisol and interleukin-6 levels were higher (p = 0.01). The mean BIS index was significantly lower in delirious patients (72.6 (69.6-89.1); median [interquartile range (IQR), 25th-75th percentiles] than in nondelirious patients, 84.8 (76.8-89.9). BIS EEG raw data analysis detected significant lower relative alpha and higher theta power. A significant correlation was found between plasma cortisol levels and BIS index.

CONCLUSIONS

Early postoperative delirium after cardiac surgery was characterized by increased stress levels and inflammatory reaction. BIS index measurements showed lower cortical activity in delirious patients with a low sensitivity (27%) and high specificity (96%).

Long-term outcome after Griggs tracheostomy

OBJECTIVE

The purpose of this study was to evaluate laryngotracheal stenoses in the long-term outcome after percutaneous tracheostomy.

METHODS

Between 1997 and 2000, 162 patients were tracheostomized during their postoperative stay at the intensive care unit of the Department of Cardiac Surgery, University of Heidelberg. Thirty-eight of 80 long-term surviving patients (mean follow-up: 22 months, range: 7-50 months) gave their informed consent to follow-up laryngotracheoscopy. By using this technique, we localized the tracheostomy site, evaluated the laryngotracheal morphology, and quantified laryngotracheal stenosis planimetrically.

RESULTS

Clinically relevant stenoses were found in one patient. Another patient had undergone surgical revision of the percutaneous dilatational tracheostomy (PDT) prior to our examination. The endoscopic examination revealed that 89.5% (34/38) of the patients exhibited tracheal stenosis, less than 25% without clinical symptoms. Despite endoscopic guidance during PDT, the location of the puncture site was found to vary greatly. Cricoidal lesions were identified in 15 patients. In only 12 patients (31.6%), the PDT had been placed at the optimal location between the first and the second tracheal ring. In these patients, we found the lowest rate of tracheal stenosis in tracheotomies without fractured tracheal rings.

CONCLUSION

Since clinically relevant tracheal stenosis has been found to depend mainly on the puncture site of the PDT and tracheal fractures during PDT, we want to emphasize the importance of adequate endoscopic guidance during and the careful performance of the PDT. Further follow-up studies are necessary to improve and ensure the quality of PDT techniques.

Laryngotracheoscopic findings in long-term follow-up after Griggs tracheostomy

OBJECTIVE

Analysis of laryngotracheoscopic findings of the upper airway tract following percutaneous tracheostomy using the technique according to Griggs.

DESIGN

Retrospective cohort study

PATIENTS

Nineteen of 32 long-term surviving patients (mean follow-up duration, 17 months; range, 11 to 23 months) underwent a modified Griggs tracheostomy during their stay in the ICU following cardiothoracic surgery.

INTERVENTIONS

Nineteen patients gave their informed consent for laryngotracheoscopy to localize and assess the percutaneous dilatational tracheostomy (PDT) puncture site, to evaluate the laryngotracheal morphology, and to quantify tracheal stenosis if present. In addition, specific symptoms of the upper airway tract were evaluated.

RESULTS

At the time of examination, no clinically relevant cases of stenoses were found, although one patient had undergone surgical revision of the PDT for extensive granulation prior to our examination. The endoscopic examination revealed that 12 of 19 patients (63%) had tracheal stenoses > 10%, and 2 patients had tracheal stenoses > 25%. In 7 of 19 patients (32%), the cricoid cartilage was affected by the PDT site. Despite endoscopic guidance during PDT, the location of the puncture site was found to vary greatly.

CONCLUSION

In contrast to recent reports on the long-term outcome after Griggs PDT, we found tracheal stenoses > 10% in 63% of our patients. The grade of stenosis depended mainly on the puncture site of the PDT. Based on these results, we would emphasize the importance of adequate endoscopic guidance during PDT. Further studies are required in order to clarify the risk of long-term complications arising after PDT using the technique of Griggs.