Effect of Volatile Anesthetics on Myocardial Infarction After Coronary Artery Surgery: A Post Hoc Analysis of a Randomized Trial

OBJECTIVE

To investigate the effect of volatile anesthetics on the rates of postoperative myocardial infarction (MI) and cardiac death after coronary artery bypass graft (CABG).

DESIGN

A post hoc analysis of a randomized trial.

SETTING

Cardiac surgical operating rooms.

PARTICIPANTS

Patients undergoing elective, isolated CABG.

INTERVENTIONS

Patients were randomized to receive a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or total intravenous anesthesia (TIVA). The primary outcome was hemodynamically relevant MI (MI requiring high-dose inotropic support or prolonged intensive care unit stay) occurring within 48 hours from surgery. The secondary outcome was 1-year death due to cardiac causes.

MEASUREMENTS AND MAIN RESULTS

A total of 5,400 patients were enrolled between April 2014 and September 2017 (2,709 patients randomized to the volatile anesthetics group and 2,691 to TIVA). The mean age was 62 ± 8.4 years, and the median baseline ejection fraction was 57% (50-67), without differences between the 2 groups. Patients in the volatile group had a lower incidence of MI with hemodynamic complications both in the per-protocol (14 of 2,530 [0.6%] v 27 of 2,501 [1.1%] in the TIVA group; p = 0.038) and as-treated analyses (16 of 2,708 [0.6%] v 29 of 2,617 [1.1%] in the TIVA group; p = 0.039), but not in the intention-to-treat analysis (17 of 2,663 [0.6%] v 28 of 2,667 [1.0%] in the TIVA group; p = 0.10). Overall, deaths due to cardiac causes were lower in the volatile group (23 of 2,685 [0.9%] v 40 of 2,668 [1.5%] than in the TIVA group; p = 0.03).

CONCLUSIONS

An anesthetic regimen, including volatile agents, may be associated with a lower rate of postoperative MI with hemodynamic complication in patients undergoing CABG. Furthermore, it may reduce long-term cardiac mortality.

First Clinical Experience With the Pressure Sensor-Based Autoregulation of Blood Flow in an Artificial Heart

The CARMAT-Total Artificial Heart (C-TAH) is designed to provide heart replacement therapy for patients with end-stage biventricular failure. This report details the reliability and efficacy of the autoregulation device control mechanism (auto-mode), designed to mimic normal physiologic responses to changing patient needs. Hemodynamic data from a continuous cohort of 10 patients implanted with the device, recorded over 1,842 support days in auto-mode, were analyzed with respect to daily changing physiologic needs. The C-TAH uses embedded pressure sensors to regulate the pump output. Right and left ventricular outputs are automatically balanced. The operator sets target values and the inbuilt algorithm adjusts the stroke volume and beat rate, and hence cardiac output, automatically. Auto-mode is set perioperatively after initial postcardiopulmonary bypass hemodynamic stabilization. All patients showed a range of average inflow pressures of between 5 and 20 mm Hg during their daily activities, resulting in cardiac output responses of between 4.3 and 7.3 L/min. Operator adjustments were cumulatively only required on 20 occasions. This report demonstrates that the C-TAH auto-mode effectively produces appropriate physiologic responses reflective of changing patients' daily needs and represents one of the unique characteristics of this device in providing almost physiologic heart replacement therapy.

Association of thrombophilia prospective detection with hemocompatibility related outcomes in left ventricular assist device patients

INTRODUCTION

Inherited thrombophilias represent a concerning risk factor due to a proclivity to an aberrant clot formation. However, in patients with left ventricular assist device (LVAD), their impact on bleeding and thrombotic complications remains still poorly understood. The aim of the present study was to evaluate the effect of thrombophilic mutation directed anticoagulation therapy on adverse clinical outcomes in LVAD patients.

MATERIALS AND METHODS

About 138 consecutive patients indicated for LVAD implant (HeartMate II, Abbott, Plymouth, USA) were prospectively screened for three major thrombophilic mutations: factor II (prothrombin), factor V Leiden, and homozygous methylenetetrahydrofolate reductase (MTHFR). Subsequently, discordant individualized anticoagulation targets of INR 2.5-3.0 in thrombophilia positive and INR 1.8-2.2 in negative patients were established; notably without anti-platelet agents given the center standard of care.

RESULTS

Mean age was 50 ± 12.7 years, 83% male. Mean duration of support was 464.5 days (SD 482.9; SEM 41.1) and median of 310 days (IQR 162; 546). Full thrombophilia positive cohort analysis has not revealed any significant impact on event free survival. In contrast, detailed analysis of specific thrombophilias subsets has revealed Factor II prothrombin mutation as a significant predisposition for the pump thrombosis risk (SHR 10.48; p = 0.001) despite more aggressive prespecified anticoagulation target. Moreover, the incidence of bleeding events in prothrombin group was also significantly increased (SHR 6.0; p = 0.03).

CONCLUSIONS

Our observations suggest that specific thrombophilias in LVAD patients may pose different intensity predisposition for thrombotic complications. Factor II (prothrombin) positive mutation was identified as significant risk factor associated with the pump thrombosis.

Levosimendan Efficacy and Safety: 20 years of SIMDAX in Clinical Use

Levosimendan was first approved for clinic use in 2000, when authorisation was granted by Swedish regulatory authorities for the haemodynamic stabilisation of patients with acutely decompensated chronic heart failure. In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitisation and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced heart failure, right ventricular failure and pulmonary hypertension, cardiac surgery, critical care and emergency medicine. Levosimendan is currently in active clinical evaluation in the US. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and non-cardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, UK and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute heart failure arena in recent times and charts a possible development trajectory for the next 20 years.

Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use

Levosimendan was first approved for clinical use in 2000, when authorization was granted by Swedish regulatory authorities for the hemodynamic stabilization of patients with acutely decompensated chronic heart failure (HF). In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitization and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced HF, right ventricular failure, pulmonary hypertension, cardiac surgery, critical care, and emergency medicine. Levosimendan is currently in active clinical evaluation in the United States. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and noncardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute HF arena in recent times and charts a possible development trajectory for the next 20 years.

Volatile Anesthetics versus Total Intravenous Anesthesia for Cardiac Surgery

BACKGROUND

Volatile (inhaled) anesthetic agents have cardioprotective effects, which might improve clinical outcomes in patients undergoing coronary-artery bypass grafting (CABG).

METHODS

We conducted a pragmatic, multicenter, single-blind, controlled trial at 36 centers in 13 countries. Patients scheduled to undergo elective CABG were randomly assigned to an intraoperative anesthetic regimen that included a volatile anesthetic (desflurane, isoflurane, or sevoflurane) or to total intravenous anesthesia. The primary outcome was death from any cause at 1 year.

RESULTS

A total of 5400 patients were randomly assigned: 2709 to the volatile anesthetics group and 2691 to the total intravenous anesthesia group. On-pump CABG was performed in 64% of patients, with a mean duration of cardiopulmonary bypass of 79 minutes. The two groups were similar with respect to demographic and clinical characteristics at baseline, the duration of cardiopulmonary bypass, and the number of grafts. At the time of the second interim analysis, the data and safety monitoring board advised that the trial should be stopped for futility. No significant difference between the groups with respect to deaths from any cause was seen at 1 year (2.8% in the volatile anesthetics group and 3.0% in the total intravenous anesthesia group; relative risk, 0.94; 95% confidence interval [CI], 0.69 to 1.29; P = 0.71), with data available for 5353 patients (99.1%), or at 30 days (1.4% and 1.3%, respectively; relative risk, 1.11; 95% CI, 0.70 to 1.76), with data available for 5398 patients (99.9%). There were no significant differences between the groups in any of the secondary outcomes or in the incidence of prespecified adverse events, including myocardial infarction.

CONCLUSIONS

Among patients undergoing elective CABG, anesthesia with a volatile agent did not result in significantly fewer deaths at 1 year than total intravenous anesthesia. (Funded by the Italian Ministry of Health; MYRIAD ClinicalTrials.gov number, NCT02105610.).

A Systematic Review and International Web-Based Survey of Randomized Controlled Trials in the Perioperative and Critical Care Setting: Interventions Increasing Mortality

OBJECTIVE

Reducing mortality is a key target in critical care and perioperative medicine. The authors aimed to identify all nonsurgical interventions (drugs, techniques, strategies) shown by randomized trials to increase mortality in these clinical settings.

DESIGN

A systematic review of the literature followed by a consensus-based voting process.

SETTING

A web-based international consensus conference.

PARTICIPANTS

Two hundred fifty-one physicians from 46 countries.

INTERVENTIONS

The authors performed a systematic literature search and identified all randomized controlled trials (RCTs) showing a significant increase in unadjusted landmark mortality among surgical or critically ill patients. The authors reviewed such studies during a meeting by a core group of experts. Studies selected after such review advanced to web-based voting by clinicians in relation to agreement, clinical practice, and willingness to include each intervention in international guidelines.

MEASUREMENTS AND MAIN RESULTS

The authors selected 12 RCTs dealing with 12 interventions increasing mortality: diaspirin-crosslinked hemoglobin (92% of agreement among web voters), overfeeding, nitric oxide synthase inhibitor in septic shock, human growth hormone, thyroxin in acute kidney injury, intravenous salbutamol in acute respiratory distress syndrome, plasma-derived protein C concentrate, aprotinin in high-risk cardiac surgery, cysteine prodrug, hypothermia in meningitis, methylprednisolone in traumatic brain injury, and albumin in traumatic brain injury (72% of agreement). Overall, a high consistency (ranging from 80% to 90%) between agreement and clinical practice was observed.

CONCLUSION

The authors identified 12 clinical interventions showing increased mortality supported by randomized controlled trials with nonconflicting evidence, and wide agreement upon clinicians on a global scale.

A Complex Heart Team's Approach to a Patient With Giant Cell Myocarditis

Giant cell myocarditis is known as a rare and frequently fatal type of myocarditis that is usually characterized by progressive congestive heart failure and frequent ventricular arrhythmias. We report a rare case of giant cell myocarditis in a 64-year-old previously healthy woman. The case was complicated by the rapid development of progressive acute heart failure, which required the comprehensive care of our heart team. Using a broad spectrum of therapeutic approaches, the patient successfully underwent heart transplantation.

Major themes for 2014 in cardiothoracic and vascular anaesthesia and intensive care

There has been significant progress throughout 2014 in cardiothoracic and vascular anaesthesia and intensive care. There has been a revolution in the clinical approach to acute and chronic adult aortic diseases. Contemporary management of adult aortic disease is based on etiology, clinical presentation, extent, and integrated intervention with medical, endovascular and/or surgical measures. Further European guidelines have explored in depth the cardiovascular management in non-cardiac surgery with a thematic focus to reduce perioperative mortality from the leading offender, namely myocardial ischemia. Integrated guidelines address the management of myocardial revascularization including the percutaneous and surgical options. Despite 50 years since the first coronary artery bypass grafting procedure and impressive advances in interventional cardiology, surgical revascularization remains a gold standard for many patients with coronary artery disease. These advances in 2014 will likely further improve perioperative outcomes for our patients.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2013

This article reviewed selected research highlights of 2013 that pertain to the specialty of cardiothoracic and vascular anesthesia. The first major theme is the commemoration of the sixtieth anniversary of the first successful cardiac surgical procedure with cardiopulmonary bypass conducted by Dr Gibbon. This major milestone revolutionized the practice of cardiovascular surgery and invigorated a paradigm of mechanical platforms for contemporary perioperative cardiovascular practice. Dr Kolff was also a leading contributor in this area because of his important contributions to the refinement of cardiopulmonary bypass and mechanical ventricular assistance. The second major theme is the diffusion of echocardiography throughout perioperative practice. There are now guidelines and training pathways to guide its generalization into everyday practice. The third major theme is the paradigm shift in perioperative fluid management. Recent large randomized trials suggest that fluids are drugs that require a precise prescription with respect to type, dose, and duration. The final theme is patient safety in the cardiac perioperative environment. A recent expert scientific statement has focused attention on this issue because most perioperative errors are preventable. It is likely that clinical research in this area will blossom because this is a major opportunity for improvement in our specialty. The patient care processes identified in these research highlights will further improve perioperative outcomes for our patients.

Hereditary spherocytosis in a patient undergoing coronary artery bypass grafting with cardiopulmonary bypass--a case report

Hereditary spherocytosis is a genetically determined abnormality of red blood cells. It is the most common cause of inherited haemolysis in Europe and North America within the Caucasian population. We document a patient who underwent an aortocoronary bypass procedure on cardiopulmonary bypass. In view of the uncertain tolerance of the abnormal red cells in hereditary spherocytosis to cardiopulmonary bypass, we reviewed the patient's chart and analyzed recorded values of these parameters: free plasma haemoglobin, renal parameters, cystatin C, bilirubin, liver tests, urine samples. From the results, we can see that slight haemolysis-elevated bilirubin in the blood sample and elevated bilirubin and urobilinogen in the urine sample occurred on the first postoperative day. The levels of these parameters slowly decreased during the next postoperative days. There was no real clinical effect of this haemolysis on renal functions.

The year in cardiothoracic and vascular anesthesia: selected highlights from 2012

Cardiothoracic and vascular critical care has emerged as a subspecialty due to procedural breakthroughs, an aging population, and a multidisciplinary collaboration. This subspecialty now has a dedicated professional society, recently published guidelines, and plans for standardized certification. This paradigm shift represents a major collaboration opportunity for our specialty. The rise of evidence-based perioperative practice has produced a culture of large trials in our specialty to search for solutions to the challenging outcome questions. Besides the growth in the development of evidence, the consensus conference format and postpublication peer review have both emerged as effective processes for identifying the most relevant high-quality evidence. The quest for best perioperative practice has highlighted the importance of teamwork at all phases of care with respect to transitions in care, blood component transfusion, and research misconduct. The emergence of ultrasound as a standard for central vascular access also has been emphasized in recent multisociety guidelines. There also has been a paradigm shift in the management of patients with coronary artery disease. Recent guidelines have emphasized the roles of the cardiac anesthesiologist and the interventional cardiologist as part of the heart team approach. Major recent trials in comparative effectiveness have challenged the advantages of percutaneous coronary intervention, off-pump coronary artery bypass surgery, and intra-aortic balloon counterpulsation. The year 2012 has witnessed the emergence of new paradigms of care in our specialty with the emphasis on teamwork, safety, and quality. These processes will further improve perioperative outcome.

Major themes for 2012 in cardiovascular anesthesia and intensive care

There was major progress through 2012 in cardiovascular anesthesia and intensive care. Although recent meta-analysis has supported prophylactic steroid therapy in adult cardiac surgery, a large Dutch multicenter trial found no outcome advantage with dexamethasone. A second large randomized trial is currently testing the outcome effects of methyprednisolone in this setting. Due to calibration drift, the logistic EuroSCORE has recently been recalibrated. Despite this model revision, EuroSCORE II still overestimates mortality after transcatheter aortic valve implantation. It is likely that a specific perioperative risk model will be developed for this unique patient population. Recent global consensus has prioritized 12 non-surgical interventions that merit further study for reducing mortality after surgery. There is currently a paradigm shift in the conduct of adult aortic arch repair. Recent advances have facilitated aortic arch reconstruction with routine antegrade cerebral perfusion at mild-to-moderate hypothermia. Further integration of hybrid endovascular techniques may allow future aortic arch repair without hypothermia or circulatory arrest. These advances will likely further improve patient outcomes.

The year in Cardiothoracic and Vascular Anesthesia: selected highlights from 2011

There have been rapid advances in oral anticoagulation. The oral factor Xa inhibitors rivaroxaban and apixaban and the oral direct thrombin inhibitor dabigatran recently have been rigorously evaluated. These novel anticoagulants will usher in a new paradigm for perioperative anticoagulation. Perioperative blood conservation in cardiac surgery recently has been highlighted in the updated guidelines by the Society of Cardiovascular Anesthesiologists and the Society of Thoracic Surgeons. These recommendations reflect a comprehensive evaluation of the recent evidence to optimize transfusion practice. Transcatheter mitral valve repair continues to mature. Transcatheter aortic valve implantation for aortic stenosis has entered the clinical mainstream, with randomized trials showing its superiority over medical management and its equivalency to surgical valve replacement in high-risk patients. This transformational technology represents a major leadership opportunity for the cardiac anesthesiologist. Minimally invasive valve surgery has shown effectiveness in high-risk patients. Radial access is equivalent to femoral access for percutaneous coronary intervention in acute coronary syndromes but significantly reduces the risk of local vascular complications. Recent trials have further clarified the roles of medical therapy, percutaneous coronary intervention, and coronary artery bypass surgery in patients with significant coronary artery disease and left ventricular dysfunction. The past year has witnessed major advances in cardiovascular practice with new drugs, new devices, and new guidelines. The coming year most likely will advance these achievements to enhance the care of patients.

Implantation of left ventricular assist device complicated by undiagnosed thrombophilia

A patient with dilated cardiomyopathy and no history of thromboembolic events received a surgically implanted axial-flow left ventricular assist device. After implantation, transesophageal echocardiography revealed a giant thrombus on the lateral and anterior aspects of the left ventricle. The inflow cannula inserted through the apex of the left ventricle was not obstructed, and the device generated satisfactory blood flow. Laboratory screening for thrombophilia showed protein S deficiency, heterozygous factor V Leiden mutation, and heterozygous MTHFR C667T mutation. During the entire duration of circulatory support, no significant suction events were detected, and the patient was listed for heart transplantation. Ventricular assist device implantation can unmask previously undiagnosed thrombophilia; therefore, it should be necessary to identify thrombophilic patients before cardiac support implantation.

Major themes for 2011 in cardiovascular anesthesia and intensive care

The past year has witnessed major advances in of cardiovascular anesthesia and intensive care. Perioperative interventions such as anesthetic design, inotrope choice, glycemic therapy, blood management, and noninvasive ventilation have significant potential to enhance perioperative outcomes even further.The major theme for 2011 is the international consensus conference that focused on ancillary interventions likely to reduce mortality in cardiac anesthesia and intensive care. This landmark conference prioritized volatile anesthetics, levosimendan, and insulin therapy for their promising life-saving perioperative potential. Although extensive evidence has demonstrated the cardioprotective effects of volatile anesthetics, levosimendan as well as glucose, insulin and potassium therapy, the clinical relevance of these beneficial effects remains to be fully elucidated. Furthermore, controversy still persists about how tight perioperative glucose control should be in adult cardiac surgery because of the risk of hypoglycemia.A second major theme in 2011 has been perioperative hemostasis with the release of multispecialty guidelines. Furthermore, hemostatic agents such as recombinant factor VIIa and tranexamic acid have been studied intensively, even in the setting of major non-cardiac surgery. This review then highlights the remaining two major themes for 2011, namely the expanding role of noninvasive ventilation in our specialty and the formation of the Roland Hetzer International Cardiothoracic and Vascular Surgery Society.In conclusion, it is time for large adequately powered multicenter trials to test whether prioritized perioperative interventions truly reduce mortality and morbidity in cardiac surgical patients. This essential paradigm shift represents a major clinical opportunity for the global cardiovascular anesthesia and critical care community.

Major themes for 2010 in cardiothoracic and vascular anesthesia

Significant variability in transfusion practice persists despite guidelines. Although the lysine analogues are effective antifibrinolytics, safety concerns exist with high doses tranexamic acid. Despite recombinant activated factor VII promising results in massive bleeding after cardiac surgery, it significantly increases arterial thromboembolic risk. Aortic valve repair may evolve to standard of care. Transcatheter aortic valve implantation is an established therapy for aortic stenosis. The cardiovascular anesthesiologist features prominently in the new guidelines for thoracic aortic disease. Although intense angiotensin blockade improves outcomes in heart failure, it might aggravate the maintenance of perioperative systemic vascular tone. Ultrafiltration is an alternative to diuresis for volume overload in heart failure. Management of heart failure titrated to brain natriuretic peptide activity reduces mortality. A major surgical advance has been the significant outcome improvement achieved with continuous-flow left ventricular assist devices. Advanced liver disease is a significant predictor for perioperative bleeding, transfusion and mortality after ventricular assist device insertion. Acquired von Willebrand syndrome is not only common in patients with these devices but often aggravating bleeding and transfusion in this setting. Metabolic myocardial modulation with perhexilene significantly enhances effort tolerance in hypertrophic cardiomyopathy. A landmark report has highlighted future priorities in this disease. Pediatric cardiac surgical trials have revealed the importance of perioperative cerebral oxygen saturation monitoring and the Sano shunt. Advances in pediatric-specific ventricular assist devices will likely revolutionize pediatric heart failure. Recent reports have highlighted the priorities for future perioperative trials and for training models in pediatric cardiac anesthesia.

Anesthesia management of a patient with a ventricular assist device for noncardiac surgery

Congestive heart failure represents a severe health condition with unfavourable long-term prognosis despite all the progress in pharmacological therapy of heart failure. Another therapeutic option is represented by mechanical cardiac support devices. Ventricular assist devices (VAD) constitute largest subgroup of these devices. Patients supported with VAD carry many considerations which are important for successful perioperative management of these patients for noncardiac surgery. The general perioperative considerations include consultation with VAD management personnel, detailed assessment of end-organ dysfunction before surgery, appropriate antibiotic prophylaxis, deactivation of implantable cardioverter-defibrillator for the time of surgical procedure, and the choice between general and regional anesthesia. Intraoperative monitoring depends primarily on the type of blood flow generated by VAD. For devices generating pulsatile blood flow, standard monitoring arrangements are needed. In the patients supported by devices which provide nonpulsatile blood flow, pulse oximetry and noninvasive blood pressure measurement are not reliable monitoring methods, and placement of intra-arterial catheter is warranted. In all the patients supported with VAD, transesophageal echocardiography is extremely useful method for monitoring the function of VAD itself, and in the case of univentricular VAD for monitoring the function of nonsupported cardiac ventricle. The most important issue in hemodynamic management of the patients with VAD is avoiding hypovolemia because it can cause inadequate VAD output with resulting low cardiac output and hypotension. All the patients with VAD need some degree of anticoagulation, and for noncardiac surgery the question of interrupting or decreasing the level of anticoagulation should be discussed among members of the caring team.

Major themes for 2009 in cardiothoracic and vascular anesthesia

The hybrid operating room is the venue for transcatheter therapy with the convergence of three specialties: cardiac surgery, cardiovascular anesthesiology, and interventional cardiology. Transcatheter aortic valve replacement is proof that cardiac specialists have embraced the endovascular revolution. Since pharmacologic and ischemic myocardial conditioning are safe and effective, they are currently the focus of multiple trials. Angiotensin blockade, anemia and endoscopic saphenous vein harvesting worsen outcome after coronary artery bypass grafting (CABG). Although off-pump CABG is equivalent to on-pump CABG, it may improve outcomes in high-risk groups. Although percutaneous coronary intervention (PCI) significantly decreases mortality after myocardial infarction, the evidence is less convincing for intra-aortic balloon counterpulsation. Even though prasugrel was recently approved for platlet blockade in PCI, it may be superceded by ticagrelor. Although PCI and CABG appear equivalent for multivessel coronary disease, CABG lowers revascularization rates and also has superior outcomes in diabetics and the elderly. Hetastarch and N-acetylcysteine both increase bleeding and transfusion in cardiac surgery. Factor VII can treat life-threatening bleeding, but its safety requires further evaluation. Since eltrombopag and romiplostim stimulate platelet production, they may have a future role in hemostasis after cardiac surgery. Even though fenoldopam, atrial natriuretic peptide and sodium bicarbonate are nephroprotective, further trials must confirm these findings. Intensive insulin therapy offers no further outcome advantage and significantly increases hypoglycemic risk. The past year has witnessed the advent of a new clinical venue, new devices, and new drugs. The coming year will most likely advance these achievements.

The effect of medetomidine-ketamine anesthesia on hemodynamic parameters during hemorrhagic shock in minipigs

Hemorrhagic shock (HS) represents an acute event with high mortality. The optimal combination of anesthetics that would prevent hemodynamic collapse and allow damage control surgery has not yet been determined. We tested the hypothesis that a combination of dissociative anesthetic ketamine with alpha2- agonist medetomidine (MK group, n=10) would provide superior hemodynamic control compared to propofol-remifentanil (PR group, n=10) during HS in minipigs. A modified Wiggers‘ model of HS with a target mean arterial pressure (MAP) of 40 mm Hg and 2 h duration was used. All minipigs survived. HS led to a ~50 % decrease in cardiac output in both groups (P<0.001 for baseline vs. HS 120 min) with no differences between groups. Total volume of removed blood was larger in the MK group (1321±133 ml vs. 1111±246 ml in the PR group, respectively; P<0.05). MAP was higher during the initial phases of HS in the MK group than in PR group (P<0.05 at HS 30-90 min). HR was lower in the MK group at the late phases of HS (P<0.05 at HS 60-120 min). In conclusion, medetomidine-ketamine provides a feasible and possibly a more favorable alternative to the propofol-remifentanil combination in our model of HS in minipigs.

Recent progress in heart failure treatment and heart transplantation

There has been significant progress in heart failure treatment; its stages are defined as a management platform for cardiovascular specialists. Surgical ventricular restoration adds no outcome advantage in ischemic heart failure over coronary artery bypass surgery alone. Novel medical therapies may include cytokine blockade and the vasodilator, relaxin. Although diastolic failure is prevalent, its clinical significance is unclear. Cardiac resynchronization reduces mortality and hospitalization. Perioperative enoximone facilitates beta-blockade for prophylaxis against myocardial ischemia. Heart failure still determines outcome in pulmonary embolism and cardiac surgery. The practice of ventricular assist devices continues to progress. A profile system based on urgency of mechanical support will guide future outcome assessment. Clinical scoring systems will guide the management of right heart failure. Device flow determines the risk of cerebral hyperperfusion and neurologic dysfunction. Regardless of device type, renal dysfunction remains an important outcome determinant. Postoperative heparinization is increasingly challenged because of the risks of bleeding and heparin-induced thrombocytopenia. The practice of heart transplantation continues to mature. The bicaval rather than the biatrial technique improves short-term outcome. Oral sildenafil is effective for pulmonary hypertension and right ventricular support. Although immunosuppression with tacrolimus is beneficial, sirolimus is less nephrotoxic and preserves coronary vasomotor function. The induction of immunosuppression may be modified as it has a weak evidence base. Psychosocial factors also continue to influence clinical outcome significantly. The future of heart failure treatment is bright with signs of active growth and progress in this vibrant subspecialty.

Single-stage extensive chronic type A dissecting aortic aneurysm repair and continuous-flow ventricular assist device implantation

The surgical technique of simultaneous heart transplantation and aortic aneurysm repair has been reported previously. However, there is a subgroup of patients with end-stage cardiomyopathy requiring major aortic surgery who do not meet heart transplant criteria. The optimal treatment strategy for these patients is still to be defined. In this report, we describe the use of an implantable continuous-flow left ventricular assist device (LVAD) as an adjunct to extensive aortic repair for providing patients with an acceptable risk surgical alternative to palliative treatment. To the best of our knowledge, this is the first report of this approach in the published literature.

Prophylactic application of levosimendan in cardiac surgical patients with severe left ventricle dysfunction

BACKGROUND

Levosimendan improves myocardial contractility, and increases systemic, pulmonary and coronary vasodilation. The present study investigates the perioperative hemodynamic effects of a prophylactic infusion of levosimendan in high-risk cardiac surgery patients with severe left ventricle dysfunction, and compares short-term clinical outcomes with a historical control group in which dobutamine and milrinone were used.

PATIENTS AND METHODS

A retrospective, observational study was performed in 10 adult patients with EuroSCOREs greater than six and severe left ventricle dysfunction. In the study group, prophylactic levosimendan infusion was started after the induction of general anesthesia (bolus 24 mug/kg over 10 min; continuous infusion 0.1 mug/kg/min over the next 24 h). The historical control group (12 patients) was treated with dobutamine and milrinone. The hemodynamic measurements were performed at eight predetermined time points. Short-term clinical outcomes recorded in both groups were the length of intensive care unit stay, the need for dialysis, the length of hospital stay, predicted mortality (logistic EuroSCORE) and 30-day mortality.

RESULTS

Hemodynamic measurements performed in the study group revealed an increase in cardiac index 30 min after levosimendan infusion was started. Cardiac performance was sufficient throughout the entire perioperative period. The length of intensive care unit stay was not different between the groups, but the length of hospital stay (10.4+/-5.0 versus 26.6+/-17.6 days; P=0.01) and 30-day mortality (0% versus 41.7%; P=0.04) were significantly lower in levosimendan-treated patients.

CONCLUSIONS

Levosimendan seemed to be an effective choice for preventing left ventricle failure in high-risk cardiac surgical patients with severe left ventricle dysfunction compared with patients receiving dobutamine and milrinone.

IL-10 and TNF-β gene polymorphisms have no major influence on lactate levels after cardiac surgery☆

OBJECTIVE

Lactate levels after cardiac surgery are influenced by different proinflammatory (TNF, IL-6, IL-8) and anti-inflammatory (IL-10) cytokines. The goal of the study was to determine the relationship between polymorphism in the IL-10 (-1082G/A) and TNF-beta (+252G/A) genes and lactate levels in patients after cardiac surgery.

METHODS

We performed prospective observational study in 168 consecutive adult patients without left ventricle dysfunction undergoing elective coronary artery bypass grafting. Lactic acid levels were documented at five different time points: 10 min after beginning of cardiopulmonary bypass, 40 min after cardiopulmonary bypass termination, and 30 min, 8h, and 16 h after the surgery. Genetic analysis for polymorphism was performed by mismatched polymerase chain reaction and restriction analysis.

RESULTS

No association was found between single polymorphism in IL-10 or TNF-beta gene and lactate levels, but the carriers of IL-10/TNF-beta genotype combination +A/GG had significantly different course of lactate levels in time with decrease in lactate (in comparison with increase in other groups) at 8h after the surgery.

CONCLUSIONS

IL-10 (-1082G/A) and TNF-beta (+252G/A) gene polymorphisms have a little, yet measurable influence on the time course of changes in lactate levels after cardiac surgery.