Factors associated with vasoplegic shock in the postoperative period of cardiac surgery and influence on morbidity and mortality of the use of arginine vasopressin as rescue therapy

OBJECTIVES

Analyzing associated factors with vasoplegic shock in the postoperative period of Cardiac Surgery. Analyzing the influence of vasopressin as rescue therapy to first-line treatment with norepinephrine.

DESIGN

Cohort, prospective and observational study.

SETTING

Main hospital Postoperative Cardiac ICU.

PATIENTS

Patients undergoing cardiac surgery with subsequent ICU admission from January 2021 to December 2022.

INTERVENTIONS

Record of presurgical, perioperative and ICU discharge clinical variables.

MAIN VARIABLES OF INTEREST

chronic treatment, presence of vasoplegic shock, need for vasopressin, cardiopulmonary bypass time, mortality.

RESULTS

773 patients met the inclusion criteria. The average age was 67.3, with predominance of males (65.7%). Post-CPB vasoplegia was documented in 94 patients (12.2%). In multivariate analysis, vasoplegia was associated with age, female sex, presurgical creatinine levels, cardiopulmonary bypass time, lactate level upon admission to the ICU, and need for prothrombin complex transfusion. Of the patients who developed vasoplegia, 18 (19%) required rescue vasopressin, associated with pre-surgical intake of ACEIs/ARBs, worse Euroscore score and longer cardiopulmonary bypass time. Refractory vasoplegia with vasopressin requirement was associated with increased morbidity and mortality.

CONCLUSIONS

Postcardiopulmonary bypass vasoplegia is associated with increased mortality and morbidity. Shortening cardiopulmonary bypass times and minimizing products blood transfusion could reduce its development. Removing ACEIs and ARBs prior to surgery could reduce the incidence of refractory vasoplegia requiring rescue with vasopressin. The first-line treatment is norepinephrine and rescue treatment with VSP is a good choice in refractory situations. The first-line treatment of this syndrome is norepinephrine, although rescue with vasopressin is a good complement in refractory situations.

Perioperative stress and anxiety in parents of children operated on for congenital heart disease

INTRODUCTION

Levels of stress and anxiety suffered by parents of children with congenital heart disease (PCUCS) during their children's admission for cardiac surgery may be higher than those suffered by other parents who go through the same experience.

OBJECTIVE

General objective of this study was to measure the stress and anxiety suffered by PCUCS and parents of children undergoing renal surgery (PCURS) in relation to the intervention of their children. The specific objective of the quantitative study was to compare global stress and anxiety according to sex, time of the perioperative period, and cohort. The general objective of the qualitative section is to explore the experience that PCUCS and PCURS have during their hospital stay and to identify the specific factors that influence the genesis of stress and anxiety.

METHOD

A cohort study was carried out in which PCURS and PCUCS were included. The quantitative part was performed by comparing the scores of three questionnaires that measure stress levels (PSS-14), state anxiety (STAIE) and trait anxiety (STAIR) throughout three perioperative moments. At the same time, a qualitative study was carried out with semi-structured interviews and collection of diaries on which a descriptive phenomenological analysis was carried out, according to Munhall. The analysis of the text was carried out according to Colaizzi.

RESULTS

Stress and anxiety levels were significantly higher in PCUCS compared to PCURS. Mothers in the cardiac cohort were those with the highest scores on all scales. In the qualitative study, four themes emerged: "stress and anxiety from the moment of diagnosis", "surgical intervention as a critical moment", "harshness of the postoperative period in the Intensive Care Unit" and "joy and gratitude versus dependence and fear for the future".

CONCLUSIONS

PCUCS suffer higher levels of stress and anxiety than PCURS, being the mothers of the cardiac cohort those who suffer these disorders with greater intensity. This study can constitute a starting point to develop strategies that cover these parental needs.

Perioperative analgesia by erector spinae plane block in left ventricular assist implant

In recent years, left ventricular assist devices have become an important element in the management of left ventricular failure refractory to pharmacological treatment. Their implantation (performed by left thoracotomy or sternotomy) generates significant perioperative pain, which can be managed with locoregional anaesthesia techniques. However, opinions vary on their use in cardiac surgery due to interference with the anticoagulant therapy required in these patients. The erector spinae plane block is an alternative to classic locoregional techniques. It does not produce hemodynamic alterations and does not interfere with antiplatelet and anticoagulant therapy, and is therefore an alternative to be considered in cardiac surgery. We present a case of left ventricular assist device implantation under this block prior to the surgical procedure and postoperative infusion through a catheter, obtaining satisfactory results in the management of perioperative pain.

Tranexamic acid in cardiac surgery: Are low doses enough?

OBJECTIVES

Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia.

MATERIALS AND METHODS

A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12 h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID.

RESULTS

There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12 h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P = .014) and ID (P = .040) but more fresh frozen plasma than group ID (P = .0002).

CONCLUSIONS

Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

Tranexamic acid in cardiac surgery: Are low doses enough?

OBJECTIVES

Tranexamic acid is used to prevent hyperfibrinolysis and reduce postoperative bleeding and blood transfusions in on-pump cardiac surgery. We evaluate the efficacy of low or high dose tranexamic acid in a prospective cohort study conducted in Valencia.

MATERIALS AND METHODS

A total of 427 patients were recruited between January 2019 and January 2020, 207 in the Hospital General Universitario (low dose [LD]) and 220 in the Hospital Universitario y Politécnico La Fe (high dose [HD] and intermediate dose [ID]). We recorded the presence of hyperfibrinolysis on rotational thromboelastometry, intra- and postoperative administration of blood products, chest tube output within the first 12h, and incidence of convulsions. Univariate and multivariate comparisons were performed. Univariate analysis of all categories was performed after propensity score matching between LD and HD and between LD and ID.

RESULTS

There were no statistically significant differences in: appearance of hyperfibrinolysis, administration of blood products, postoperative chest tube output within the first 12h, or occurrence of convulsions. Group LD received less fibrinogen than group HD (P=.014) and ID (P=.040) but more fresh frozen plasma than group ID (P=.0002).

CONCLUSIONS

Administration of low-dose tranexamic acid is as effective as higher doses in hyperfibrinolysis prophylaxis and the prevention of postoperative bleeding in cardiac surgery.

Universal definition of perioperative bleeding in cardiac surgery adults and association with mortality in a Mexican Cardiovascular Critical Care Unit

Background

Bleeding as a complication is associated with poorer results in cardiac surgery. There is increasing evidence that the use of blood products is an independent factor of increased morbidity, mortality, and hospital costs. Dyke et al. established the universal definition of perioperative bleeding (UDPB). This classification is more precise defining mortality in relation to the degree of bleeding.

Methods

A descriptive and analytical retrospective study of a database of patients underwent cardiac surgery from January 1, 2016, to December 31, 2017, was performed. The primary objective of the study was to look at mortality associated with the degree of bleeding using the UDPB.

Results

A total of 918 patients who went to cardiac surgery were obtained. Most of the population was classified as insignificant bleeding class (n = 666, 72.9%), and for massive bleeding the lowest proportion (n = 25, 2.7%). For the primary outcome of 30-day mortality, a significant difference was found between the groups, observing that it increased to a higher degree of bleeding. This was corroborated by multivariate logistic regression analysis that was adjusted to EuroScore II and cardiopulmonary bypass (CPB) duration, finding an independent association of the bleeding class with 30-day mortality (OR, 95%, 5.82 [2.22-15.26], p = 0.0001).

Conclusions

We found that the higher the degree in UDPB was associated with higher mortality independently to EuroScore II and CPB duration for adult patients undergoing cardiac surgery.

Prognostic value of APACHE II score in postoperative of cardiac surgery

Antecedentes y objetivos

El sistema de calificación APACHE II permite predecir la mortalidad intrahospitalaria en terapia intensiva. Sin embargo, no está validado para cirugía cardíaca, ya que no posee buena capacidad diferenciadora. El objetivo es determinar el valor pronóstico de APACHE II en el postoperatorio de procedimientos cardíacos.

Materiales y métodos

Se analizó en forma retrospectiva la base de cirugía cardíaca. Se incluyó a pacientes intervenidos entre 2017 y 2018, de los cuales se calculó la puntuación APACHE II. Se utilizó curva ROC para determinar el mejor valor de corte. El punto final primario fue mortalidad intrahospitalaria. Como puntos finales secundarios se evaluó la incidencia de bajo gasto cardíaco (BGC), accidente cerebrovascular (ACV), sangrado quirúrgico y necesidad de diálisis. Se realizó un modelo de regresión logístico multivariado para ajustar a las variables de interés.

Resultados

Se analizó a 559 pacientes. La media del sistema de calificación APACHE II fue de 9.9 (DE 4). La prevalencia de mortalidad intrahospitalaria global fue de 6.1%. El mejor valor de corte de la calificación para predecir mortalidad fue de 12, con un área bajo la curva ROC de 0.92. Los pacientes con APACHE II ≥ 12 tuvieron significativamente mayor mortalidad, incidencia de BGC, ACV, sangrado quirúrgico y necesidad de diálisis. En un modelo multivariado, el sistema APACHE II se relacionó de modo independiente con mayor tasa de mortalidad intrahospitalaria (OR, 1.14; IC95%, 1.08-1.21; p < 0.0001).

Conclusiones

El sistema de clasificación APACHE II demostró ser un predictor independiente de mortalidad intrahospitalaria en pacientes que cursan el postoperatorio de cirugía cardíaca.

Background and objectives

The APACHE II score allows predicting in-hospital mortality in patients admitted to intensive care units. However, it is not validated for patients undergoing cardiac surgery, since it does not have a good discriminatory capacity in this clinical scenario. The aim of this study is to determine prognostic value of APACHE II score in postoperative of cardiac surgery.

Materials and methods

The study was performed using the cardiac surgery database. Patients undergoing surgery between 2017 and 2018, with APACHE II score calculated at the admission, were included. The ROC curve was used to determine a cut-off value The primary endpoint was in-hospital death. Secondary endpoints included low cardiac output (LCO), stroke, surgical bleeding, and dialysis requirement. A multivariable logistic regression model was developed to adjust to various variables of interest.

Results

The study evaluated 559 patients undergoing cardiac surgery. The mean of APACHE II Score was 9.9 (SD 4). The prevalence of in-hospital death was 6.1%. The best prognostic cut-off value for the primary endpoint was 12, with a ROC curve of 0.92. Patients with an APACHE II score greater than or equal to 12 had significantly higher mortality, higher incidence of LCO, stroke, surgical bleeding and dialysis requirement. In a multivariate logistic regression model, the APACHE II score was independently associated with higher in-hospital death (OR, 1.14; 95CI%, 1.08-1.21; p < 0.0001).

Conclusions

The APACHE II Score proved to be an independent predictor of in-hospital death in patients undergoing postoperative cardiac surgery, with a high capacity for discrimination.

Atrial fibrillation in cardiac surgery

Atrial fibrillation is the most frequent arrhythmia in the postoperative period of cardiac surgery. It is associated with heart failure, renal insufficiency, systemic embolism and increase in days of in-hospital and mortality. Atrial fibrillation in the postoperative period of cardiac surgery (FAPCC) usually appears in the first 48 h after surgery. The main mechanisms involved in the appearance and maintenance of FAPCC are the increase in sympathetic tone and the inflammatory response. The associated risk factors are advanced age, chronic obstructive pulmonary disease, chronic kidney disease, valve surgery, fraction of ejection of the left ventricle < 40% and the withdrawal of beta-blocker drugs. There are instruments that have been shown to predict the appearance of FAPCC. Prophylactic treatment with beta-blockers and amiodarone, is associated with a decrease in the appearance of FAPCC. Given its transient nature, it is suggested that the initial treatment of FAPCC be the heart rate control and only if the treatment does not achieve a return to sinus rhythm, the use of electrical cardioversion is suggested. It is unknown what should be the long-term follow-up and complications beyond this period are little known. FAPCC is not a benign or isolated arrhythmia in patients undergoing cardiac surgery, so the identification of risk factors, their prevention, and follow-up in the outpatient setting, should be part of the units dedicated to the care and care of these patients.

Correlation between NT-proBNP levels and the maximun vasoactive-inotropic score in the first 24 hours post-intervention of cardiac surgery

Introduction

The clinical utility of brain natriuretic peptide (NT-proBNP) as a prognostic marker in pediatric patients with heart failure is controversial. The maximum vasoactive inotropic score at 24 h after cardiac surgery in pediatric patients is an important predictor of morbidity and postoperative mortality.

Objective

To determine if there is a correlation between the serum levels of NT-proBNP and the maximum vasoactive inotropic score at 24 hours after cardiac surgery in pediatric patients seen in the Intensive Care Unit.

Material and methods

An analytical cross-sectional study. A Spearman correlation analysis (r_s) was performed between the serum level of NT-proBNP and the maximum inotropic score both taken at 24 hours postoperatively. A value of p < 0.05 was considered statistically significant.

Results

40 patients were included, 52.5% to the male sex, 72.5% were older than 1 year of age at the time of surgery. A low correlation (r_s = 0.26) was found between the serum levels of NT-proBNP and the maximum vasoactive inotropic score at 24 hours, this correlation was not statistically significant (p = 0.09).

Conclusions

To our understanding, the present study is the first to investigate whether there is a correlation between these markers, so our results could set an important precedent that marks the beginning of multiple investigations in our critically ill patients in order to establish new diagnostic, prognostic and therapeutic approaches.

Cardiac, cerebral, renal, optic nerve, and lung ultrasound study (CCROSS) protocol

The use of echocardiography is very useful in the evaluation, treatment, and follow-up of the patient in critical condition. Along with clinic and the stethoscope, it is a tool that complements the act of the physician faced with the diversity of etiologies that determine the state of shock and increase morbidity and mortality, especially in post-cardiac surgery patients, in whom there are no management emergency post-surgical algorithms. In view of this situation, at the National Institute of Cardiology Ignacio Chávez, a management algorithm has been made and improved in cardiac post-surgical patients: through focused ultrasonography, including transthoracic echography, pulmonary ultrasound, optic nerve ultrasound, and renal ultrasound by evaluating renal resistive indices. Several societies have created their protocols for addressing patients in critical condition, so in the institute, specifically in cardiovascular intensive therapy, has created the cardiac, cerebral, renal, optic nerve, and lung ultrasound study (CCROSS) protocol for the initial approach of these patients, and a study is currently taking place for its validation, reproducibility, and efficacy.

Evaluation of two intensive care models in relation to successful extubation after cardiac surgery

OBJECTIVE

To compare outcomes between intensivist-directed and cardiac surgeon-directed care delivery models.

DESIGN

This retrospective, historical-control study was performed in a cohort of adult cardiac surgical patients at Zhongshan Hospital (Fudan University, China). During the first phase (March to August 2015), cardiac surgeons were in charge of postoperative care while intensivists were in charge during the second phase (September 2015-June 2016). Both phases were compared regarding successful extubation rate, intensive care unit (ICU) length of stay (LOS), and in-hospital mortality.

SETTING

Tertiary Zhongshan Hospital (Fudan University, China).

PATIENTS

Consecutive adult patients admitted to the cardiac surgical ICU (CSICU) after heart surgery.

INTERVENTIONS

Phase I patients treated by cardiac surgeons, and phase II patients treated by intensivists.

MAIN VARIABLES OF INTEREST

Successful extubation, ICU LOS and in-hospital mortality.

RESULTS

A total of 1792 (phase I) and 3007 patients (phase II) were enrolled. Most variables did not differ significantly between the two phases. However, patients in phase II had a higher successful extubation rate (99.17% vs. 98.55%; p=0.043) and a shorter median duration of mechanical ventilation (MV) (18 vs. 19h; p<0.001). In relation to patients with MV duration >48h, those in phase II had a comparatively higher successful extubation rate (p=0.033), shorter ICU LOS (p=0.038) and a significant decrease in in-hospital mortality (p=0.039).

CONCLUSIONS

The intensivist-directed care model showed improved rates of successful extubation and shorter MV durations after cardiac surgery.

Protocolo ultrasonográfico enfocado en cirugía cardiaca posquirúrgica CCROSS (Cardiac, Cerebral, Renal, Optic nerve, lung ultraSound Study)

The use of echocardiography is very useful in the evaluation, treatment and follow-up of the patient in critical condition. Along with clinic and the stethoscope, it is a tool that complements the act of the physician faced with the diversity of etiologies that determine the state of shock and increase morbidity and mortality, especially in post cardiac surgery patients, in whom there are no management emergency postsurgical algorithms. In view of this situation, at the National Institute of Cardiology Ignacio Chávez, a management algorithm has been made and improved in cardiac postsurgical patients: through focused ultrasonography, including transthoracic echography, pulmonary ultrasound, optic nerve ultrasound, and renal ultrasound by evaluating renal resistive indices. Several societies have created their protocols for addressing patients in critical condition, so in the Institute, specifically in cardiovascular intensive therapy, has created the CCROSS protocol (Cardiac, Cerebral, Renal, Optic nerve, lung UltraSound Study) for the initial approach of these patients, and it is being carried out a study for its validation, reproducibility and efficacy.

Regionalization of congenital heart disease care: A pending goal

Congenital heart diseases (CHDs) are considered the most frequent malformations. In Mexico, every year between 12 and 16 thousand children are born with some type of CHD and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of CHDs is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with CHD in all the country.

The world database for pediatric and congenital heart surgery: A collaboration with the Registro Nacional de Cirugía Cardiaca Pediátrica

Objective

Following the notable work accomplished by the Mexican Association of Specialists in Congenital Heart Disease (Asociación Mexicana de Especialistas en Cardiopatías Congénitas) with the development of a national registry for congenital cardiac surgery, the World Society for Pediatric and Congenital Heart Surgery has implemented an international platform to collect data and analyze outcomes of children with congenital heart disease.

Methodology

This manuscript proposes a possible collaboration between Mexico's national congenital cardiac database (Registro Nacional de Cirugía Cardíaca Pediátrica) and the World Database for Pediatric and Congenital Heart Surgery.

Conclusion

Such a partnership would advance the countries' desire for the ongoing development of quality improvement processes and improve the overall treatment of children with congenital heart disease.

Dexmedetomidine implementation in pain management in the immediate postoperative period of cardiac surgery

BACKGROUND

This study arose from the need to improve all tasks related to monitoring pain in post cardiac surgery patients.

OBJECTIVES

Checking and quantifying the pain suffered by patients undergoing cardiac surgery in the first 24hours of their stay in the intensive care unit (ICU), treated with Dexmedetomidine (Dex) as analgesic adjuvant, as well as their degree of sedation and the need for opiates such as rescue analgesia.

MATERIAL AND METHODS

Unicentric study, observational, descriptive, from April 2016 to September 2017. Both genders, all adult, undergoing cardiac surgery, operating theatre-extubated and Dex continuous infusion carriers. Pain degree level was evaluated by the Visual analogue Scale of Pain (VAS), from immediately post-surgery until 24hours from ICU entry and sedation degree, by the Richmond Sedation Agitation Scale (RASS), only while the Dex infusion lasted.

RESULTS

109 patients were included. The results obtained showed that the average pain suffered by patients during the first 24hours was .47 with standard deviation (SD) of 1.25; the average maximum pain experienced was 3.58 with a range of 0 to 8 and the RASS average was -.68 (SD: 0,80). In addition, 44.04% of the patients needed rescue opiates, although only 7.32% showed severe pain greater than 6.

CONCLUSIONS

The Dex infusion patients showed mild levels of pain, however, a small percentage, who must be taken into account, suffered severe pain.

Impact of goal directed basic echocardiography on diagnostic and therapeutic management in an ICU of cardiac surgery

OBJECTIVE

Few studies have evaluated the impact in diagnosis and therapeutic management of basic transthoracic echocardiography in postoperated cardiac surgery. The aim of our study was to evaluate the impact of basic transthoracic echocardiography in the management of this kind of patients.

DESIGN

Over an 18-month period, we prospectively studied all patients admitted to a university hospital Intensive Care Unit following heart surgery. We evaluated clinically all of them to establish a diagnosis and an initial treatment. We performed basic transthoracic echocardiography for a diagnosis evaluation that was compared with clinical diagnosis. If they differed, we assessed to change treatment and evaluate the therapeutic response. We performed a descriptive analysis.

RESULTS

We included 136 patients and performed 203 echocardiographies. Transthoracic echocardiography differed of initial diagnosis in 101 (49.8%) echocardiographies. In 56 of these echocardiographies (55.44%), we could give an alternative diagnosis with a change in the treatment in 30patients (53,6%). We found clinical improvement in 26 patients (86.76%) in the following 30-60minutes.

CONCLUSIONS

Basic transthoracic echocardiography is useful in diagnostic and therapeutic management of postoperative cardiac surgery patients. We could not confirm the clinical diagnosis in half of the performed echocardiographies. In most patients in whom we observe a change in the diagnosis due to echocardiography, we observed a clinical improvement after changing the treatment.

The world database for pediatric and congenital heart surgery: A collaboration with the Registro Nacional de Cirugía Cardiaca Pediátrica

Objective

Following the notable work accomplished by the Mexican Association of Specialists in Congenital Heart Disease (Asociación Mexicana de Especialistas en Cardiopatías Congénitas) with the development of a national registry for congenital cardiac surgery, the World Society for Pediatric and Congenital Heart Surgery has implemented an international platform to collect data and analyze outcomes of children with congenital heart disease.

Methodology

This manuscript proposes a possible collaboration between Mexico's national congenital cardiac database (Registro Nacional de Cirugía Cardíaca Pediátrica) and the World Database for Pediatric and Congenital Heart Surgery.

Conclusion

Such a partnership would advance the countries' desire for the ongoing development of quality improvement processes and improve the overall treatment of children with congenital heart disease.

La regionalización de la atención de cardiopatías congénitas: una meta pendiente

Congenital heart diseases are considered the most frequent malformations. In Mexico every year between 12 and 16 thousand children are born with some type of congenital heart disease and it is the second cause of mortality in children under 1 year of age and in children aged between 1 and 4 years. The problem of the care of congenital heart diseases is analyzed from a perspective of health policies in the country with an emphasis on regionalizing their care in order to rationalize the use of available resources and with the aim of serving the largest number of patients and achieve the best clinical results. It emphasizes the need to promote cooperation among the different civil society organizations and institutions to exchange ideas to create consensus and joint projects for a better use of available resources to achieve universal and quality care of children with congenital heart disease in all the country.

Anaphylactic risk due to systemic mastocytosis: Perioperative management in cardiac surgery

Mastocytosis is a disease characterised by an abnormal proliferation of mast cells. The degranulation of mast cells can be triggered by chemical, physical, and psychological factors, and in severe cases may be accompanied by cardiovascular alterations and shock. Tryptase concentrations greater than 20ug/L may be associated with an increased risk of mastocyte degranulation. The case is presented on a 71 year-old man that underwent an aortic valve replacement and aortic-coronary bypass surgery. He had an indolent systemic mastocytosis and a history of histaminergic crises, with a baseline value of tryptase prior to surgery of 58.1ug/L.

Evaluation of intensivist basic training in transthoracic echocardiography in the postoperative period of heart surgery

BACKGROUND

Transthoracic echocardiography can significantly change the management of many critical patients, and is being incorporated into many Intensive Care Units (ICU). Very few studies have examined the feasibility and impact of intensivists performing basic transthoracic echocardiography upon the management of critical patients after cardiac surgery. The present study therefore evaluates the quality of acquisition and accuracy of intensivist interpretation of basic transthoracic echocardiograms in the postoperative period of heart surgery.

METHODS

Over an 8-month period we prospectively studied 148 patients within 24h after admission to a university hospital ICU following heart surgery. We performed basic transthoracic echocardiography to evaluate ventricular function, pericardial effusion, hypovolemia and mitral regurgitation. Cohen's Kappa was used to compare transthoracic echocardiograms obtained by intensivists with basic versus advanced training. Concordance on image acquisition and interpretation was evaluated.

RESULTS

We analyzed data of adequate transthoracic echocardiograms in 148 patients (92.5%). Apical four-chamber view and advanced trainees obtained better quality images. Concordance was good for right and left ventricular function (kappa=0.7±0.14 and 0.87±0.05, respectively), and moderate for the remaining parameters. Interpretation concordance between basic and advanced training intensivists was good (kappa=0.73±0.05).

CONCLUSIONS

Intensivists with basic training in echocardiography are capable of performing and interpreting echocardiograms in most patients during the postoperative period of heart surgery.

Estimated glomerular filtration rate is an early biomarker of cardiac surgery-associated acute kidney injury

BACKGROUND

and objective Acute kidney injury (AKI) diagnosis is still based on serum creatinine and diuresis. However, increases in creatinine are typically delayed 48h or longer after injury. Our aim was to determine the utility of routine postoperative renal function blood tests, to predict AKI one or 2days in advance in a cohort of cardiac surgery patients.

PATIENTS AND METHODS

Using a prospective database, we selected a sample of patients who had undergone major cardiac surgery between January 2002 and December 2013. The ability of the parameters to predict AKI was based on Acute Kidney Injury Network serum creatinine criteria. A cohort of 3,962 cases was divided into 2groups of similar size, one being exploratory and the other a validation sample. The exploratory group was used to show primary objectives and the validation group to confirm results. The ability to predict AKI of several kidney function parameters measured in routine postoperative blood tests, was measured with time-dependent ROC curves. The primary endpoint was time from measurement to AKI diagnosis.

RESULTS

AKI developed in 610 (30.8%) and 623 (31.4%) patients in the exploratory and validation samples, respectively. Estimated glomerular filtration rate using the MDRD-4 equation showed the best AKI prediction capacity, with values for the AUC ROC curves between 0.700 and 0.946. We obtained different cut-off values for estimated glomerular filtration rate depending on the degree of AKI severity and on the time elapsed between surgery and parameter measurement. Results were confirmed in the validation sample.

CONCLUSIONS

Postoperative estimated glomerular filtration rate using the MDRD-4 equation showed good ability to predict AKI following cardiac surgery one or 2days in advance.

Low cardiac output syndrome in the postoperative period of cardiac surgery. Profile, differences in clinical course and prognosis. The ESBAGA study

OBJECTIVES

An analysis is made of the clinical profile, evolution and differences in morbidity and mortality of low cardiac output syndrome (LCOS) in the postoperative period of cardiac surgery, according to the 3 diagnostic subgroups defined by the SEMICYUC Consensus 2012.

DESIGN

A multicenter, prospective cohort study was carried out.

SETTING

ICUs of Spanish hospitals with cardiac surgery.

PATIENTS

A consecutive sample of 2,070 cardiac surgery patients was included, with the analysis of 137 patients with LCOS.

INTERVENTIONS

No intervention was carried out.

RESULTS

The mean patient age was 68.3±9.3 years (65.2% males), with a EuroSCORE II of 9.99±13. NYHA functional class III-IV (52.9%), left ventricular ejection fraction<35% (33.6%), AMI (31.9%), severe PHT (21.7%), critical preoperative condition (18.8%), prior cardiac surgery (18.1%), PTCA/stent placement (16.7%). According to subgroups, 46 patients fulfilled hemodynamic criteria of LCOS (group A), 50 clinical criteria (group B), and the rest (n=41) presented cardiogenic shock (group C). Significant differences were observed over the evolutive course between the subgroups in terms of time subjected to mechanical ventilation (114.4, 135.4 and 180.3min in groups A, B and C, respectively; P<.001), renal replacement requirements (11.4, 14.6 and 36.6%; P=.007), multiorgan failure (16.7, 13 and 47.5%), and mortality (13.6, 12.5 and 35.9%; P=.01). The mean maximum lactate concentration was higher in cardiogenic shock patients (P=.002).

CONCLUSIONS

The clinical evolution of these patients leads to high morbidity and mortality. We found differences between the subgroups in terms of the postoperative clinical course and mortality.

[Anemia in candidates for heart surgery]

Heart surgery patients have a high prevalence of anemia. Its etiology is multifactorial, and iron deficiency is one of the most common correctable causes. Anemia is an independent risk factor for postsurgical morbidity and mortality. It also predisposes patients to a greater need for transfusions, which increases the associated complications and the use of resources. The etiological diagnosis of anemia is no different from that of other surgical procedures, but the time available for correcting it before surgery is shorter. Studies have been conducted on therapeutic regimens with iron deficiency replenishment with total dose and erythropoiesis-stimulating agents, which enable the rapid correction of anemia and reduce transfusion requirements. There is considerable variability in terms of dosage, adverse effects, administration time and routes, drug combinations and results. New studies are needed to investigate the most ideal regimens for correcting anemia in these patients.

Effects of hypertonic saline vs normal saline on lactate clearance after cardiovascular surgery

BACKGROUND

The postoperative care of patients subjected to cardiac surgery frequently require a complete recovery with intravenous fluids, but crystalloid solutions like normal saline may increase the interstitial oedema, and it is also well known that fluid overload increases mortality.

OBJECTIVE

To compare the effect of 7.5% hypertonic saline (HS) with 0.9% normal saline (NS) on lactate clearance, as well as the haemodynamic response of patients during the first day after cardiovascular bypass surgery.

METHODS

The study included patients 18 years of age and older with coronary artery disease and/or heart valve disease, and who underwent bypass surgery and/or cardiac valve replacement and were randomly assigned to receive 4mL/kg of HS or NS intravenously for 30min once they were admitted to the ICU. Lactate, arterial blood gases, heart rate, central venous pressure, and pulmonary wedge pressure were measured at 0, 6, 12, and 24h after being admitted to the ICU. The analyses were carried out with an intention-to-treat principle.

RESULTS

Out of a total of 494 patients evaluated, 102 were included and assigned to the HS groups (51 patients) or NS (51 patients). The mean age of the participants was 59±14 years, and 59.8% were male. No statistically significant differences were observed between two groups in the lactate clearance, or in any of the secondary outcomes.

CONCLUSIONS

Our study failed to show a better lactate clearance in the group on hypertonic saline, and with no evidence of a higher incidence of adverse effects in that group.

Microcirculatory changes during cardiac surgery with cardiopulmonary bypass

OBJECTIVE

To evaluate microcirculation in intermediate and high mortality risk patients undergoing cardiac surgery (CS) with cardiopulmonary bypass (CPB).

PATIENTS AND METHODS

The study included 22 patients with a Euroscore >3. Using the Videomicroscopy Side Stream Dark Field system, and evaluation was made of, capillary density, proportion of perfused capillaries, density of perfused capillaries, microcirculatory flow index (MFI), and heterogeneity flow index. Three to five video sequences were recorded: after induction of anaesthesia (T1), at the beginning of the CPB (T2), before finalising CPB (T3), at the end of the surgery, and before the patient was transferred to Intensive Care Unit (T4). Mean arterial pressure decreased, while the blood lactate increased significantly, when comparing the initial and final values (P<.05). MFI increased significantly in T3 and T4 (P<.05) with regards to the initial values. When the patients with and without postoperative complications were compared, significant differences were found in, Euroscore, left ventricular ejection fraction, and MFI in T3.

CONCLUSIONS

in patients with intermediate/high preoperative risk, CS and CBP can involve an increase in MFI and blood lactate at the end of the study. These alterations suggest the possibility of a functional microcirculatory shunt at tissue perfusion level, secondary to the surgical injury and the CPB. Further investigation is needed to have a better understanding of the mechanisms involved.

[Hydatidosis simulating a cardiac tumour with pulmonary metastases]

BACKGROUND

The presence of multiple symptomatic pulmonary nodules and one cardiac tumour in a child requires urgent diagnosis and treatment. Until a few decades ago, the diagnosis of a cardiac tumour was difficult and was based on a high index of suspicion from indirect signs, and required angiocardiography for confirmation. Echocardiography and other imaging techniques have also helped in the detection of cardiac neoplasms. However, it is not always easy to make the correct diagnosis.

CLINICAL CASE

The case is presented of a 12 year-old boy with pulmonary symptoms, and diagnosed with a cardiac tumour with lung metastases. The presence of numerous pulmonary nodules was confirmed in our hospital. The echocardiogram detected a solid cardiac nodule in the right ventricle. Magnetic resonance imaging confirmed the findings and the diagnosis. Puncture-aspiration of a lung nodule gave the diagnosis of hydatidosis. He underwent open-heart surgery with cardiac cyst resection and treated with anthelmintics. The lung cysts were then excised, and he recovered uneventfully.

DISCUSSION

This child had multiple pulmonary nodules and a solid cardiac nodule, and was suspected of having a cardiac tumour with pulmonary metastases. However, given the clinical history, background and morphology of pulmonary nodules, another possible aetiology for consideration is echinococcosis. The clinical picture of cardiac hydatidosis and its complications is highly variable. The clinical history is essential in these cases, as well as having a high index of suspicion.

CONCLUSION

Hydatidosis should be included in the differential diagnosis of a solid, echogenic, cardiac nodule. The treatment for cardiopulmonary hydatid cysts is surgical, followed by anthelmintics.

Prognostic indicators after cardiac surgery in children and their relationship with the oxidative stress response

OBJECTIVES

To analyse the trend in lipid peroxidation and antioxidant response as key markers of oxidative stress after paediatric cardiovascular surgery, and compare them with other internationally accepted clinical prognostic indicators.

PATIENTS AND METHODS

A prospective study was conducted on 30 children aged one month to 14 years, weight>5 kg, undergoing cardiopulmonary bypass surgery. Blood samples were taken just before the intervention, immediately after surgery, and after 18-20 h. Cell membrane lipid peroxidation was analysed by quantifying malondialdehyde, as well as measuring total glutathione (oxidized and reduced), as representatives of antioxidant response. An analysis was also performed on clinical variables for establishing a score for the systemic inflammatory response syndrome associated with cardiopulmonary bypass.

RESULTS

The study included 30 children with a mean age of 4.1 years old (interquartile range [IQR]: 2.7; 8.0). Of these, 62.1% were girls. The standard deviation of the median weight was -0.39 (IQR: -0.76; 0.24), the median height was -0.22 (IQR: -0.74; 0.27), and the median BMI was -0.43 (IQR: -1; 0.45). The final surgery times were divided into 2 parts: total time of extracorporeal circulation, with a mean of 79 min (IQR: 52.5; 125.5), and the clamping time, a measurement included in the previous figure with a mean value of 38.5 min (IQR: 22; 59). Malondialdehyde increased and glutathione decreased in postoperative time, with clear, statistically significant direct correlation between time of extracorporeal circulation and percentage decrease in total glutathione between preoperative and immediate postoperative time, and a decline between the preoperative and late postoperative. There was a statistical correlation between total glutathione levels at 18-20 h postoperatively and the duration of mechanical ventilation and inflammatory systemic response syndrome.

CONCLUSIONS

Surgery with extracorporeal circulation performed in children activates inflammatory mediators, being maximum after aortic clamping, and improving after the first 24h. The level of oxidative stress activation depends on surgical times. The development of systemic inflammatory response syndrome is associated with longer duration of mechanical ventilation, longer stay in intensive care, higher scores in the Aristotle model and longer surgical times. Those who do not meet criteria for inflammatory response have higher levels of glutathione in first 24h.

[Effect of autologous platelet-rich plasma on heart infarction in sheep]

OBJECTIVE

Myocardial infarction is the most common cause of congestive heart failure. The objective of this work is to evaluate, in experimental animals, morphological and histological effects of the implantation of autologous platelet-rich plasma in infarcted heart sheep.

METHODS

Twenty-four ewes were used, they were surgically infarcted through left thoracotomy and two coronary arteries were ligated (first and second diagonal). After coronary artery ligation three sheep died of ventricular fibrillation. Three weeks after coronary ligation, sheep were reoperated through median sternotomy. Normal saline solution was injected in the infarcted zone in 6 of them (control group) whereas platelet gel was injected in 15 of them. All sheep were euthanized at 9 weeks of evolution of the second surgery.

RESULTS

Noteworthy is the formation of new vessels in hematoxylin-eosin-stained sections and factor viii in plasma rich in growth-factors (PRGF)-treated hearts.

CONCLUSIONS

Injection of platelet growth factors, PRGF, in previously infarcted sheep hearts promotes mitogenesis and angiogenesis. The use of autologous PRGF is simple and safe, causing no toxicity or immune-inflammatory reactions.

[Risk factors for surgery of congenital heart disease in adults: twenty-two years of experience. Who should operate them?]

OBJECTIVE

To assess the association between mortality in surgery of congenital heart disease in adults, and factors related to patients and operations.

METHOD

Descriptive study of operations performed by specialized surgeons in congenital heart surgery (238), adult acquired surgery (117), and specialty residents (108). The association of mortality with surgical risk and complexity, specialization of surgeon, cardiopulmonary by-pass and aortic cross clamping was assessed fitting logistic regression models.

RESULTS

A total of 463 operations were included (442 with cardiopulmonary by-pass) in the study performed between 1991 and 2012. Median age at surgery: 34; 52.8% were women. First surgery: 295, reoperation: 168. Median score of Aristotle was 6.8, with significantly higher complexity since 2001, after restructuring the Unit. Overall hospital mortality was 3.9%. Mortality was significantly associated to number of previous surgeries (OR: 5.02; 95%CI: 1.44-17.52), operations by acquired heart disease surgeons (OR: 3.53; 95%CI: 1.14-10.98), higher Aristotle (OR: 1,64; 95%CI: 1.18-2.29), and high cardiopulmonary by-pass time (OR: 1.13; 95%CI: 1.07-1.19).

CONCLUSIONS

Surgery of congenital heart disease in adults has been performed with low mortality. High complexity interventions, prolonged cardiopulmonary by-pass times and multiple reoperations were associated to higher mortality. Participation of cardiac surgeons specialized in congenital heart disease is associated with better outcomes.

[Evaluation of non-invasive hemoglobin measurements using the Masimo Rainbow Radical-7® device in a patient with extracorporeal membrane oxygenation]

Circulatory assist devices such as extracorporeal membrane oxygenation are indicated in cases of cardiogenic shock refractory to optimal conventional treatment. Bleeding is a serious complication of such systems, mainly due to coagulation disorders caused by continuous administration of heparin, as well as platelet dysfunction. Serial coagulation and hemoglobin (Hb) measurements are essential. Hb measurements can be performed through repeated arterial blood gasometry, and more recently with a new spectrophotometric sensor, Masimo Rainbow Radical-7® device, which gives Hb values continuously and non-invasively. We report a case of a patient undergoing cardiac surgery who required extracorporeal membrane oxygenation for severe cardiogenic shock immediately after surgery. We compare the correlation and the level of agreement with Hb levels measured by 2 existing systems in clinical practice. Our results indicate that the Masimo® spectrophotometric monitor showed statistically comparable Hb values, in the correlation (r=.85; P<.01) and in agreement with those obtained by serial blood gas analyzer, ABL800 FLEX® (wavelength). In view of these results we consider the Masimo® device as a valid alternative for the continuous follow-up of the Hb and control of bleeding in these patients.

[The changes in the oxygen saturations in the superior vena cava and the pulmonary artery are not the same during cardiac surgery]

OBJECTIVE

To evaluate the changes over time (trend) in sign and magnitude for SSVO2 and SVO2 during and after cardiac surgery.

PATIENTS AND METHODS

A prospective and observational study was conducted on 34 cardiac surgery patients. Venous blood samples were taken simultaneously from the introductor (SVCO2) and distal (SVO2) port of the pulmonary artery catheter at predefined intervals. Systemic and pulmonary hemodynamic variables were measured at the same time. The trend was calculated as the difference between 2 consecutive measurements (tSO2). Data were processed with ANOVA for multiple comparisons, Pearson correlation coefficient and Bland-Altman analysis.

RESULTS

There was a significant correlation between SVCO2 and tSVO2 (R(2)=0.55), the mean of the differences was 0.36±7.75%, and the limits of agreement ranged from -15.1 to 15.9%. The sign of the trend was similar in 85.1% of the paired data. However, the magnitude of the changes in tSVCO2 and tSVO2 were not always equivalent. Between 0 and 5% of the change in the tSVCO2 was coincident with only 44.7% of the tSVO2. A wide variation was found between both trends when the signs and magnitudes of the changes were taken into account.

CONCLUSIONS

When considering the sign and magnitude, the change over time of central venous O2 saturations were not interchangeable in cardiac surgery patients. Clinical decisions based exclusively on tSVCO2 monitoring should be taken with caution.

[Iliac aneurysm rupture during preconditioning with levosimendan for coronary artery bypass graft]

We present the case of a 77 year-old patient scheduled for coronary artery bypass. During the infusion of levosimendan as preconditioning for surgery, a rupture of right common iliac artery occurred. Surgery was delayed and an urgent aorto-bifemoral bypass was performed. We believe that the rupture of the artery was triggered by an increase in transmural pressure due to the inotropic effects of levosimendan in a dilated diseased vessel. To our knowledge, there are no cases of aneurysm rupture as a complication during levosimendan infusion, but the coincidence of events in time strongly suggests some kind of causal relationship.

[Anaestheia for valve replacement in the second trimester of pregnancy]

Cardiac surgery in the pregnant woman gives rise to several anesthetic challenges, as the mother, but mainly the fetus, have a risk of high morbidity and mortality. In this context, the cardiopulmonary bypass is the most complex period, owing to the risks of fetal hypoxia it entails. Due to the absence, for ethical reasons, of prospective trials that provide generally accepted guidelines in intraoperative management, it means that physicians have to work based on case reports in the literature. These procedures also require team coordination to be successful. The case is presented of a 19 weeks pregnant woman, who required a mitral valve replacement, which was achieved with success, and enabled her to complete her pregnancy without complications. Details are provided on the published references on which our management was based.

[Nitrid oxide, levosimendan and sildenafile in a patient with right ventricle dysfunction and severe pulmonary hypertension after cardiac surgery]

Pulmonary hypertension (PHT) and the resulting right ventricle dysfunction are important risk factors in patients who undergo cardiac surgery. The treatment of PHT and right ventricle dysfunction should be focused on maintaining the correct right ventricle after load, improving right ventricle function and reducing the right ventricle pre-load and therefore reducing pulmonary vascular resistance by means of vasodilators. A combined therapy of vasodilators and medicines which have different mechanisms of action, is becoming an option for the treatment of PHT. We present a 65 year old woman that suffered from mitral regurgitation, aortic valve disease, tricuspid and ascending aortic dilation with 115mmHg of pulmonary artery pressure (by ultrasound evaluation). The patient was operated on of mitral, aortic valve and tricuspid plastia and proximal aortic artery plastia as well. Previosly to surgery the patient suffered right ventricle dysfunction and PHT and was treated with nitric oxide, intravenous sildenafil and levosimendan. Subsequent evolution was satisfactory, PHT being controlled, without arterial hypotension nor respiratory alterations.

[Neurological disorders after cardiac surgery: Diagnosis of cerebral tumors in the postoperative period]

The incidence of neurologic disorders in the postoperative period of cardiac surgery is high and usually due to a combination of pre- and intraoperative factors. We present 2 patients with brain tumors diagnosed in the immediate postoperative period after sudden onset of neurologic dysfunction. Image studies yielded clinically useful information in these 2 cases.

[High risk infective endocarditis embolism during pregnancy: Medical or surgical management?]

A 22-year-old pregnant woman was seen at 14 weeks of pregnancy for infective endocarditis with a vegetation of 15 mm and wide mobility, which affected the native mitral valve accompanied by severe valvular insufficiency. Antibiotic treatment was given for 4 weeks despite the embolism risk. Due to persistence of vegetation size and after considering the fetal and maternal risk, the surgical procedure was favored. We decided to perform valvuloplasty and removal of lesion at 18 weeks of pregnancy. Fetal protection techniques were used and a bioprosthesis was placed before attempting a repair. The postoperative follow-up was satisfactory, achieving a successful birth by cesarean section at 30 weeks.

[Regional cerebral oxygen saturation as a marker of hemodynamic state following cardiac surgery]

INTRODUCTION

Regional cerebral oxygen saturation (rSO₂) is a measure of the general state of perfusion and oxygenation. We aim to analyze the relationship between this and various hemodynamic and respiratory parameters.

PATIENTS AND METHODS

Forty-three patients, operated on between October 2011 and July 2012, were included in this prospective observational descriptive study. The following parameters were measured: mean arterial pressure, both arterial and central venous oxygen saturation and partial pressures of oxygen and carbon dioxide, and lactate levels. From these parameters, the oxygenation index and the oxygen extraction ratio were calculated. These measurements were studied to evaluate whether rSO₂ correlated significantly with the other parameters.

RESULTS

The average age and weight of the patients were 27.3 months and 9.2 kg, respectively. The rSO₂ correlated positively with both central venous oxygen saturation (r=0.73, P<.01) and mean arterial pressure (r=0.59, P<.01), and negatively with the oxygen extraction ratio (r=-0.7, P<.01). No correlation was found with the respiratory parameters. Concordance analysis established an acceptable Kappa index (> 0.4) between the rSO₂ and central venous oxygen saturation, and between the rSO₂ and oxygen extraction ratio.

CONCLUSIONS

Regional cerebral oxygen saturation correlates well with hemodynamic parameters - mean arterial pressure, venous saturation, and the tissue oxygen extraction. However, it does not correlate with respiratory parameters.