Galina Leyvi

An investigation of a new activated clotting time "MAX-ACT" in patients undergoing extracorporeal circulation

Activated clotting time (ACT) is a test used in the operating room for monitoring heparin effect. However, ACT does not correlate with heparin levels because of its lack of specificity for heparin and its variability during hypothermia and hemodilution on cardiopulmonary bypass (CPB). A modified ACT using maximal activation of Factor XII, MAX-ACT (Actalyke MAX-ACT; Array Medical, Somerville, NJ), may be less variable and more closely related to heparin levels. We compared MAX-ACT with ACT in 27 patients undergoing CPB. We measured ACT, MAX-ACT, temperature, and hematocrit at six time points: baseline; postheparin; on CPB 30, 60, and 90 min; and postprotamine. Additionally, we assessed anti-Factor Xa heparin activity and antithrombin III activity at four of these six time points. With institution of CPB and hemodilution, MAX-ACT and ACT did not change significantly but had a tendency to increase, whereas concomitant heparin levels decreased (P = 0.065). Neither test correlated with heparin levels. ACT and MAX-ACT did not differ during normothermia but did during hypothermia, and ACT was significantly longer than MAX-ACT (P = 0.009). At the postheparin time point, ACT-heparin sensitivity (defined as [ACT postheparin − ACT baseline]/[heparin concentration postheparin − heparin concentration baseline]) was greater than MAX-ACT-heparin sensitivity (analogous calculation for MAX-ACT; 520 [266 − 9366] s · U−1 · mL−1 vs 468 [203 − 8833] s · U−1 · mL−1;P = 0.022).

Thromboelastograph with platelet mappingTM predicts postoperative chest tube drainage in patients undergoing coronary artery bypass grafting

OBJECTIVE The goal of this study was to evaluate the ability of Thromboelastograph with Platelet Mapping (TEG-PM(TM)) to predict postoperative bleeding tendency in patients with a history of recent anti-platelet therapy undergoing coronary artery bypass grafting (CABG). DESIGN A retrospective analysis. Association between predictor variables (MAADP [maximum amplitude produced by adenosine diphosphate], MAAA [maximum amplitude produced by arachidonic acid], percent of platelets inhibited by clopidogrel, percent of platelets inhibited by aspirin) and the outcomes as elevated chest tube drainage (CTD) and blood transfusion were investigated by logistic regression model. CTD was considered elevated if it was ≥ 600 mL within 12 hours after surgery. SETTING A university hospital. PARTICIPANTS Patients on antiplatelet therapy scheduled to undergo CABG that had TEG-PM(TM) done as a point-of-care test. INTERVENTIONS None. RESULTS A total of 78 patients had preoperative TEG-PM(TM) test and on-pump CABG surgeries performed on the same day. Among them, 20 patients (25.6%) had elevated CTD. Decreased MAADP (odds ratio [OR] 0.94), increased percent inhibition of platelets by clopidogrel (OR 1.03), and lower body mass index (BMI) (OR 0.78) were significantly associated with elevated CTD. The same parameters were also associated with platelets transfusion: MAADP (OR 0.94), percent of inhibition of platelets by clopidogrel (OR 1.03) and BMI (OR 0.77). CONCLUSIONS TEG-PM(TM) parameters and BMI are predictive of elevated CTD and platelets transfusion. A 1 mm decrease in MAADP increases the likelihood of elevated CTD and the likelihood of platelets transfusion by 6% whereas 1 unit decrease in BMI is associated with an increased likelihood of elevated CTD and platelets transfusion by 22% and 23% respectively.

Single-Ventricle Patient: Pathophysiology and Anesthetic Management

e C 1 VARIETY OF pathologic conditions give rise to a singleventricle (SV) physiology. This occurs when one of the entricles is hypoplastic or absent. These patients often require series of procedures to provide effective palliation. Surgical herapy commits the single ventricle to the delivery of oxygented blood to the systemic circulation. Deoxygenated blood is irected to the pulmonary circulation bypassing the ventricle. ith improved surgical techniques and medical care, SV paients are living longer. However, over time, they can present ith a number of comorbidities related to SV physiology. dditionally, many SV patients appear in need of anesthesia for outine general and obstetric procedures. Anesthesiologists, eneralists, and subspecialists alike increasingly may encounter he patient with SV physiology. This review highlights the natomy and physiology of the SV patient before, during, and fter surgical palliation. Anesthetic challenges presented by the V patient are reviewed.

A comparison of the effect of aprotinin and ε-aminocaproic acid on renal function in children undergoing cardiac surgery

OBJECTIVE To assess the incidence of renal injury among pediatric patients who received aprotinin while undergoing cardiac surgery compared with those who received ε-aminocaproic acid (EACA). DESIGN A retrospective observational study. SETTING A single academic center. PARTICIPANTS Pediatric cardiac patients who had cardiopulmonary bypass and received aprotinin or EACA. INTERVENTION Patients undergoing pediatric cardiac surgery received aprotinin from 2005 to 2007 and EACA from 2008 to 2009. MEASUREMENTS AND MAIN RESULTS The primary outcome was acute kidney injury (AKI) defined as serum Cr elevation at discharge more than 1.5 times the baseline value. Secondary outcomes included bleeding, blood transfusion, and the volume of chest tube drainage in the first 24 hours postoperatively. One hundred seventy-eight patients met inclusion criteria; 120 patients received aprotinin, and 58 patients received EACA. These 2 groups did not differ significantly in age, weight, or duration of cardiac bypass. Logistic regression analysis, adjusted for confounding variables (ie, baseline Cr, sex, age, CPB time, inotropic support and vasopressors), showed a higher odds of suffering AKI at discharge with the usage of aprotinin (odds ratio = 4.7; 95% confidence interval, 1.1-19.5; p = 0.03). The volume of the first 24 hours of chest tube drainage was not significantly different between groups, as well as packed red blood cells and cryoprecipitate units. However, fresh frozen plasma and platelets showed statistically significant differences with more transfusion in the EACA group. CONCLUSION In this retrospective study, the authors observed a higher odds of AKI for aprotinin usage compared with EACA, suggesting that the known concern for adults with adverse kidney effects with aprotinin is also appropriate for pediatric patients.

Comparison of Index Hospitalization Costs Between Robotic CABG and Conventional CABG: Implications for Hybrid Coronary Revascularization

OBJECTIVES To compare the direct costs of the index hospitalization and 30-day morbidity and mortality incurred during robotic and conventional coronary artery bypass grafting at a single institution based on hospital clinical and financial records. DESIGN Retrospective study, propensity-matched groups with one-to-one nearest neighbor matching. SETTING University hospital, a tertiary care center. PARTICIPANTS Two thousand eighty-eight consecutive patients who underwent primary coronary artery bypass grafting (CABG) from January 2007 to March 2012. INTERVENTIONS One hundred forty-one matched pairs were created and analyzed. MEASUREMENTS AND MAIN RESULTS Robotic CABG was associated with a decrease in operative time (5.61±1.1 v 6.6±1.15 hours, p<0.001), a lower need for blood transfusion (12.8% v 22.6%, p = 0.04), a shorter length of stay (6 [4-9]) v 7 [5-11] days, p = 0.001), a shorter ICU stay (31 [24-49] hours v 52 [32-96.5] hours, p<0.001) and lower NY state complications composite rate (4.26% v 13.48%, p = 0.01). In spite of that, the cost of robotic procedures was not significantly different from matched conventional cases (

Congenitally corrected transposition of the great arteries and concomitant coronary artery and valvular disease in the adult patient.

18,717.35 [11,316.1-34,550.6] versus

Pulmonary Artery Flow Patterns After the Fontan Procedure Are Predictive of Postoperative Complications

18,601 [13,137-50,194.75], p = 0.13), except 26 hybrid coronary revascularizations in which angioplasty was performed on the same admission (hybrid 25,311.1 [18,537.1-41,167.85] versus conventional 18,966.13 [13,337.75-56,021.75], p = 0.02). CONCLUSION Robotically assisted CABG does not increase the cost of the index hospitalization when compared to conventional CABG unless hybrid revascularization is performed on the same admission.

A Comparison of Inflammatory Responses Between Robotically Enhanced Coronary Artery Bypass Grafting and Conventional Coronary Artery Bypass Grafting: Implications for Hybrid Revascularization

Congenitally corrected transposition of the great arteries (ccTGA) accounts for less that 1% of cardiac anomalies, and is defined as ventriculoarterial and atrioventricular (AV) discordance. The double discordant connection allows for survival with the right ventricle performing as the systemic ventricle, and the left ventricle as the pulmonary ventricle. We report a case of ccTGA in a 35-year-old male with situs inversus totalis status post repair of a ventricular septal defect (VSD) with a residual VSD, severe systemic AV valve regurgitation, and coronary artery disease who presented with chest pain. He subsequently underwent tricuspid valve replacement and VSD repair, followed by percutaneous coronary revascularization. This case highlights many important issues of adults with congenital cardiac disease, as well as the specific surgical management of anomalies associated with ccTGA. We review the literature and discuss the management of these complicated patients.

Case 2-2009. Hybrid surgery in a patient with congenitally corrected transposition of the great arteries and situs inversus requiring tricuspid valve replacement and coronary artery revascularization.

OBJECTIVE Pulmonary artery (PA) flow reversal has been associated with poor outcome in patients with atriopulmonary (APC) and total cavopulmonary connection (TCPC) lateral tunnel (LT) Fontan modification. The authors studied PA flow after TCPC in relation to the incidence of early Fontan outcome and complications. DESIGN A prospective observational study. SETTING A university hospital. PARTICIPANTS Pediatric patients undergoing a Fontan procedure. INTERVENTION Nineteen patients were studied. PA flow was measured by pulse-wave Doppler during the surgery after chest closure. Patients were divided into 2 groups according to patterns of PA flow: group 1, positive (biphasic or continuous flow), and group 2, negative (with flow reversal component). The postoperative complications were recorded. MEASUREMENTS AND MAIN RESULTS There were no deaths or reoperations for Fontan takedown. Ten patients had positive and 9 had negative flow. There were no differences between groups regarding age, weight, length of procedure, and cardiopulmonary bypass. The chest tube drainage in patients with negative flow was significantly longer than those in the positive-flow group (8.3 +/- 7.0 days in the negative-flow group v 2.8 +/- 1.7 days in the positive-flow group, p = 0.03). The total number of complications was higher in the negative-flow group compared with the positive-flow group (3.0 +/- 1.3 v 1.2 +/- 0.6, p = 0.003). The differences between groups in terms of pediatric intensive care unit and/or hospital length of stay did not reach statistical significance, possibly because of the low number of patients. CONCLUSION PA flow pattern appears to be predictive of the length of postoperative chest tube drainage and the number of postoperative complications.

Assessment of cerebral oxygen balance during deep hypothermic circulatory arrest by continuous jugular bulb venous saturation and near-infrared spectroscopy.

OBJECTIVE The inflammatory response elicited by robotically enhanced coronary artery bypass grafting (r-CABG) has not been well described. When r-CABG is performed as part of hybrid coronary revascularization, the inflammatory milieu and the timing of percutaneous coronary intervention may affect the stent patency negatively in the short and long term. The goal of this study was to describe the extent and time course of cytokine release after r-CABG compared with conventional CABG (c-CABG) and to elucidate the optimal timing for r-CABG in the setting of hybrid coronary revascularization for a future study. DESIGN Prospective, observational study. SETTING Tertiary-care center in a university hospital. PARTICIPANTS The study comprised patients scheduled to undergo r-CABG or c-CABG from October 2012 to November 2014. INTERVENTIONS Cytokine levels of interleukin (IL)-6, IL-8, IL-10; tumor necrosis factor-α; and C-reactive protein (CRP) were measured at the following time points: preprocedure; at the end of the procedure; and at 4, 8, 12, 24, and 48 hours after the procedure. MEASUREMENTS AND MAIN RESULTS Twenty-eight patients undergoing r-CABG and 10 patients undergoing c-CABG were enrolled. The levels of cytokines after r-CABG and c-CABG were compared using the mixed-effect linear regression model for longitudinal data. Cytokine release in the r-CABG group was comparatively less for IL-6, IL-10, tumor necrosis factor, and CRP levels. They all trended toward the baseline by the 48th hour in both groups, except CRP levels, which reached their peak at 48 hours in both groups. CONCLUSIONS The inflammatory response to r-CABG was blunted compared with that of c-CABG. The high CRP levels on the second postoperative day after r-CABG were a cause for concern in regard to percutaneous coronary intervention performed at that time period, but additional studies are necessary.