Giuseppe Crescenzi

Renoprotective action of fenoldopam in high-risk patients undergoing cardiac surgery: A prospective, double-blind, randomized clinical trial

Background—Acute renal failure is a serious complication of cardiac surgery causing high morbidity and mortality. The aim of this study was to evaluate the usefulness of fenoldopam, a specific agonist of the dopamine-1 receptor, in patients at high risk of perioperative renal dysfunction. Methods and Results—A prospective single-center, randomized, double-blind trial was performed after local ethical committee approval and after written consent was obtained from 80 patients undergoing cardiac surgery. Patients received either fenoldopam at 0.05 &mgr;g/kg per minute or dopamine at 2.5 &mgr;g/kg per minute after the induction of anesthesia for a 24-hour period. All these patients were at high risk of perioperative renal dysfunction as indicated by Continuous Improvement in Cardiac Surgery Program score >10. Primary end point was defined as 25% creatinine increase from baseline levels after cardiac surgery. The 2 groups (fenoldopam versus dopamine) were homogeneous cohorts, and no difference in outcome was observed. Acute renal failure was similar: 17 of 40 (42.5%) in the fenoldopam group and 16 of 40 (40%) in the dopamine group (P=0.9). Peak postoperative serum creatinine level, intensive care unit and hospital stay, and mortality were also similar in the 2 groups. Conclusions—Despite an increasing number of reports of renal protective properties from fenoldopam, we observed no difference in the clinical outcome compared with dopamine in a high-risk population undergoing cardiac surgery.

Morbidity, mortality, and quality of life after circumferential pulmonary vein ablation for atrial fibrillation ☆

Objectives This study was designed to investigate the potential of circumferential pulmonary vein (PV) ablation for atrial fibrillation (AF) to maintain sinus rhythm (SR) over time, thus reducing mortality and morbidity while enhancing quality of life (QoL). Background Circumferential PV ablation is safe and effective, but the long-term outcomes and its impact on QoL have not been assessed or compared with those for medical therapy. Methods We examined the clinical course of 1,171 consecutive patients with symptomatic AF who were referred to us between January 1998 and March 2001. The 589 ablated patients were compared with the 582 who received antiarrhythmic medications for SR control. The QoL of 109 ablated and 102 medically treated patients was measured with the SF-36 survey. Results Median follow-up was 900 days (range 161 to 1,508 days). Kaplan-Meier analysis showed observed survival for ablated patients was longer than among patients treated medically (p < 0.001), and not different from that expected for healthy persons of the same gender and calendar year of birth (p = 0.55). Cox proportional-hazards model revealed in the ablation group hazard ratios of 0.46 (95% confidence interval [CI], 0.31 to 0.68; p < 0.001) for all-cause mortality, of 0.45 (95% CI, 0.31 to 0.64; p < 0.001) for morbidities mainly due to heart failure and ischemic cerebrovascular events, and of 0.30 (95% CI, 0.24 to 0.37; p < 0.001) for AF recurrence. Ablated patients’ QoL, different from patients treated medically, reached normative levels at six months and remained unchanged at one year. Conclusions Pulmonary vein ablation improves mortality, morbidity, and QoL as compared with medical therapy. Our findings pave the way for randomized trials to prospect a wider application of ablation therapy for AF.

Desmopressin reduces transfusion needs after surgery: a meta-analysis of randomized clinical trials.

Background:Perioperative pathologic microvascular bleeding is associated with increased morbidity and mortality and could be reduced by hemostatic drugs. At the same time, safety concerns regarding existing hemostatic agents include excess mortality. Numerous trials investigating desmopressin have lacked power to detect a beneficial effect on transfusion of blood products. The authors performed a meta-analysis of 38 randomized, placebo-controlled trials (2,488 patients) investigating desmopressin in surgery and indicating at least perioperative blood loss or transfusion of blood products. Methods:Pertinent studies were searched in BioMed Central, CENTRAL, and PubMed (updated May 1, 2008). Further hand or computerized searches involved recent (2003–2008) conference proceedings. Results:In most of the included studies, 0.3 &mgr;g/kg desmopressin was used prophylactically over a 15- to 30-min period. In comparison with placebo, desmopressin was associated with reduced requirements of blood product transfusion (standardized mean difference = −0.29 [−0.52 to −0.06] units per patient; P = 0.01), which were more pronounced in the subgroup of noncardiac surgery and were without a statistically significant increase in thromboembolic adverse events (57/1,002 = 5.7% in the desmopressin group vs. 45/979 = 4.6% in the placebo group; P = 0.3). Conclusions:Desmopressin slightly reduced blood loss (almost 80 ml per patient) and transfusion requirements (almost 0.3 units per patient) in surgical patients, without reduction in the proportion of patients who received transfusions. This meta-analysis suggests the importance of further large, randomized controlled studies using desmopressin in patients with or at risk of perioperative pathologic microvascular bleeding.

Management and decision-making strategy for systolic anterior motion after mitral valve repair

OBJECTIVE Systolic anterior motion can complicate mitral valve repair. It can have no clinical consequence or cause low cardiac output syndrome and hypotension. The management of systolic anterior motion in the operating room remains controversial: some groups advocate nonsurgical management, and others propose immediate surgical correction. Conventional hemodynamic measures require time and can be unsuccessful. While describing our experience, we propose a simple and innovative management and classification of this complication. METHODS Presenting the data of 608 consecutive patients who underwent mitral valve repair for degenerative mitral valve disease, we describe a novel 2-step conservative management consisting of intravascular volume expansion and discontinuation of inotropic drug (step 1) and increasing afterload by means of ascending aortic manual compression while administering beta-blockers (step 2). We also describe a novel classification of systolic anterior motion: easy to revert (responding to step 1), difficult to revert (responding to step 2), or persistent. RESULTS The overall incidence of systolic anterior motion was 9.8% (60/608): 40 patients had easy-to-revert systolic anterior motion, and 15 had difficult-to-revert systolic anterior motion. Five patients had a persistent condition and underwent surgical intervention within 48 hours. CONCLUSIONS Systolic anterior motion after repair of a degenerative mitral valve is common. Surgical revision in the minority of patients unresponsive to standard conservative management is suggested.

Vacuum-assisted venous drainage in extrathoracic cardiopulmonary bypass management during minimally invasive cardiac surgery.

The diffusion of minimally invasive cardiac surgery (MICS) during open-heart surgery has increased the use of assisted venous drainage support for cardiopulmonary bypass (CPB). Peripheral cannulation with small cannulae and vacuum-assisted venous drainage (VAVD) during MICS has been adopted in our institution since 1998. After the Heartport technique (HP) experience, the trans-thoracic clamp technique is now currently used. The aim of this study is to report our experience with extrathoracic CPB with VAVD application (on CPB) during open-heart MICS. From October 1999 to June 2006, 193 patients underwent MICS. Thirty-seven (19.2%) patients were treated with the HP - 13 (35%) with robotic technology and 156 (80.8%) with trans-thoracic aortic clamping (TTAC). Mean age was 39 years (range: 12-77), and 114 patients (59.1%) were female. A total of 128 patients (66.3%) underwent mitral valve surgery, 57 (29.6%) atrial septal defect closure, five (2.6%) cardiac mass removal, and three (1.5%) tricuspid valve repair. Four patients (2.0%) had a previous cardiac procedure. Peripheral CPB was established with a standard coated circuit. A 14 Fr arterial cannula was inserted into the right jugular vein and positioned at the atrial/superior vena cava junction. A 21 or 28 percutaneous femoral cannula, depending on body surface area, was inserted in the femoral vein and an arterial cannula in the right femoral artery. Gravitational drainage was combined with VAVD. To improve the safety and effectiveness of this technique, we monitored the pressure on each venous cannula and in the reservoir. The mean CPB time was 74.8∓30 min (TTAC) and 119∓48 min (HP); mean aortic clamping time was 51∓19 min (TTAC) and 73∓29 min (HP). We did not record any neurological complication. Two patients (1.0%), one from each group, were converted to sternotomy. Three patients (1.5%) underwent re-exploration for bleeding. In-hospital mortality was 0.5% (N = 1) (HP). Mechanical ventilation time and intensive care unit stay were comparable to those recorded with conventional sternotomy. In conclusion, we found that extrathoracic CPB and VAVD during trans-thoracic clamping is a safe, simple, and effective technique for MICS. However, there is a potential risk of haemolysis and air embolism, which can be prevented with vacuum monitoring, and with the addition of gravitational drainage to reduce vacuum pressure.

N-Terminal B-Natriuretic Peptide After Coronary Artery Bypass Graft Surgery

OBJECTIVE To investigate N-terminal amino-acid sequence of the B-natriuretic peptide (NT-proBNP) release and its prognostic characteristics after coronary artery bypass graft surgery with and without cardiopulmonary bypass. DESIGN Observational study. SETTING Teaching hospital. PARTICIPANTS One hundred eighty-four patients. INTERVENTIONS The authors determined plasma concentrations of NT-proBNP just before anesthesia induction and 24 hours after the end of the surgery. MEASUREMENTS AND MAIN RESULTS NT-proBNP concentrations (median [interquartile range]) increased from 270 (75-716) pg/mL preoperatively to 1,664 (978-3,193) pg/mL on postoperative day 1 (p < 0.001), and all postoperative values were higher than the preoperative ones. NT-proBNP concentrations at day 1 were correlated to those at day 0 (r(2) = 0.34, p < 0.001). Patients showing elevated concentration of cTnI at day 1 (>14 ng/mL) had significantly (p = 0.04) higher plasma NT-proBNP levels than patients with a low cardiac troponin I concentration. Patients with prolonged intensive care unit (ICU) stay (>4 days) showed at day 1 significantly higher (p = 0.003) plasma NT-proBNP levels than patients with ICU stay <4 days. Elevated NT-proBNP at day 1 was significantly (p = 0.001) associated with in-hospital mortality, 18,584 (11,896-29,158) pg/mL versus 1,597 (965-3,034) pg/mL in survivors. CONCLUSIONS The present results show, for the first time, that postoperative NT-proBNP levels are associated with in-hospital mortality and prolonged ICU stay after CABG surgery. These findings support the prognostic value of postoperative plasma levels of NT-proBNP.

Role of cardiac biomarkers (troponin I and CK-MB) as predictors of quality of life and long-term outcome after cardiac surgery

Perioperative and postoperative morbidity and mortality associated with cardiac surgery affect both the outcome and quality of life. Markers such as troponin effectively predict short-term outcome. In a prospective cohort study in a University Hospital we assessed the role of cardiac biomarkers, also as predictors of long-term outcome and life quality after cardiac surgery with a three-year follow-up after conventional heart surgery. Patients were interviewed via phone calls with a structured questionnaire examining general health, functional status, activities of daily living, perception of life quality and need for hospital readmission. Descriptive statistics and multivariate analysis were performed. Out of 252 consecutive patients, 8 (3.2%) died at the three years follow up: 7 for cardiac complications and 1 for cancer. Thirty-six patients (13.5%) had hospital readmission for cardiac causes (mostly for atrial fibrillation or other arrhythmias (9.3%), but none needed cardiac surgical reintervention; 21 patients (7.9%) were hospitalised for non-cardiac causes. No limitation in function activities of daily living was reported by most patients (94%), 92% perceived their general health as excellent, very good or good and none considered it insufficient; 80% were NYHA I, 17% NYHA II, 3% NYHA III and none NYHA IV. Multivariate analysis indicated preoperative treatment with digitalis or nitrates, and postoperative cardiac biomarkers release was independently associated to death. Elevated cardiac biomarker release and length of hospital stay were the only postoperative independent predictors of death in this study.

Epidural Anesthesia in Elderly Patients Undergoing Coronary Artery Bypass Graft Surgery

OBJECTIVES The purpose of this study was to evaluate the effects of thoracic epidural anesthesia on postoperative N-terminal pro B-natriuretic peptide (NT-proBNP) release in elderly patients undergoing elective coronary artery bypass graft (CABG) surgery. DESIGN A case-matched, nonrandomized study. SETTING A university hospital, single institution. PARTICIPANTS 46 consecutive and 46 control patients. INTERVENTIONS Ninety-two elderly patients (>65 years old) undergoing elective CABG surgery were recruited. Forty-six patients receiving general and epidural anesthesia were case matched (preoperative medications, ejection fraction, and comorbidities) with 46 control subjects receiving general anesthesia. The primary outcome measure was postoperative NT-proBNP release. The preoperative or intraoperative variables significantly associated with an intensive care unit stay longer than 4 days were determined by logistic regression. MEASUREMENTS AND MAIN RESULTS The median (interquartile range) plasma concentrations of NT-proBNP before surgery were 402 (115-887 pg/mL) in the epidural group versus 508 (228-1,285 pg/mL) in the general anesthesia group (p = 0.9), whereas 24 hours after surgery it increased to 1846 (1,135-3,687 pg/mL) versus 5,005 (2,220-11,377 pg/mL) (p = 0.001), respectively. There were more patients (p = 0.043) in the control group (9/46 = 19.5%) than in the thoracic epidural anesthesia group (4/46 = 8.8%) with an intensive care unit stay longer than 4 days. The absence of preoperative beta-blocker therapy (odds ratio = 3.94; 95% confidence interval, 1.123-13.833; p =0.03) and of an epidural catheter (odds ratio = 3.91; 95% confidence interval, 1.068-14.619; p = 0.04) were the only preoperative and intraoperative variables independently associated with a prolonged intensive care unit stay. CONCLUSIONS Epidural anesthesia added to general anesthesia for CABG surgery significantly attenuates NT-proBNP release in elderly patients and reduces the incidence of prolonged intensive care unit stay.

Reduction of hemodilution in small adults undergoing open heart surgery: a prospective, randomized trial

Background. Given that there is an association between the degree of hemodilution during cardiopulmonary bypass (CPB) and postoperative complications, patients-outcome might be improved if the nadir hematocrit concentration is kept within an optimal range. Smaller patients are more likely to have a low hematocrit during CPB: this phenomenon may be related, at least partially, to the extreme hemodilution induced by a large fixed CPB priming volume. Methods. Forty patients with a body surface area (BSA) < 1.7 m2 undergoing open heart operations were randomized to either standard CPB with full prime volume (control group) or reduced prime extracorporeal circuit and vacuum-assisted venous drainage (VAVD) (study group). Results. There were no significant differences between the groups with respect to baseline characteristics, body surface area, hematologic profile and operative data. Clinical outcomes were similar. Nadir hematocrit and hemoglobin on bypass were significantly lower in the control group (22 ± 2.3 vs 24 ± 2.5%, p < 0.02 and 7.4 ± 0.7 vs 8 ± 0.9g/dl, p < 0.04, respectively). Postoperative chest tube drainage was significantly higher in the control group (272 ± 253vs 139 ± 84ml, p < 0.04). There was no difference in blood transfusion in the two groups (0.5 ± 1.14 v 1.0 ± 1.77 units of packed red blood cells (PRBC), p = 0.29). Conclusions. Lowering CPB priming volume by means of using a small oxygenator and vacuum-assisted venous drainage (VAVD) resulted in a significant decrease of intraoperative hemodilution. This technique should be strongly considered for patients with a small BSA (<1.7 m2) undergoing open heart surgery. Perfusion (2007) 22, 317—322.

Desmopressin after cardiac surgery in bleeding patients. A multicenter randomized trial.

Previous studies showed that desmopressin decreases post‐operative blood loss in patients undergoing cardiac surgery. These studies were small and never studied the effect of desmopressin in patients with active bleeding. Objective of the study was to determine whether desmopressin reduces red blood cells transfusion requirements in patients with active bleeding after cardiac surgery who had been pre‐treated with tranexamic acid.