Kyriakos Anastasiadis

Neurocognitive outcome after coronary artery bypass surgery using minimal versus conventional extracorporeal circulation: a randomised controlled pilot study

Objective Neurocognitive impairment can be a debilitating complication after cardiac surgery. The aim of this study was to assess the effect of minimal extracorporeal circulation (MECC) versus conventional extracorporeal circulation (CECC) on neurocognitive function after elective coronary artery bypass grafting (CABG) and whether this can be attributed to improved cerebral perfusion intraoperatively. Methods and results 64 patients scheduled for elective CABG surgery were prospectively randomly assigned to surgical revascularisation with MECC versus CECC. All patients were continuously monitored for changes in cerebral oxygenation with near-infrared spectroscopy during the procedure. Neurocognitive assessment was performed before surgery, on the day of discharge and at 3 months postoperatively using a battery of standardised neurocognitive tests. Both groups were comparable in terms of demographic and clinical data. MECC was associated with improved cerebral perfusion during cardiopulmonary bypass (CPB). Eleven patients operated on with MECC and 17 with CECC experienced at least one episode of cerebral desaturation (38% vs 55%, p=0.04) with similar duration (10 vs 12.3 min, p=0.1). At discharge patients operated on with MECC showed a significantly improved performance on complex scanning, visual tracking, focused attention and long-term memory. At 3 months significantly improved performance was also evident on visuospatial perception, executive function, verbal working memory and short-term memory. Patients operated on with MECC experienced a significantly lower risk of early cognitive decline both at discharge (41% vs 65%, p=0.03) and at 3-month evaluation (21% vs 61%, p<0.01). Conclusions Use of MECC attenuates early postoperative neurocognitive impairment after coronary surgery compared with conventional CPB. This finding may have important implications on the surgical management strategy for coronary artery disease. Clinical trial registration number The study is registered at ClinicalTrials.gov, number NCT01213511.

Cardiogenic shock in ACS. Part 2: role of mechanical circulatory support

This Review explores contemporary circulatory support in profound postinfarction cardiogenic shock. Frequently, death is the only alternative to implantation of a blood pump, so prospective randomized trials of device versus medical treatment are unacceptable and evidence is derived from clinical experience. Irrespective of ACC/AHA and European guidelines, no study has shown survival benefit for the intra-aortic balloon pump in patients with established shock. In the past 10 years, the safety and durability of mechanical blood pumps has improved considerably. New temporary and long-term rotary pumps have transformed outcomes for patients with acute heart failure. For urgent resuscitation, outreach salvage, and transportation extracorporeal membrane oxygenation (ECMO) is a reliable, but time limited, first step. ECMO decompresses the venous system, provides flow, and ensures oxygenation, but does not unload the failing left ventricle. Myocardial stunning takes days, and sometimes weeks, to recover. Effective ventricular unloading is best achieved by surgical implantation of a temporary rotary or volume-displacement pump. After cardiopulmonary resuscitation, hemodynamic stabilization allows assessment of cerebral injury and prognosis. Published series demonstrate that 50–75% of patients with profound shock can be salvaged either through native heart recovery, urgent transplantation, or switch to a long-term pump.

Early reoperation performed for the management of complications in patients undergoing general thoracic surgical procedures

OBJECTIVE To detect the rate and predisposing factors for the development of postoperative complications requiring re-operation for their control in the immediate postoperative period. METHODS During the time period 2009-2012, 719 patients (male: 71.62%, mean age: 54±19 years) who underwent a wide range of general thoracic surgery procedures, were retrospectively collected. Data of patients who underwent early re-operation for the management of postoperative complications were assessed for identification of the responsible causative factors. RESULTS Overall, 33/719 patients (4.6%) underwent early re-operation to control postoperative complications. Early re-operation was obviated by the need to control bleeding or to drain clotted hemothoraces in nine cases (27.3%), to manage a prolonged air leak in six cases (18.2%), to drain a post-thoracotomy empyema in five cases (15.2%), to revise the thoracotomy incision or an ischemic musculocutaneous flap in five cases (15.2%), to manage a bronchopleural fistula in four cases (12.1%), to manage persistent atelectasis of the remaining lung in two cases (6.1%), to cease a chyle leak in one case (3%) and to plicate the right hemidiaphragm in another one case (3%). The factors responsible for the development of complications requiring reopening of the chest for their management were technical in 17 cases (51.5%), initial surgery for lung or pleural infections in 9 (27.3%), the recent antiplatelet drug administration in 4 (12.1%) and advanced lung emphysema in 3 (9.1%). Mortality of re-operations was 6.1% (2/33) and it was associated with the need to proceed with completion pneumonectomy in the two cases with persistent atelectasis of the remaining lung and permanent parenchymal damage. The majority of complications requiring reoperation were observed after lung parenchyma resection (17 out of the 228 procedures/7.4%) or pleurectomy (7 out of the 106 procedures/6.5%). Reoperations after video-assisted thoracic surgery (VATS) were uncommon (2 out of the 99 procedures/2%). CONCLUSIONS The rate of complications requiring reoperation after general thoracic surgery procedures is low and it is mainly related to technical issues from the initial surgery, the recent administration of antiplatelet drugs, the presence of advanced emphysema and surgery for infectious diseases. The need to proceed with completion pneumonectomy has serious risk for fatal outcome.

Serum levels of matrix metalloproteinases -1,-2,-3 and -9 in thoracic aortic diseases and acute myocardial ischemia

BackgroundMatrix metalloproteinases (MMPs) constitute a family of zinc-dependent proteases (endopeptidases) whose catalytic action is the degradation of the extracellular matrix components. In addition, they play the major role in the degradation of collagen and in the process of tissue remodeling. The present clinical study investigated blood serum levels of metalloproteinases- 1, -2, -3 and -9 in patients with acute and chronic aortic dissection, thoracic aortic aneurysm and acute myocardial ischemia compared to healthy individuals.MethodsThe blood serum levels of MMP-1, -2, -3 and -9 were calculated in 31 patients with acute aortic dissection, 18 patients with chronic aortic dissection, 18 patients with aortic aneurysm and in 13 patients with acute myocardial ischemia, as well as in 15 healthy individuals who served as the control group. Serum MMP levels were measured by using an ELISA technique.ResultsThere were significantly higher levels of MMP-3 in patients with acute myocardial ischemia as compared to acute aortic dissection (17.33 ± 2.03 ng/ml versus 12.92 ± 1.01 ng/ml, p < 0.05). Significantly lower levels of MMP-1 were found in healthy controls compared to all groups of patients (1.1 ± 0.38 ng/ml versus 2.97 ± 0.68 in acute aortic dissection, 3.09 ± 0.98 in chronic dissection, 3.16 ± 0.51 in thoracic aortic aneurysm and 4.58 ± 1.04 in acute myocardial ischemia, p < 0.05). Higher levels of MMP-1 and MMP-3 were detected on males. There was a positive correlation with increasing age (r = 0.38, p < 0.05). In patients operated for acute type A aortic dissection, the levels of MMP-1, MMP-3 and MMP-9 increased immediately after surgery, while the levels of MMP-2 decrease. At 24 hours postoperatively, levels of MMP -1, -2 and -9 are almost equal to the preoperative ones.ConclusionMeasurement of serum MMP levels in thoracic aortic disease and acute myocardial ischemia is a simple and relatively rapid laboratory test that could be used as a biochemical indicator of aortic disease or acute myocardial ischemia, when evaluated in combination with imaging techniques.

Use of minimal invasive extracorporeal circulation in cardiac surgery: principles, definitions and potential benefits. A position paper from the Minimal invasive Extra-Corporeal Technologies international Society (MiECTiS)

Minimal invasive extracorporeal circulation (MiECC) systems have initiated important efforts within science and technology to further improve the biocompatibility of cardiopulmonary bypass components to minimize the adverse effects and improve end-organ protection. The Minimal invasive Extra-Corporeal Technologies international Society was founded to create an international forum for the exchange of ideas on clinical application and research of minimal invasive extracorporeal circulation technology. The present work is a consensus document developed to standardize the terminology and the definition of minimal invasive extracorporeal circulation technology as well as to provide recommendations for the clinical practice. The goal of this manuscript is to promote the use of MiECC systems into clinical practice as a multidisciplinary strategy involving cardiac surgeons, anaesthesiologists and perfusionists.

Hybrid approach of ventricular assist device and autologous bone marrow stem cells implantation in end-stage ischemic heart failure enhances myocardial reperfusion

We challenge the hypothesis of enhanced myocardial reperfusion after implanting a left ventricular assist device together with bone marrow mononuclear stem cells in patients with end-stage ischemic cardiomyopathy. Irreversible myocardial loss observed in ischemic cardiomyopathy leads to progressive cardiac remodelling and dysfunction through a complex neurohormonal cascade. New generation assist devices promote myocardial recovery only in patients with dilated or peripartum cardiomyopathy. In the setting of diffuse myocardial ischemia not amenable to revascularization, native myocardial recovery has not been observed after implantation of an assist device as destination therapy. The hybrid approach of implanting autologous bone marrow stem cells during assist device implantation may eventually improve native cardiac function, which may be associated with a better prognosis eventually ameliorating the need for subsequent heart transplantation. The aforementioned hypothesis has to be tested with well-designed prospective multicentre studies.

Treatment of Infected Thoracic Aortic Prosthetic Grafts with the In Situ Preservation Strategy: A Review of its History, Surgical Technique, and Results

For cardiothoracic surgeons prosthetic graft infection still represents a difficult diagnostic and treatment problem to manage. An aggressive surgical strategy involving removal and in situ replacement of all the prosthetic material combined with extensive removal of the surrounding mediastinal tissue remains technically challenging in any case. Mortality and morbidity rates following such a major and risky surgical procedure are high due to the nature of the aggressive surgical approach and multi-organ failure typically caused by sepsis. However, removal of the infected prosthetic graft in patients who had an operation to reconstruct the ascending aorta and/or the aortic arch is not always possible or necessary for selected patients according to current alternative treatment options. Rather than following the traditional surgical concept of aggressive graft replacement nowadays a more conservative surgical approach with in situ preservation and coverage of the prosthetic graft by vascular tissue flaps can result in a good outcome. In this article, we review the relevant literature on this specific topic, particularly in terms of graft-sparing surgery for infected ascending/arch prosthetic grafts with special emphasis on staged treatment and the use of omentum transposition.

Enhanced Recovery After Elective Coronary Revascularization Surgery With Minimal Versus Conventional Extracorporeal Circulation: A Prospective Randomized Study

OBJECTIVE A minimal extracorporeal circulation (MECC) circuit integrates the advances in cardiopulmonary bypass (CPB) technology into a single circuit and is associated with improved short-term outcome. The aim of this study was to prospectively evaluate MECC compared with conventional CPB in facilitating fast-track recovery after elective coronary revascularization procedures. DESIGN Prospective randomized study. SETTING All patients scheduled for elective coronary artery surgery were evaluated, excluding those considered particularly high risk for fast-track failure. The fast-track protocol included careful preoperative patient selection, a fast-track anesthetic technique based on minimal administration of fentanyl, surgery at normothermia, early postoperative extubation in the cardiac recovery unit, and admission to the cardiothoracic ward within the first 24 hours postoperatively. PARTICIPANTS One hundred twenty patients were assigned randomly into 2 groups (60 in each group). INTERVENTIONS Group A included patients who were operated on using the MECC circuit, whereas patients in Group B underwent surgery on conventional CPB. MEASUREMENTS AND MAIN RESULTS Incidence of fast-track recovery was significantly higher in patients undergoing MECC (25% v 6.7%, p = 0.006). MECC also was recognized as a strong independent predictor of early recovery, with an odds ratio of 3.8 (p = 0.011). Duration of mechanical ventilation and cardiac recovery unit stay were significantly lower in patients undergoing MECC together with the need for blood transfusion, duration of inotropic support, need for an intra-aortic balloon pump, and development of postoperative atrial fibrillation and renal failure. CONCLUSIONS MECC promotes successful early recovery after elective coronary revascularization procedures, even in a nondedicated cardiac intensive care unit setting.

Haematological effects of minimized compared to conventional extracorporeal circulation after coronary revascularization procedures.

During the last decade, minimized extracorporeal circulation (MECC) systems have shown beneficial effects to the patients over the conventional cardiopulmonary bypass (CECC) circuits. This is a prospective randomized study of 99 patients who underwent coronary artery bypass grafting (CABG) surgery, evaluating the postoperative haematological effects of these systems. Less haemodilution (p=0.001) and markedly less haemolysis (p<0.001), as well as better preservation of the coagulation system integrity (p=0.01), favouring the MECC group, was found. As a clinical result, less bank blood requirements were noted and a quicker recovery, as far as mechanical ventilation support and ICU stay are concerned, was evident with the use of MECC systems. As a conclusion, minimized extracorporeal circulation systems may attenuate the adverse effects of conventional circuits on the haematological profile of patients undergoing CABG surgery.

Left Ventricular Decompression During Peripheral Extracorporeal Membrane Oxygenation Support With the Use of the Novel iVAC Pulsatile Paracorporeal Assist Device

Extracorporeal membrane oxygenation (ECMO) has become a widely accepted short-term mechanical circulatory support device in patients with refractory cardiogenic shock. A major drawback of the peripheral venoarterial extracorporeal membrane oxygenation is that in patients with profoundly reduced left ventricular contractility associated with high left-heart filling pressure, there is always concern for venting the failing ventricle. We describe a minimally invasive technique for decompressing the left ventricle in this setting using a novel pulsatile paracorporeal assist device, the iVAC 3L (PulseCath, Groningen, The Netherlands). It is implanted through the right axillary artery and provides hemodynamic support while directly off-loading the left ventricle.