Polychronis Antonitsis

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.

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.

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.

Minimal invasive Extra-Corporeal Circulation (MiECC): a revolutionary evolution in perfusion

Since the beginning of extracorporeal circulation (ECC) in cardiac surgery, a multitude of changes and improvements were aimed to reduce the adverse systemic effects caused by the artificial surfaces of the perfusion circuit. The clinical picture is similar to a systemic inflammatory response syndrome [1]. The magnitude of the inflammatory response adversely influences clinical outcomes [2]. Hence, the overall morbidity associated with cardiac surgery is substantial [3]. The off-pump coronary artery bypass (OPCAB) technique was introduced as a strategy to decrease the side effects of cardiopulmonary bypass (CPB). But the real advantages of OPCAB have been questioned in recent years [4]. In the early 2000s, a simplified perfusion system comprising all technological advancements was designed [5]. The modifications of the new system were much more revolutionary than the individual improvements to the existing conventional CPB circuits. The idea was to create a system including all established benefits in one CPB set-up. The Minimal Extra-Corporeal Circulation (MiECC) technology was born. Since then, MiECC systems have been developed to increase the technical ease of on-pump surgery while tempering its disadvantages. For many years, cardiac surgeons, anaesthesiologists and perfusionists considered MiECC systems as a miniaturization or simplification of traditional CPB only. MiECC significantly attenuated morbidity attributed to conventional ECC, as for beatingheart procedures, while permitting optimal technical surgical conditions [6]. ‘The authors believe that MiECC technology represents more than a miniaturization process: it is a major step forward and a totally new philosophy to be integrated in contemporary cardiac surgery’. The idea of MiECC systems has initiated new efforts to improve the biocompatibility of CPB systems and minimize their side effects, offering finally better postoperative end-organ function. Characteristics of MiECC include the following: (1) a blood pump with optimal biocompatibility, low thrombogenicity, minimal haemolysis and activation of leucocytes as well as proinflammtory mediators; (2) a minimal tubing length to reduce the priming volume required and thus minimize haemodilution, decreasing the need for foreign blood transfusions; (3) coated surfaces to reduce protein adsorption and platelet activation; (4) separation of shed blood and exclusion of activated blood components via cell salvage; (5) closed system to avoid blood–air contact; (6) temperature management depending on the need and magnitude of surgery should be possible; (7) use of modern concepts of myocardial protection, like blood cardioplegia, must be easy to integrate; (8) safe de-airing must be possible following open heart procedures; (9) finally, it should help modern concepts of fast-track anaesthesia [7, 8]. These characteristics will help to make MiECC an element of a minimal invasive procedure rather than simply a miniaturized CPB system. Numerous randomized clinical studies have proved that MiECC exerts significant beneficial effects on postoperative morbidity, by reducing haemodilution, mediastinal bleeding, need for blood transfusion and inflammatory response. Clinical benefits are: improved end-organ (myocardial, renal and cerebral) protection and reduction of the length of intensive care unit stay [5–8]. Moreover, it is associated with a significant survival benefit in coronary procedures compared with conventional ECC as shown in a recent meta-analysis. This analysis reported randomized trials including 24 studies with a total of 2770 patients [9] and provided a Scientific Class I, Level of evidence A for implementation of MiECC, at least for coronary revascularization. Despite these clear clinical advantages, penetration of the MiECC technology into clinical practice remains significantly low. Thus, the authors took the initiative to organize the ‘1st International Symposium on Minimal invasive Extracorporeal Circulation Technologies (1st MiECT)’ in Thessaloniki, Greece during June 13–14 to create a dedicated international forum to stimulate the exchange of ideas in clinical application and research in the field of Minimal invasive Extracorporeal Circulation Technology without geographical bias (www.miect.org). More than 400 participants from all continents registered. Beside scientific sessions, wet-labs with two simulators for ‘hands-on training’ allowed participants to practice on all commercially available MiECC systems. Twenty abstracts were selected for publication and are part of this Interactive Cardiovascular and Thoracic Surgery issue. During the congress, the ‘Minimal invasive Feedback from the 1st International Symposium on Minimal invasive Extracorporeal Circulation Technologies, Thessaloniki, Greece, 13–14 June 2014.

Use of minimal extracorporeal circulation circuit for left ventricular assist device implantation.

We describe successful use of a minimal extracorporeal circulation circuit (MECC) as an alternative to conventional cardiopulmonary bypass (CPB) for the implantation of left ventricular assist device (LVAD) in a 65-year-old patient with ischemic dilated cardiomyopathy. A Jarvik 2000 was implanted through a median sternotomy with the outflow graft anastomosed to the ascending aorta. MECC circuit provides optimal circulatory support throughout the procedure and prevents hemodynamic instability caused by marked displacement of the heart for exposure of the left ventricular apex, while minimizing the adverse effects of conventional CPB.

Use of Minimized Extracorporeal Circulation System in Noncoronary and Valve Cardiac Surgical Procedures—A Case Series

The aim of this report is to explore application of minimized cardiopulmonary bypass (CPB) circuits in areas of cardiac surgery other than coronary bypass grafting and aortic valve surgery. We report three cases operated under minimal extracorporeal circulation support. Replacement of the descending thoracic aorta was performed in two patients; one with a descending aortic aneurysm and one with pseudoaneurysm formation after previous coarctation repair. We have also implanted a left ventricular assist device for destination therapy. The minimized extracorporeal circulation system provides optimal circulatory support, while it is associated with reduced postoperative morbidity, minimizing the side effects from the use of CPB. Moreover, when off-pump technique is attempted, it can be used as a standby circuit connected to the patient so as to enhance safety of the procedure. Minimized extracorporeal circulation systems can be used with safety and efficacy in a wide range of cardiac surgeries including descending aorta pathology and assist device implantation.