S.-E. Ricksten

Coronary and systemic hemodynamic effects of clevidipine, an ultra-short-acting calcium antagonist, for treatment of hypertension after coronary artery surgery

Background: The aim was to evaluate the use of clevidipine, a new vascular selective, ultra‐short‐acting calcium antagonist for blood pressure control after coronary artery bypass grafting (CABG).

Long-term infusion of atrial natriuretic peptide (ANP) improves renal blood flow and glomerular filtration rate in clinical acute renal failure.

Background: Short‐term infusion of atrial natriuretic peptide (ANP) increases renal blood flow (RBF) and glomerular filtration rate (GFR) in patients with acute renal dysfunction. In the present study we evaluated the effects of long‐term infusion (>48 h) of ANP on (RBF) and (GFR) in 11 postcardiac surgical patients requiring pharmacological circulatory support and with acute renal impairment.

Low-dose vasopressin increases glomerular filtration rate, but impairs renal oxygenation in post-cardiac surgery patients.

Background: The beneficial effects of vasopressin on diuresis and creatinine clearance have been demonstrated when used as an additional/alternative therapy in catecholamine‐dependent vasodilatory shock. A detailed analysis of the effects of vasopressin on renal perfusion, glomerular filtration, excretory function and oxygenation in man is, however, lacking. The objective of this pharmacodynamic study was to evaluate the effects of low to moderate doses of vasopressin on renal blood flow (RBF), glomerular filtration rate (GFR), renal oxygen consumption (RVO2) and renal oxygen extraction (RO2Ex) in post‐cardiac surgery patients.

Management of a giant intracranial aneurysm using surface‐heparinized extracorporeal circulation and controlled deep hypothermic low flow perfusion. A case report

Extracorporeal circulation with controlled hypothermic low flow perfusion was introduced during the surgical treatment of a patient with a giant intracranial aneurysm of the anterior communicating artery. Heparin‐coated equipment (Carmeda Bio‐Active Surface; CBAS) was utilized, thus reducing the need for systemic heparinization. Direct cannulation of the right atrium and aorta was established through thoracotomy. Blood flow through the circuit was kept at 4.5 1/min during normothermia. Core cooling, in combination with external surface cooling, was performed for 30 min to a temperature of 18d̀C (nasopharynx). During a period of 25 min, the time for surgical repair of the aneurysm, blood flow was minimized to 0.4 1 · min‐1, equilibrating central and peripheral blood pressures to approximately 5–10 mmHg (0.65–1.3 kPa). Reper‐fusion was started immediately after the low flow period concomitantly with rewarming, aiming at a temperature of 36d̀C following 150 min. The patient could be weaned off the extracorporeal circulation with minimal inotropic support. The postoperative course was uneventful apart from a left‐sided hemiparesis, probably due to an infarction in the area of the right pericallosal artery (A2). The patient was weaned off the ventilator after 6 days. He recovered and the hemiparesis regressed slowly.

Bone cement implantation syndrome in cemented hemiarthroplasty for femoral neck fracture: incidence, risk factors, and effect on outcome

BACKGROUND Bone cement implantation syndrome (BCIS) is characterized by hypoxia, hypotension, and loss of consciousness occurring around the time of bone cementation. Using a recently proposed severity classification of BCIS, we estimated the incidence of and risk factors for BCIS and its impact on mortality in cemented hemiarthroplasty for femoral neck fractures. METHODS In this retrospective study, 1016 patients undergoing cemented hemiarthroplasty were included. Medical history and medication were obtained from medical records. Anaesthesia charts for all patients were reviewed for mean arterial pressure, arterial oxygen saturation, and heart rate before, during, and after cementation. Each patient was classified as having no BCIS (grade 0) or BCIS grade 1, 2, or 3, depending on the degree of hypotension, arterial desaturation, or loss of consciousness around cementation. RESULTS The incidence of BCIS grade 1, 2, and 3 were 21%, 5.1%, and 1.7%, respectively. Early mortality in BCIS grade 1 (9.3%) did not differ significantly from BCIS grade 0 (5.2%), while early mortality in BCIS grade 2 (35%) and grade 3 (88%) were significantly higher when compared with grades 0 and 1. Early mortality was also higher in BCIS grade 3 when compared with grade 2. Independent predictors for severe BCIS were: ASA grade III-IV, chronic obstructive pulmonary disease, and medication with diuretics or warfarin. Severe BCIS was associated with 16-fold increase in mortality. CONCLUSIONS BCIS is a commonly occurring phenomenon in cemented hemiarthroplasty and severe BCIS has a huge impact on early and late mortality.

Transcranial Doppler microembolic signals and serum marker evidence of brain injury during transcatheter aortic valve implantation

Recent studies have shown that transcatheter aortic valve implantation (TAVI) is associated with new foci of restricted diffusion on cerebral magnetic resonance imaging suggestive of cerebral microembolism. The aim of the present investigation was to quantify the cerebral embolic load and to evaluate during which phase of the TAVI procedure microembolism occurs. We also evaluated the association between the cerebral embolic load and post‐procedural release of S100B, a serological marker of cerebral injury.

Renal Effects of Levosimendan: A Consensus Report

Renal dysfunction is common in clinical settings in which cardiac function is compromised such as heart failure, cardiac surgery or sepsis, and is associated with high morbidity and mortality. Levosimendan is a calcium sensitizer and potassium channel opener used in the treatment of acute heart failure. This review describes the effects of the inodilator levosimendan on renal function. A panel of 25 scientists and clinicians from 15 European countries (Austria, Finland, France, Hungary, Germany, Greece, Italy, Portugal, the Netherlands, Slovenia, Spain, Sweden, Turkey, the United Kingdom, and Ukraine) convened and reached a consensus on the current interpretation of the renal effects of levosimendan described both in non-clinical research and in clinical study reports. Most reports on the effect of levosimendan indicate an improvement of renal function in heart failure, sepsis and cardiac surgery settings. However, caution should be applied as study designs differed from randomized, controlled studies to uncontrolled ones. Importantly, in the largest HF study (REVIVE I and II) no significant changes in the renal function were detected. As it regards the mechanism of action, the opening of mitochondrial KATP channels by levosimendan is involved through a preconditioning effect. There is a strong rationale for randomized controlled trials seeking beneficial renal effects of levosimendan. As an example, a study is shortly to commence to assess the role of levosimendan for the prevention of acute organ dysfunction in sepsis (LeoPARDS).

Open‐heart surgery increases cerebrospinal fluid levels of Alzheimer‐associated amyloid β

Neurocognitive dysfunction occurs frequently after open‐heart surgery. It has been suggested that cognitive decline after cardiac surgery with cardiopulmonary bypass (CPB) could be a functional consequence of Alzheimers disease (AD)‐like neuropathological changes. The aim of the present study was to evaluate the cerebrospinal fluid (CSF) levels of amyloid β peptide (Aβ1–42) and soluble fragments of amyloid precursor protein (sAPP) as well as the cerebral inflammatory response to open‐heart surgery.

Levosimendan beyond inotropy and acute heart failure: Evidence of pleiotropic effects on the heart and other organs: An expert panel position paper

Levosimendan is a positive inotrope with vasodilating properties (inodilator) indicated for decompensated heart failure (HF) patients with low cardiac output. Accumulated evidence supports several pleiotropic effects of levosimendan beyond inotropy, the heart and decompensated HF. Those effects are not readily explained by cardiac function enhancement and seem to be related to additional properties of the drug such as anti-inflammatory, anti-oxidative and anti-apoptotic ones. Mechanistic and proof-of-concept studies are still required to clarify the underlying mechanisms involved, while properly designed clinical trials are warranted to translate preclinical or early-phase clinical data into more robust clinical evidence. The present position paper, derived by a panel of 35 experts in the field of cardiology, cardiac anesthesiology, intensive care medicine, cardiac physiology, and cardiovascular pharmacology from 22 European countries, compiles the existing evidence on the pleiotropic effects of levosimendan, identifies potential novel areas of clinical application and defines the corresponding gaps in evidence and the required research efforts to address those gaps.

Pulmonary haemodynamics and right ventricular function during cemented hemiarthroplasty for femoral neck fracture

Background: Bone cement implantation syndrome (BCIS) is characterised by hypoxia, hypotension and loss of consciousness occurring early after bone cementation. The haemodynamic perturbations during BCIS have not been extensively studied, particularly not in patients with femoral neck fracture. We evaluated the effects of cemented hemiarthroplasty, in these patients, on pulmonary haemodynamics, right ventricular performance, intrapulmonary shunting and physiological dead space.