Sergio Bevilacqua

Small-dose recombinant activated factor VII (NovoSeven) in cardiac surgery.

Recombinant activated factor VII (rFVIIa) has been used at different doses in cardiac surgery patients. We tested the efficacy of small-dose rFVIIa in patients with intractable bleeding after cardiac surgery. The study group comprised 15 cardiac surgery patients with intractable bleeding treated with small-dose (1.2 mg) rFVIIa as a slow IV bolus at the end of complete step-by step transfusion protocol. Fifteen matched patients undergoing the same transfusion protocol in the pre-rFVIIa era represented the control group. Blood loss at the end of the transfusion protocol was a primary outcome. Median, 25th–75th 24-h blood loss percentiles were 1685 (1590–1770) mL versus 3170 (2700–3850) mL in study group and controls, respectively (P = 0.0004). Transfused red blood cells, fresh-frozen plasma, and platelets in the study group and controls were as follows: 7 (4–8) U versus 18 (12–21) U (P = 0.001); 7.5 (6–11) U versus 11 (9–15) U (P = 0.003); 0 (0–4) U versus 9 (6–13) U (P = 0.001). In addition, significant improvements of prothrombin time (P = 0.015), international normalized ratio (P = 0.006), activated partial prothrombin time (P = 0.01), and platelet count (P = 0.003) were detected in the study group versus controls. Finally, patients receiving rFVIIa showed a reduced intensive care unit length of stay (&khgr;2 = 15.9, P = 0.0001) and had infrequent surgical re-exploration (&khgr;2 = 16.2,P < 0.0001). Small-dose rFVIIa showed satisfactory results in cardiac patients with intractable bleeding. Further randomized studies are necessary to confirm our findings.

Dynamic response of liquid-filled catheter systems for measurement of blood pressure: precision of measurements and reliability of the Pressure Recording Analytical Method with different disposable systems ☆

PURPOSE We aimed to compare the effects of a blood pressure transducer system specifically manufactured to limit underdamping artifacts with those of a standard system on hemodynamic parameter estimation and accuracy. MATERIALS AND METHODS Forty-three consecutive patients undergoing vascular surgery at the University of Florence, Italy, were included. Arterial blood pressure signal was simultaneously registered with 2 MostCare monitors, connected to the artery either by a standard transducer or a specific transducer manufactured to avoid underdamping artifacts (Resonance Over-Shoot Eliminator [R.O.S.E.]; Becton Dickinson, Becton Drive, NJ). Patients were divided into 2 groups: absence (C group) or presence (R group) of underdamping/resonance artifacts of blood pressure signal. Systolic blood pressure, cardiac index, maximal pressure/time ratio (dP/dt(MAX)), and cardiac cycle efficiency were recorded every 30 seconds for 30 minutes. A total of 2675 measurements were performed with 34.9% incidence of underdamping/resonance artifacts. RESULTS All hemodynamic parameters showed clinically acceptable differences in the C group; in contrast, the results differed greatly in the R group between standard and R.O.S.E. transducer (systolic blood pressure bias, 16.7 mm Hg; cardiac index bias, 0.24 L min(-1) m(-2); dP/dt(MAX) bias, 0.92 mm Hg/ms; cardiac cycle efficiency bias, 0.018 units). CONCLUSIONS Underdamping/resonance artifacts frequently affect blood pressure measurement in operating rooms and intensive care units and cause severe overestimation of systolic blood pressure and incorrect estimation of hemodynamic parameters when the pulse contour method is used.

Anesthesia for Carotid Endarterectomy: The Third Option. Patient Cooperation During General Anesthesia

BACKGROUND: Carotid endarterectomy is typically performed using either regional or general anesthesia techniques, which exhibit several differences, especially regarding the intraoperative neurological monitoring of patients. In this study, we introduce a technique of general anesthesia (cooperative patient general anesthesia), which allows neurological monitoring of the awake patient during surgery. METHODS: We prospectively enrolled 181 consecutive adult patients scheduled for carotid endarterectomy. Patients were anesthetized with a total IV anesthesia technique. During carotid clamping, anesthesia was reduced and maintained only with high-dose remifentanil, such that the patient was able to respond to verbal statements and neurological monitoring could be performed. The technique is described in detail. Patient neurological and cardiac outcomes were investigated. Patient and surgeon satisfaction with the technique were also evaluated. RESULTS: General anesthesia with a cooperative patient was achieved in 179 patients. No postoperative neurological events were observed. Two (1.1%) nonfatal myocardial infarctions occurred in the early postoperative period in two patients. Eighty-one percent of patients described the operation duration as brief, whereas 19.3% accurately perceived the time they were conscious. Both patients and surgeons were highly satisfied with the technique. CONCLUSIONS: In our series, cooperative patient general anesthesia proved to be a safe and satisfactory anesthetic technique for both the patient and surgeon. The technique was characterized by hemodynamic stability, excellent control of ventilatory pattern, continuous neurological monitoring, and immediate and safe conversion to general anesthesia whenever required. Further studies are needed to highlight the advantages of this technique compared with standard general and local anesthesia.

Cardiac output by arterial pulse contour: reliability under hemodynamic derangements

Pulse contour methods (PCM) for the measurements of cardiac output (CO) are gaining popularity in intensive care settings but their reliability during hemodynamic instability has been questioned. Pressure-recording-analytical-method (PRAM) is a newly developed uncalibrated hemodynamic monitor and its capability in measuring CO during hemodynamic instability is still under investigation. Dobutamine (2.5 and 5 microg/kg/min), vasoconstriction (arginine-vasopressin 4, 8 and 16 IU/h), hemorrhage (-10%, -20%, -35%, and -50% of the theoretical volemia), and volume resuscitation were induced in eight swine. CO by means of thermodilution (CO(ThD)), transesophageal echocardiography (CO(TEE)) and PRAM (CO(PRAM)) were contemporarily registered. R(2), bias, and percentage error were used to compare the methods. Comparison between CO(PRAM) and CO(ThD) resulted in: r(2)=0.87; bias=-0.006 l/min; precision=+/-0.87 l/min; percentage error=22.8%. Comparison between CO(PRAM) and CO(TEE) resulted in: r(2)=0.85; bias=-0.007 l/min; precision=+/-0.86 l/min; percentage error=22%. Sub-group analysis revealed disagreement between methods only during the last two steps of hemorrhage: CO(PRAM) vs. CO(ThD): r(2)=0.67, bias=-0.37 l/min, precision=+/-1.04 l/min, limits of agreement=-1.39+0.66 l/min, and percentage error=45%; CO(PRAM) vs. CO(TEE): r(2)=0.38, bias=0.4 l/min, precision=+/-1.42 l/min, limits of agreement=-0.99+1.79 l/min, and percentage error=62%. PRAM resulted to be accurate in measuring CO during hemodynamic stability, tachycardia, and vasoconstriction. When volemia was reduced by >35%, disagreement between methods was observed.

Severe Hypoplasia of the Posterior Mitral Leaflet

A rare case of a 14-year-old child with congenital mitral insufficiency secondary to hypoplasia of the posterior leaflet is reported. Echocardiography revealed the almost complete absence of the posterior mitral leaflet, which determined massive regurgitation. At surgical inspection the posterior leaflet was almost completely absent, represented only by tags of fibrous tissue that strictly adhered to the posterior annulus with a total absence of chordae inserting into the hypoplastic leaflet. The mitral valve was successfully repaired by restrictive annuloplasty, which gained a satisfactory surface of coaptation between the anterior leaflet and the primordial posterior structure, resulting in stable valve continence.

Pulse Contour Cardiac Output Monitoring During a Complicated Percutaneous Aortic Valve Replacement

v ORTIC STENOSIS (AS) is the most common valvular heart disease in the aging population. Critical AS affects n estimated 3% of individuals over the age of 75 years. lthough medical therapy has little to offer in terms of progosis or symptomatic relief, at least one third of patients with evere AS are denied valve surgery as a result of age and omorbidity.1,2 In these very high-risk patients, percutaneous ortic valve replacement (P-AVR) recently has emerged as an lternative technique to open-chest surgery. P-AVR is freuently performed under local anesthesia and is usually assoiated with mild intravenous sedation.3 As a consequence, nvasive hemodynamic monitoring (ie, pulmonary artery cathter or transesophageal echocardiography) is limited to specific ituations, such as severe left ventricular dysfunction and/or ulmonary hypertension. However, hemodynamic stability is ne of the primary goals during P-AVR. The goals of hemoynamic management during this procedure are the same as uring surgical aortic valve replacement. Preload optimization s needed to maintain an adequate stroke volume (SV). Neverheless, in clinical practice, most of these patients are usually onitored only by means of an electrocardiogram, SpO2, and nvasive blood pressure.4 Minimally invasive cardiac output CO) monitoring systems based on the peripheral blood presure waveform analysis have been gaining popularity in differnt clinical settings.5 A complicated case of P-AVR that was onitored by means of the pressure recording analytic method PRAM), which is an uncalibrated blood pressure CO monioring system, is presented.

Comparison between mixed and central venous oxygen saturation in patients with severe acute heart failure after cardiac surgery: A prospective observational study.

[1] Maron BJ, Towbin JA, Thiene G, et al. Contemporary definitions and classification ofthe cardiomyopathies.An American Heart Associationscientific statementfromtheCouncil on Clinical Cardiology, Heart Failure and Transplantation Committee;Quality of Care and Outcomes Research and Functional Genomics and TranslationalBiology Interdisciplinary Working Groups; and Council on Epidemiology andPrevention. Circulation April 2006;113(14):1807–16.[2] Elliott P, Andersson B, Arbustini E, et al. Classification of the cardiomyopathies: aposition statement from the European Society Of Cardiology Working Group onMyocardial and Pericardial Diseases. Eur Heart J Jan 2008;29(2):270–6.0167-5273/

Anatomic characteristics of bileaflet mitral valve prolapse - Barlow disease – in patients undergoing mitral valve repair

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Extracorporeal Membrane Oxygenation-Assisted Esophagectomy

OBJECTIVE Barlow disease is a still challenging pathology for the surgeon. Aim of the present study is to report anatomic abnormalities of mitral valve in patients undergoing mitral valve repair. METHODS Between January 1st, 2007, and December 31st, 2010, 85 consecutive patients (54 men and 31 women, mean age 59 +/- 14 years--range: 28-85 years) with the features of a Barlow mitral valve disease underwent mitral repair Forty seven percent of patients were in New York Heart Association functional class III or IV. Preoperative transesophageal echocardiography was compared with anatomical findings at the moment of surgery. RESULTS Transthoracic echocardiography diagnosis of Barlow disease according to the criteria described by Carpentier was confirmed at anatomical inspection. Annular calcifications were found in 28 patients while 7 patients presented single or multiple clefts. A flail posterior mitral leaflet was detected in 32 subjects, while a flail anterior leaflet in 8. Elongation of chordae tendineae was demonstrated in 45 patients and chordal rupture in 31. All patients showed at trans esophageal echocardiography the typical features of Barlow disease. Seventy-seven (90.6%) patients had severe mitral valve regurgitation, in the remaining 9.4% it was moderate to severe. Transesophageal echocardiography failed to identify clefts in 2/7 and chordal rupture in 4/31. CONCLUSIONS bileaflet prolapse > 2 mm, billowing valve with excess tissue and thickened leaflets > or = 3 mm, and severe annular dilatation, are characteristics of Barlow disease, however the identification of the associated and complex abnormalities of mitral valve is necessary to obtain optimal valve repair.

Lung-protective Ventilation during General Anesthesia: What about the Oxygen?

CASE REPORTA 41-year-old man required an esophagectomy due to multipleareas of stenoses. His past surgical history included multiple esoph-ageal surgeries and dilation procedures in his childhood due toesophageal atresia and, later, tracheobronchial reconstruction for aniatrogenic trachea-esophageal fistula. His medical history was otherwisenoncontributory. To allow right lung collapse and to enable surgicalaccess to the esophagus via a right thoracotomy, one-lung ventilation(OLV) traditionally is required. However, OLV obtained via conven-tional measures (double-lumen endobronchial tube or bronchialblocker) was not feasible given the past surgical modification of histracheobronchial bifurcation. Moreover, the complex anatomic relation-ship between the airway and digestive tract required the availability oftotal extracorporeal ventilatory support if needed (ie, if surgicalcircumstances would not allow for mechanical ventilation). Ultra-lowtidal volume ventilation and VV- ECMO assistance via the rightinternal jugular vein was then planned, and a written informed consentto perform the surgery in this manner was obtained from the patient.Anesthesia was induced with 3 mg/kg of propofol and 1 μg/kg ofsufentanil. After the administration of 0.9 mg/kg of rocuronium, thetrachea was intubated under fiberoptic guidance with a 6.5-mm(internal diameter) oral-tracheal tube, with the tip positioned just belowthe vocal cords. Anesthesia was maintained with 4-to-6 mg/kg/h ofpropofol and 0.1-to-0.2 μg/kg/min of remifentanil; 0.1-0.3 mg/kg/hr ofrocuronium was administered according to the train-of-four monitoring.The American Society of Anesthesiologists standard monitoring wasimplemented with MostCare (Vygon, Vytech, Padova, Italy), a pulsecontour-based system for cardiac output estimation that received itsarterial waveform via the left radial artery with a standard pressuretransducer. The MostCare system provides hemodynamic data byanalyzing the arterial waveform at high sampling rate (1000 Hz) and,therefore, is not influenced by the VV-ECMO. In fact, the VV-ECMOdrains and injects blood into the right side of the cardiovascular systemwithout modifying, at steady state, right and left ventricular preload. A27-Fr double-lumen Avalon (Avalon Labs, Rancho Dominguez, CA)ECMO cannula was inserted into the right internal jugular vein undertransthoracic echography guidance using the subcostal approach. Afterthe administration of 5,000 IU of unfractionated heparin and radiologicconfirmation of proper placement, the cannula was connected to anheparin-coated ECMO circuit (Rotaflow System, Maquet Cardiopul-monary AG; GmbH & Co. KG; Rastatt, Germany) and primed withlactated Ringer’s solution. Activated partial thromboplastin time wastargeted to 50 to 70 seconds, and no further heparin administration wasnecessary throughout the case. During the thoracic portion of thesurgery, the mean pump flow was 2.06 L/min (SD 0.1; range 1.96-2.24). Mean inspired oxygen fraction (F