Tomas Kotulak

Comparison of Three Protocols for Tight Glycemic Control in Cardiac Surgery Patients

OBJECTIVE We performed a randomized trial to compare three insulin-titration protocols for tight glycemic control (TGC) in a surgical intensive care unit: an absolute glucose (Matias) protocol, a relative glucose change (Bath) protocol, and an enhanced model predictive control (eMPC) algorithm. RESEARCH DESIGN AND METHODS A total of 120 consecutive patients after cardiac surgery were randomly assigned to the three protocols with a target glycemia range from 4.4 to 6.1 mmol/l. Intravenous insulin was administered continuously or in combination with insulin boluses (Matias protocol). Blood glucose was measured in 1- to 4-h intervals as requested by the protocols. RESULTS The eMPC algorithm gave the best performance as assessed by time to target (8.8 ± 2.2 vs. 10.9 ± 1.0 vs. 12.3 ± 1.9 h; eMPC vs. Matias vs. Bath, respectively; P < 0.05), average blood glucose after reaching the target (5.2 ± 0.1 vs. 6.2 ± 0.1 vs. 5.8 ± 0.1 mmol/l; P < 0.01), time in target (62.8 ± 4.4 vs. 48.4 ± 3.28 vs. 55.5 ± 3.2%; P < 0.05), time in hyperglycemia >8.3 mmol/l (1.3 ± 1.2 vs. 12.8 ± 2.2 vs. 6.5 ± 2.0%; P < 0.05), and sampling interval (2.3 ± 0.1 vs. 2.1 ± 0.1 vs. 1.8 ± 0.1 h; P < 0.05). However, time in hypoglycemia risk range (2.9–4.3 mmol/l) in the eMPC group was the longest (22.2 ± 1.9 vs. 10.9 ± 1.5 vs. 13.1 ± 1.6; P < 0.05). No severe hypoglycemic episode (<2.3 mmol/l) occurred in the eMPC group compared with one in the Matias group and two in the Bath group. CONCLUSIONS The eMPC algorithm provided the best TGC without increasing the risk of severe hypoglycemia while requiring the fewest glucose measurements. Overall, all protocols were safe and effective in the maintenance of TGC in cardiac surgery patients.

Perioperative Tight Glucose Control Reduces Postoperative Adverse Events in Nondiabetic Cardiac Surgery Patients

CONTEXT Tight glucose control (TGC) reduces morbidity and mortality in patients undergoing elective cardiac surgery, but only limited data about its optimal timing are available to date. OBJECTIVE The purpose of this article was to compare the effects of perioperative vs postoperative initiation of TGC on postoperative adverse events in cardiac surgery patients. DESIGN This was a single center, single-blind, parallel-group, randomized controlled trial. SETTINGS The setting was an academic tertiary hospital. PARTICIPANTS Participants were 2383 hemodynamically stable patients undergoing major cardiac surgery with expected postoperative intensive care unit treatment for at least 2 consecutive days. INTERVENTION Intensive insulin therapy was initiated perioperatively or postoperatively with a target glucose range of 4.4 to 6.1 mmol/L. MAIN OUTCOME MEASURES Adverse events from any cause during postoperative hospital stay were compared. RESULTS In the whole cohort, perioperatively initiated TGC markedly reduced the number of postoperative complications (23.2% vs 34.1%, 95% confidence interval [CI], 0.60-0.78) despite only minimal improvement in glucose control (blood glucose, 6.6 ± 0.7 vs 6.7 ± 0.8 mmol/L, P < .001; time in target range, 39.3% ± 13.7% vs 37.3% ± 13.8%, P < .001). The positive effects of TGC on postoperative complications were driven by nondiabetic subjects (21.3% vs 33.7%, 95% CI, 0.54-0.74; blood glucose 6.5 ± 0.6 vs 6.6 ± 0.8 mmol/L, not significant; time in target range, 40.8% ± 13.6% vs 39.7% ± 13.8%, not significant), whereas no significant effect was seen in diabetic patients (29.4% vs 35.1%, 95% CI, 0.66-1.06) despite significantly better glucose control in the perioperative group (blood glucose, 6.9 ± 1.0 vs 7.1 ± 0.8 mmol/L, P < .001; time in target range, 34.3% ± 12.7% vs 30.8% ± 11.5%, P < .001). CONCLUSIONS Perioperative initiation of intensive insulin therapy during cardiac surgery reduces postoperative morbidity in nondiabetic patients while having a minimal effect in diabetic subjects.

Anesthesia management of a patient with a ventricular assist device for noncardiac surgery.

Congestive heart failure represents a severe health condition with unfavourable long-term prognosis despite all the progress in pharmacological therapy of heart failure. Another therapeutic option is represented by mechanical cardiac support devices. Ventricular assist devices (VAD) constitute largest subgroup of these devices. Patients supported with VAD carry many considerations which are important for successful perioperative management of these patients for noncardiac surgery. The general perioperative considerations include consultation with VAD management personnel, detailed assessment of end-organ dysfunction before surgery, appropriate antibiotic prophylaxis, deactivation of implantable cardioverter-defibrillator for the time of surgical procedure, and the choice between general and regional anesthesia. Intraoperative monitoring depends primarily on the type of blood flow generated by VAD. For devices generating pulsatile blood flow, standard monitoring arrangements are needed. In the patients supported by devices which provide nonpulsatile blood flow, pulse oximetry and noninvasive blood pressure measurement are not reliable monitoring methods, and placement of intra-arterial catheter is warranted. In all the patients supported with VAD, transesophageal echocardiography is extremely useful method for monitoring the function of VAD itself, and in the case of univentricular VAD for monitoring the function of nonsupported cardiac ventricle. The most important issue in hemodynamic management of the patients with VAD is avoiding hypovolemia because it can cause inadequate VAD output with resulting low cardiac output and hypotension. All the patients with VAD need some degree of anticoagulation, and for noncardiac surgery the question of interrupting or decreasing the level of anticoagulation should be discussed among members of the caring team.

Total artificial heart support with two continuous-flow ventricular assist devices in a patient with an infiltrating cardiac sarcoma.

Primary cardiac sarcoma is normally fatal, but cardiac replacement may provide some hope for long-term survival. A 38 year-old man with cardiac sarcoma, involving the interventricular septum and posterior wall with intermittent mitral obstruction, underwent implantation of two HeartMate II ventricular assist devices for total artificial heart support. After cardiectomy, the HeartMate sewing rings were sewn to the right neoatrium and the left atrial remnants. After the outflow grafts were sewn end to end to the pulmonary artery and aorta, the two drivelines were externalized through the abdominal wall, and perfusion started. The postoperative course was complicated by respiratory and renal dysfunction, which resolved. After 6 months of support, the patient has normal organ function and is ambulatory. Follow-up oncologic evaluation of positron emission tomography-computed tomography scan is negative.

Pulmonary valve replacement for pacing electrodes related bacterial endocarditis.

Infective endocarditis of pulmonary valve requiring surgery is rare. We report a case of 80-year-old woman with a permanent pacemaker implanted 14 years ago. She had signs of infection resistant to antibiotic therapy, secondary cachexia, and dyspnea. Echocardiography examination revealed an infectious mass on pacing electrodes in the right atrium, right ventricular dysfunction, and pulmonary hypertension. Removal of the infected pacing system was indicated. During the operation, destruction of the pulmonary valve due to bacterial endocarditis was diagnosed. Replacement with a stented porcine valve was performed. The patient was discharged on postoperative day 20. Seven months after the operation, the patient is in a good condition.

Case report: atypical fungal obstruction of the left ventricular assist device outflow cannula

We describe a very rare case of outflow cannula obstruction with fungal infectious thrombus formation. Discussion includes the etiology, diagnosis, and management of fungal infection complications related with long-term mechanical circulatory support. Left ventricular assist devices (LVADs) are increasingly used as bridge to transplant and permanent long-term therapy in the population with end-stage heart failure. Even though better clinical outcomes have been achieved with the newer-generation continuous-flow devices, infection complications are still a major risk for patients with continuous-flow LVAD implantation in long-term follow-up [Ann Thorac Surg 90:1270-1277, 2010]. Device-related infections can be categorized as driveline infections, pump-pocket infections, and LVAD-associated endocarditis [Expert Rev Med Devices 8: 627-634, 2011]. The microbiological profile is very heterogeneous; the most common pathogens are Staphylococcus, Pseudomonas, Streptococcus species, and Candida. Severe fungal infection may lead to dysfunction of the LVAD due to obstructive mass formation within the device. Due to the only anecdotal reports in the current literature, we present a very rare case of outflow fungal infectious thrombus formation leading to outflow cannula obstruction in patient with LVAD.

Is severe cardiac dysfunction a contraindication for complex combined oncotherapy of Hodgkin's lymphoma? Not any more.

Hodgkins lymphoma is a quite frequent diagnosis, particularly in younger patients, which is normally treated effectively with combined chemotherapy and radiotherapy. Cardiomyopathy induced by these treatments is not uncommon and may progress to advanced-stage heart failure. Due to the cardiotoxicity of chemotherapy for Hodgkins disease, preexisting heart failure precludes usual therapy. We present a novel strategy of hemodynamic stabilization with an implantable left ventricular assist device (LVAD) prior to radical oncotherapy for Hodgkins lymphoma. A 33-year-old man with a short history of progressive heart failure was hospitalized due to progressive symptoms. An echocardiogram revealed a dilated left ventricle with an ejection fraction of 18%, moderate right ventricular dysfunction, and moderate to severe tricuspid regurgitation. Supradiaphragmatic-stage Hodgkins lymphoma was also diagnosed. Due to severe cardiac dysfunction, the patient was not a candidate for the usual chemotherapy and radiotherapy prescribed for this diagnosis. After multidisciplinary consultation and consent from the patient, an LVAD was implanted with tricuspid valve repair. Additionally, affected lymph nodes from the ventral upper mediastinum were excised, and pathological analysis confirmed the lymphoma diagnosis. The patient recovered from surgery and the postoperative course was uneventful. With LVAD support and normalized hemodynamics, chemotherapy and radiotherapy for his Hodgkins lymphoma were completed, and the patient remains in complete remission documented by positron emission tomography/computed tomography and is well one since LVAD implantation.

Comprehensive management of severe intestinal bleeding in a patient supported for 94 days by the biventricular Levitronix CentriMag system.

The use of short-term mechanical circulatory support during postcardiotomy acute heart failure provides an opportunity to stabilize the patients hemodynamic state while determining the best long-term strategy. Because all of these devices require anticoagulation treatment of various intensities, management of major bleeding can be critical for the overall outcome of the therapy. In this regard, the newest generation of magnetically levitated centrifugal-flow pumps affords several potential advantages in terms of thrombogenicity and eventual discontinuation of anticoagulation treatment. We report the use of a short-term biventricular assist device (Levitronix CentriMag) for 94 days in a 55-year-old man with refractory ventricular arrhythmias after combined heart surgery. Despite serious complications while the patient was on the assist device, including severe intestinal bleeding with the necessity of discontinuing anticoagulation for 10 days and, ultimately, hemicolectomy, the circulatory support was completed with successful heart transplantation.

Single-stage extensive chronic type A dissecting aortic aneurysm repair and continuous-flow ventricular assist device implantation.

The surgical technique of simultaneous heart transplantation and aortic aneurysm repair has been reported previously. However, there is a subgroup of patients with end-stage cardiomyopathy requiring major aortic surgery who do not meet heart transplant criteria. The optimal treatment strategy for these patients is still to be defined. In this report, we describe the use of an implantable continuous-flow left ventricular assist device (LVAD) as an adjunct to extensive aortic repair for providing patients with an acceptable risk surgical alternative to palliative treatment. To the best of our knowledge, this is the first report of this approach in the published literature.

Atypical fungal obstruction of the left ventricular assist device outflow cannula

Background Even if better clinical outcomes have been achieved with the implantation of newer generation continuous-flow left ventricular assist devices (LVADs), infection complications are still a major risk for these patients in longterm follow-up. We present a case of a 56-year-old male with dilated cardiomyopathy who was urgently implanted with left ventricular assist device HeartMate II. During the entire postoperative period, we observed repeated life-threatening septic complications. Clinical signs of infection disappeared after prolonged treatment with broad-spectrum antibiotics and patient was discharged to outpatient monitoring. During the entire duration of circulatory support, no LVAD suction events were detected, pump power consumption remained in the normal range and the patient was listed for heart transplantation. Patient was two month rehospitalized due to worsening of his status. Hemoglobinuria, an increase of inflammatory markers, and alteration in hepatic and renal function were detected. TEE imaging showed no obstructive formation in inflow or outflow cannulas; only velocities were decreased. The LV was severely dilated and the aortic valve was opening at each contraction. Patient was initially considered for systemic thrombolysis, but this urgent status was finally solved with explantation of the LVAD and subsequent heart transplantation. Massive obstruction with thrombuslike formation was found in the outflow cannula. Histopathologic examination and microbiologic culturing of the mass showed extensive fungal growth (Aspergillus species). During the postoperative period, patient was aggressively treated with antifungal therapy. He was discharged 8 weeks after the transplantation. Conclusion We believe that clinical decision-making in patients with signs of ongoing sepsis and end-organ dysfunction together with any signs of LVAD malfunction should be very straightforward in terms of device exchange or explantation.