Perfusion-Uk最新文献

Coronary artery disease (CAD) remains one of the leading causes of death globally. In the United States of America, in 2016, 19% of all patients under the age of 65 died of cardiovascular disease despite improvements in primary prevention. The premature clinical onset of symptoms in the young population (<60 years) is much more aggressive than in the older population, and the overall long-term prognosis is poor. CAD appears to have a rapidly progressive form in those under the age of 60 due to genetic predisposition, smoking, and substance abuse, however, the ideal management strategy is still yet to be established. The two primary methods of establishing coronary revascularization are percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG). Despite the increasing prevalence of CAD in the young population, they are consistently underrepresented in major randomized clinical trials of each revascularization strategy. Both CABG and PCI are known to have similar survival rates, but PCI is associated with higher repeat revascularization rate. Many argue this may be due to the progressive nature of CAD combined with the vessel patency time required in a patient under 60 with potentially another 20-30 years of life. There is little in literature regarding the outcomes of these various revascularization strategies in populations under 60 years with CAD. This review summarises the current evidence for each revascularisation strategy in patients under the age of 60 and suggests future avenues of research for this unique age group.

Type A aortic dissection (TAAD) is a life-threatening disease with high mortality and poor prognosis, usually treated by surgery. There are many complications in its perioperative period, one of which is oxygenation impairment (OI). As a common complication of TAAD, OI usually occurs throughout the perioperative period of TAAD and requires prolonged mechanical ventilation (MV) and other supportive measures. The purpose of this article is to review the risk factors, mechanisms, and treatments of type A aortic dissection-related oxygenation impairment (TAAD-OI) so as to improve clinicians' knowledge about it. Among risk factors, elevated body mass index (BMI), prolonged extracorporeal circulation (ECC) duration, higher inflammatory cells and stored blood transfusion stand out. A reduced occurrence of TAAD-OI can be achieved by controlling these risk factors such as suppressing inflammatory response by drugs. As for its mechanism, it is currently believed that inflammatory signaling pathways play a major role in this process, including the HMGB1/RAGE signaling pathway, gut-lung axis and macrophage, which have been gradually explored and are expected to provide evidences revealing the specific mechanism of TAAD-OI. Numerous treatments have been investigated for TAAD-OI, such as nitric oxide (NO), continuous pulmonary perfusion/inflation, ulinastatin and sivelestat sodium, immunomodulation intervention and mechanical support. However, these measures are all aimed at postoperative TAAD-OI, and not all of the therapies have shown satisfactory effects. Treatments for preoperative TAAD-OI are not currently available because it is difficult to correct OI without correcting the dissection. Therefore, the best solution for preoperative TAAD-OI is to operate as soon as possible. At present, there is no specific method for clinical application, and it relies more on the experience of clinicians or learns from treatments of other diseases related to oxygenation disorders. More efforts should be made to understand its pathogenesis to better improve its treatments in the future.

Background: Although the Avalon Elite bi-caval dual lumen catheter for veno-venous extracorporeal membranous oxygenation (ECMO) has many advantages, it requires precise positioning and dislodgement is common.Case presentation: A 2-year-old male was placed on ECMO due to respiratory failure utilizing a 20 Fr Avalon Elite bi-caval dual lumen catheter (AEC). The AEC migrated twice with unsuccessful repositioning using the classic manual manipulations. The AEC was successfully repositioned on the two occasions using a novel method by direct access of the ECMO inflow tube using a combination of catheter and guide wire.Conclusions: A migrated AEC could be successfully repositioned with simple direct access of the inflow tube. This technique was successfully utilized twice at the bedside in an infant without needing additional venous access.

Multisystem inflammatory disease in childhood (MIS-C) is a novel pediatric syndrome after a COVID-19 infection that causes systemic injury, with potential life-threatening hemodynamic compromise requiring Extracorporeal Membrane Oxygenation (ECMO) support. We performed an observational retrospective cohort study in children aged 0-18 years with MIS-C and non-MIS-C myocarditis on ECMO between January 2020 and December 2021, using the ELSO Registry database. We aimed to compare the outcomes of both populations and to identify factors for decreased survival in MIS-C patients on ECMO. The Extracorporeal Life Support Organization (ELSO) Registry reported 310 pediatric ECMO patients with MIS-C (56.1%) and non-MIS-C myocarditis (43.9%). No difference was found in survival to hospital discharge between groups (67.2% for MIS-C vs 69.1% for non-MIS-C myocarditis, p 0.725). Multivariable analysis demonstrated that ECPR and co-infection were significantly associated with decreased survival to hospital discharge in MIS-C patients (OR 0.138, p 0.01 and OR 0.44, p 0.02, respectively). Outcomes of children with MIS-C on ECMO support are similar to those of non-MIS-C myocarditis despite higher infectious, multiorgan dysfunction and respiratory complications accompanying COVID-19 infections. The use of ECMO for MIS-C patients seems to be feasible and safe. Prospective studies on the use of ECMO support in MIS-C patients may improve outcomes in this pediatric population.

Objectives: Colloids are added to the priming solution of the cardiopulmonary bypass (CPB) pump to maintain colloid osmotic pressure and prevent fluid overload. This study aimed to compare the effects of 6% hydroxyethyl starch (HES) 130/0.4 and ringer's lactate (RL) priming solution on patients' outcomes undergoing isolated heart valve surgery with CPB.

Methods: This randomized clinical trial included one hundred and 20 patients undergoing heart valve surgery, and those were allocated into two groups. Patients in the RL group received 1500 mL of RL, and those in the RL + HES group were given 500 mL of HES and 1000 mL of RL.

Results: The patients' median age was 52 (IQR 42-60) and 50 (IQR 40-61) years in the RL + HES and the RL group, respectively (p = .71). The number of cases that required blood product transfusion in both the operating room and intensive care unit was also significantly higher in the RL + HES group compared to the RL group (RR 2.04, 95% CI 1.50-2.76; p < .01 and RR 1.42, 95% CI 1.01-2.01; p = .05, respectively). Declines in postoperative creatinine levels and platelet counts were higher in the RL + HES compared to the RL group (between-subjects effect p = .007 and p = .038, respectively), while the incidence of acute kidney injury was comparable between groups (RR 0.66, 95% CI 0.13-3.30; p = .55).

Conclusions: Among patients undergoing heart valve surgery with CPB, 6% HES added to RL for priming compared with only RL increased the risk of the need for blood product transfusion over the hospitalization period.

Objectives: In patients with left heart disease and severe aortic stenosis (AS), pulmonary hypertension (PH) is a common comorbidity and predictor of poor prognosis. Untreated AS aggravates PH leading to an increased right ventricular afterload and, in line to right ventricular dysfunction. The surgical benefit of aortic valve replacement (AVR) in elderly patients with severe AS and PH could be limited due to the multiple comorbidities and poor outcomes. Therefore, we purposed to investigate the impact of PH on short-term outcomes in patients with moderate to severe AS who underwent surgical AVR in our heart center.

Methods: In this study we retrospectively analyzed a cohort of 99 patients with severe secondary post-capillary PH who underwent surgical AVR (AVR + PH group) at our heart center between 2010 and 2021 with a regard to perioperative outcomes. In order to investigate the impact of PH on short-term outcomes, the control group of 99 patients without pulmonary hypertension who underwent surgical AVR (AVR group) at our heart center with similar risk profile was accordingly analyzed regarding pre-, intra- and postoperative data.

Results: Atrial fibrillation occurred significantly more often (p = .013) in patients who suffered from PH undergoing AVR. In addition, the risk for cardiac surgery (EUROSCORE II) was significantly higher (p < .001) in the above-mentioned group. Likewise, cardiopulmonary bypass time (p = .018), aortic cross-clamp time (p = .008) and average operation time (p = .009) were significantly longer in the AVR + PH group. Furthermore, the in-hospital survival rate was significantly higher (p = .044) in the AVR group compared to the AVR + PH group. Moreover, the dialysis rate was significantly higher (p < .001) postoperatively in patients who suffered PH compared to the patients without PH undergoing AVR.

Conclusion: In our study, patients with severe PH and severe symptomatic AS who underwent surgical aortic valve replacement showed adverse short-term outcomes compared to patients without PH.

Introduction: Conventional vein grafts have a high risk of thrombosis and early atherosclerosis. Percutaneous coronary intervention (PCI) in conventional vein grafts is associated with a higher incidence of late adverse cardiac events. The aim of this study was to evaluate the long-term results after PCI in saphenous vein grafts (SVG) harvested with the no-touch technique compared to the conventional technique.

Methods: This was a single-center, retrospective, cohort study, based on data from the Swedeheart register. The inclusion criterion was individuals who underwent CABG using different vein graft techniques between January 1992 and July 2020, and who required a PCI in SVGs between January 2006 and July 2020. The primary end point was long-term in-stent restenosis. The secondary endpoints were long-term major adverse cardiac events (MACE) and 1-year re-hospitalization rates. The associations between the graft types and the endpoints were evaluated using the Fine and Gray competing-risk regression analysis.

Results: The study included 346 individuals (67 no-touch, 279 conventional). The mean clinical follow-up time was 6.4 years with a standard deviation of 3.7 years. The long-term in-stent restenosis rate for the no-touch grafts was 3.2% compared to 18.7% for the conventional grafts (p < .01), with a subdistribution hazard ratio (SHR) of 0.16 (p = .010). The long-term MACE rate was 27.0% in the no-touch group and 48.3% in the conventional group (p < .01) with a SHR of 0.53 (p = .017). The short-term results were similar in both groups.

Conclusions: Percutaneous coronary intervention in a no-touch vein graft was associated with statistically significantly fewer in-stent restenoses and MACE at long-term follow-up compared to a conventional SVG.

Introduction: Cardioplegia (CP) is integral to myocardial protection during cardiac surgery. Two standard cardioplegic solutions viz. Del Nido solution (DNS) and St Thomas solution (STS) are widely used in cardiac surgeries. The DNS is a single-dose CP that offers superior myocardial protection in adults, and studies have claimed myocardial injury in STS patients. The elevated circulatory level of citric acid cycle intermediate, succinate is a metabolic hallmark of ischemia. Its rapid oxidation after reperfusion causes ischemia-reperfusion (IR) injury through mitochondrial reactive oxygen species production. Succinate has been identified as an early marker of IR injury through blood plasma/serum-based clinical metabolomics studies. The primary objective of the study was metabolomic profiling of succinate from the coronary sinus and venous blood.

Methods: Two blood samples each were obtained from coronary sinus (CS) & venous reservoir from patients before the application of aortic cross-clamp and after the release of aortic cross-clamp from 22 patients divided into two groups. The blood-serum metabolic profiles were measured by 800 MHz NMR spectrometer and compared using univariate statistical analysis methods. The study also compared the two groups' cardiopulmonary bypass variables and left ventricle functions.

Result: DNS leads to increased serum levels of succinate in the coronary sinus blood after the reperfusion compared to STS. The results of our study are consistent with a previous study that found DNS administration (90 minutes) increases the inflammatory response in the myocardium.

Conclusion: NMR-based serum metabolomics revealed significantly increased circulatory succinate in coronary sinus blood of patients administered with DNS cardioplegia in comparison to STS cardioplegia. URL- https://ctri.nic.in/Clinicaltrials/login.php.

Introduction: No clear guidelines exist for unfractionated heparin (UFH) monitoring in adult patients on veno-arterial extracorporeal life support (VA-ECLS) for refractory cardiogenic shock. In this study, we sought to compare outcomes between anti-factor Xa (FXa) and activated partial thromboplastin time (aPTT) strategies for UFH monitoring during VA-ECLS.

Methods: This is a single-center, retrospective review of VA-ECLS patients who received UFH in the cardiothoracic intensive care unit between July 2019 and November 2023. Standard protocol for UFH titration was aPTT goal of 45-60 sec (n = 52) before September 2021, then transitioned to FXa goal of 0.1-0.2 U/mL (n = 50) thereafter. Inverse probability of treatment weighting was used to balance baseline differences between cohorts.

Results: In adjusted analyses, 89.3% of FXa patients and 76.0% of aPTT patients achieved goal range for their respective assay. Total UFH duration (4.0 vs 4.0 days, p = .239) and maximum weight-adjusted UFH dose (9.3 vs 9.4 U/hr/kg, p = .823) remained comparable between adjusted FXa and aPTT cohorts. Moreover, in-hospital mortality (50.3% vs 33.9%, p = .133), major bleeding events (20.6% vs 11.2%, p = .292), and thromboembolic events (30.1% vs 30.1%, p = .998) were not significantly different. Extracorporeal circuit thrombosis and cannula site bleeding were the most frequent events in both groups. Multivariate logistic regression found the FXa strategy was not a significant risk factor for the composite outcome of major bleeding or thromboembolism (OR [95% CI]: 1.539 [0.575, 4.116], p = .393).

Conclusions: In adult VA-ECLS patients at our institution, bleeding and thromboembolic complications occurred at a similar rate regardless of which UFH monitoring strategy was utilized. Further studies in larger and more institutionally diverse cohorts are warranted.

Introduction: Extracorporeal membrane oxygenation (ECMO) provides critical support to patients in severe cardiac and respiratory failure, but it requires anticoagulation to prevent complications like bleeding and thrombosis. Heparin, the primary anticoagulant utilized, is monitored by activated partial thromboplastin time (aPTT) and anti-Factor Xa (AntiXa) levels. Discordance between the two assays complicates its titration and the impact on patient outcomes is not well-established. This study examines the prevalence of discordance, its impact on heparin dosing, and the association of bleeding, thrombosis, ICU-free days, and mortality in pediatric ECMO patients.

Methods: This secondary analysis of the Bleeding and Thrombosis on Extracorporeal Membrane Oxygenation study consisted of 511 patients under 19 years. Demographics, laboratory results, ECMO indications, daily heparin doses, and clinical outcomes were collected. Discordance was categorized as major or minor, and adjustments to heparin dosing were analyzed for appropriateness based on normal ranges of aPTT and AntiXa. Logistic regression models assessed the impact of heparin titration strategies on bleeding, clotting, ICU-free days, and mortality.

Results: Major discordance occurred on 17.5% of days with high aPTT and low AntiXa being most common. Titrating heparin based on AntiXa in scenarios of discordance was associated with an 11% lower incidence of bleeding compared to aPTT (p = .02). Higher proportion of concordance was independently associated with increased bleeding and/or clotting, but not significantly affect ICU-free days or mortality.

Conclusion: Discordance is common in pediatric ECMO patients. AntiXa-guided heparin titration, notably during discordant periods, is associated with fewer bleeding and clotting events. This emphasizes the need for improved anticoagulation protocols since discordance does not demonstrate worse ICU-free days or mortality.