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1.
Left Atrial Appendage Closure: Prevention and Management of Periprocedural and Postprocedural Complications.
Wilkins, B, Fukutomi, M, De Backer, O, Søndergaard, L
Cardiac electrophysiology clinics. 2020;(1):67-75
Abstract
Left atrial appendage closure (LAAC) is noninferior to oral vitamin K antagonist therapy for the reduction of nonvalvular atrial fibrillation-related stroke risk. Currently, the procedure is most widely accepted in patients who cannot tolerate oral anticoagulants. This patient population is generally comorbid, making any reduction in procedural complications paramount. LAAC has important complications described in the periprocedural and postprocedural periods. The prevention and management of complications regarding vascular access, transseptal puncture, pericardial effusion, device embolization, stroke, air embolusperidevice leak, device-related thrombus and device erosion/ late pericardial effusion are discussed.
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2.
Homozygous Familial Hypercholesterolemia: Anesthetic Challenges and Review of Literature.
Ladha, S, Makhija, N, Kiran, U, Aarav, SK
World journal for pediatric & congenital heart surgery. 2020;(4):NP83-NP87
Abstract
Homozygous familial hypercholesterolemia (HoFH; Fredrickson IIa) is a rare autosomal dominant hereditary disease associated with increased low-density lipoprotein cholesterol. We hereby report anesthetic challenges in a rare case of HoFH having severe progressive aortic stenosis, mitral regurgitation, diffuse aortic and carotid vessel involvement, and severe left ventricular dysfunction. The patient underwent a Konno aortoventriculoplasty with mechanical prosthesis along with mitral valve repair.
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3.
Vitamin B12 for the treatment of vasoplegia in cardiac surgery and liver transplantation: a narrative review of cases and potential biochemical mechanisms.
Charles, FG, Murray, LJ, Giordano, C, Spiess, BD
Canadian journal of anaesthesia = Journal canadien d'anesthesie. 2019;(12):1501-1513
Abstract
PURPOSE Hydroxocobalamin, or vitamin B12 (V-B12), is frequently used to treat smoke inhalation and cyanide poisoning. Recent reports have also described its use to treat vasoplegia in cardiac surgery and liver transplantation. This narrative review discusses this "off-label" indication for V-B12, focusing on the potential biochemical mechanisms of its actions. SOURCE PubMed, Cochrane, and Web of Science databases were searched for clinical reports on the use of V-B12 for vasoplegia in cardiac surgery and liver transplantation, with the biochemical mechanisms discussed being based on a survey of the related biochemistry literature. PRINCIPAL FINDINGS Forty-four patients have been treated with V-B12 for vasoplegia in various isolated case reports and one series. Although 75% of patients have increased blood pressure in response to V-B12, there were some "non-responders". The true efficacy remains unknown because clinical trials have not been performed, and significant reporting bias likely exists. Plausible biochemical explanations exist for the potential beneficial effects of V-B12 in treating vasoplegia, including binding nitric oxide and other gasotransmitters. Additional research is required to clarify if and how these mechanisms are causally involved in effective clinical responders and non-responders. CONCLUSIONS Although anecdotal reports utilizing V-B12 for vasoplegia are available, no higher-level evidence exists. Future work is necessary to further understand the dosing, timing, adverse events, and biochemical mechanisms of V-B12 compared with other therapies such as methylene blue.
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4.
Use of dexmedetomidine in pediatric cardiac anesthesia.
Kiski, D, Malec, E, Schmidt, C
Current opinion in anaesthesiology. 2019;(3):334-342
Abstract
PURPOSE OF REVIEW In recent years, ultrafast-track anesthesia with on-table extubation and concepts of accelerated postoperative care have gained increasing support in pediatric congenital cardiac surgery. It is believed that such approaches might ideally combine economic benefits with a striving for continuous improvement of patient outcomes. The present review summarizes the role of dexmedetomidine (DEX) in this setting. RECENT FINDINGS DEX is a clinical multipurpose drug that mediates its diverse responses through the activation of α2-adrenoreceptors. In pediatric cardiac surgery it has various applications. Used as a premedication, DEX provides arousable sedation and anxiolysis. As an intraoperative adjunctive agent of balanced general anesthesia the primary objectives for its administration are attenuation of the neuro-humoral stress response and facilitation of early extubation. During ICU treatment DEX spares opioids, prevents the risk of postoperative delirium or emergence agitation and impacts on important patient-centered outcomes, such as duration of mechanical ventilation, restart of enteral nutrition or length of ICU stay. SUMMARY Due to a favorable mix of beneficial physiologic actions and a limited adverse effect profile, DEX is established in the perioperative pediatric cardiac surgery setting. However, evidence from high-quality randomized controlled trials on the effects of supplemental DEX on meaningful patient outcomes is scarce, and research on the role of DEX in providing cardioprotection, neuroprotection, or renoprotection is still at its beginning. DEX has developed to one of the main agents in the armamentarium of cardiac anesthesiologists and pediatric intensivists, but it should not be regarded as the new 'magic bullet'.
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5.
Selenium in Cardiac Surgery.
Wendt, S, Schomburg, L, Manzanares, W, Stoppe, C
Nutrition in clinical practice : official publication of the American Society for Parenteral and Enteral Nutrition. 2019;(4):528-539
Abstract
Selenium (Se) is an essential trace element that plays a pivotal role in many of the body's regulatory and metabolic functions, especially during times of stress. After uptake, Se is incorporated into several Se-dependent proteins, which have potent anti-inflammatory and antioxidant capacities. Several observational clinical studies have demonstrated that Se deficiency can cause chronic cardiovascular diseases and aggravate organ dysfunction after cardiac surgery and that low levels of Se may be independently associated with the development of organ dysfunction after cardiac surgery. Based on these findings, several studies have investigated the effects of a perioperative Se supplementation strategy. Therefore, the present review describes in depth the pathophysiology and harmful stimuli during cardiac surgery, how Se may counteract these injuries, the different types of Se supplementation strategies that have been evaluated, and current evidence of its clinical significance.
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6.
A comprehensive program for preterm infants with patent ductus arteriosus.
Apalodimas, L, Waller Iii, BR, Philip, R, Crawford, J, Cunningham, J, Sathanandam, S
Congenital heart disease. 2019;(1):90-94
Abstract
OBJECTIVES Patent ductus arteriosus (PDA) is a common finding in preterm infants. A hemodynamically significant PDA may require intervention for closure. This article aims to describe a transcatheter PDA closure (TCPC) program for preterm infants and the components of a comprehensive outpatient follow-up strategy. SETTING A multidisciplinary team approach including neonatology, cardiology, anesthesiology, medical transport team, pulmonology, cardiac surgery, neurodevelopmental specialist, nutrition, speech therapy, social work, research collaborators, and other health care specialists is integral to the dedicated care and promotion of wellness of extremely low birth weight (ELBW) infants. PATIENTS To date, we have performed TCPC on 134 ELBW infants weighing <2 kg at the time of the procedure, 54 of whom were <1 kg with the smallest weighing 640 g with a median gestation age of 25 weeks (range 23-27 weeks). INTERVENTIONS A comprehensive follow-up strategy with the creation of the Memphis PDA Clinic was implemented. OUTCOME MEASURES Respiratory support, tolerance of enteral feeds, growth, and neurodevelopmental progress are indicators of favorable outcomes. RESULTS TCPC has benefited ELBW infants with faster weaning off the ventilator, increase in enteral feedings, and somatic growth with the overall shortening of the hospital length of stay. The Memphis PDA Clinic has ensured optimal postdischarge follow-up to improve long-term outcomes. CONCLUSIONS TCPC is a safe and effective alternative to manage ELBW infants with a hemodynamically significant PDA. Comprehensive follow-up after discharge provided in a multispecialty clinic developed specifically for this unique population has been successful in improving outcomes.
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7.
Modulating Perioperative Ventricular Excitability.
Howard-Quijano, K, Kuwabara, Y
Anesthesiology clinics. 2019;(4):609-619
Abstract
Ventricular arrhythmias are associated with significant morbidity and mortality. In the perioperative period, more than 10% of patients undergoing a general anesthetic have an abnormal heart rhythm. Arrhythmia development is a dynamic interplay between an arrhythmogenic substrate, myocardial electrophysiologic properties, modifying factors, and triggering factors. Imbalances in the autonomic nervous system can lead to increased myocardial excitability, which is a major contributor to the pathophysiology of ventricular tachyarrhythmias. Myocardial excitability and ventricular arrhythmogenesis is modulated perioperatively through hemodynamic management, electrolyte balance, anesthetic agents, or regional anesthetic and surgical techniques.
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8.
Sole and combined vitamin C supplementation can prevent postoperative atrial fibrillation after cardiac surgery: A systematic review and meta-analysis of randomized controlled trials.
Shi, R, Li, ZH, Chen, D, Wu, QC, Zhou, XL, Tie, HT
Clinical cardiology. 2018;(6):871-878
Abstract
We undertook a systematic review and meta-analysis to evaluate the effect of vitamin C supplementation (vitamin C solely or as adjunct to other therapy) on prevention of postoperative atrial fibrillation (POAF) in patients after cardiac surgery. PubMed, Embase, Web of Science, and Cochrane Library were systematically searched to identify randomized controlled trials assessing the effect of vitamin C supplementation in adult patients undergoing cardiac surgery, and the meta-analysis was performed with a random-effects model. Thirteen trials involving 1956 patients were included. Pooling estimate showed a significantly reduced incidence of POAF (relative risk [RR]: 0.68, 95% confidence interval [CI]: 0.54 to 0.87, P = 0.002) both in vitamin C alone (RR: 0.75, 95% CI: 0.63 to 0.90, P = 0.002) and as an adjunct to other therapy (RR: 0.32, 95% CI: 0.20 to 0.53, P < 0.001). The results remain stable and robust in subgroup and sensitivity analyses, and trial sequential analysis also confirmed that the evidence was sufficient and conclusive. Additionally, vitamin C could significantly decrease intensive care unit length of stay (weighted mean difference: -0.24 days, 95% CI: -0.45 to -0.03, P = 0.023), hospital length of stay (weighted mean difference: -0.95 days, 95% CI: -1.64 to -0.26, P = 0.007), and risk of adverse events (RR: 0.45, 95% CI: 0.21 to 0.96, P = 0.039). Use of vitamin C alone and as adjunct to other therapy can prevent POAF in patients undergoing cardiac surgery and should be recommended for patients receiving cardiac surgery for prevention of POAF.
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9.
[Role of Nutrition Support in Cardiac Surgery Patients - an Overview].
Hill, A, Goetzenich, A, Marx, G, Stoppe, C
Anasthesiologie, Intensivmedizin, Notfallmedizin, Schmerztherapie : AINS. 2018;(6):466-479
Abstract
Cardiac surgery patients regularly experience a systemic inflammation response to the surgery and a postoperative stay in the intensive care unit. Nutritional support is one strategy to improve the outcome of cardiosurgical patients. A preoperatively diagnosed malnutrition contributes to a higher morbidity and mortality in this patient group. Preoperative fasting, glucose-free infusions during long and invasive operations and delayed postoperative nutrition therapy aggravate the nutrition situation. However, conclusive evidence for this population, consisting of well-conducted clinical trials is lacking.This article outlines the main causes for malnutrition in cardiosurgical patients and summarizes possibilities to identify patients at high nutritional risk, who are most likely to profit from aggressive nutritional therapy. Despite conspicuous knowledge and evidence gaps, a rational nutritional support therapy based on current recommendations of ASPEN, ESPEN and an international multidisciplinary consensus group is presented. The amount and kind of nutrition, as well as the best time to initiate nutrition support, ways to monitor nutrition therapy and the potential use of pharmaconutrition to modulate the inflammatory response to cardiopulmonary bypass are presented to benefit patients undergoing cardiac surgery.
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10.
Global epidemiology and outcomes of acute kidney injury.
Hoste, EAJ, Kellum, JA, Selby, NM, Zarbock, A, Palevsky, PM, Bagshaw, SM, Goldstein, SL, Cerdá, J, Chawla, LS
Nature reviews. Nephrology. 2018;(10):607-625
Abstract
Acute kidney injury (AKI) is a commonly encountered syndrome associated with various aetiologies and pathophysiological processes leading to decreased kidney function. In addition to retention of waste products, impaired electrolyte homeostasis and altered drug concentrations, AKI induces a generalized inflammatory response that affects distant organs. Full recovery of kidney function is uncommon, which leaves these patients at risk of long-term morbidity and death. Estimates of AKI prevalence range from <1% to 66%. These variations can be explained by not only population differences but also inconsistent use of standardized AKI classification criteria. The aetiology and incidence of AKI also differ between high-income and low-to-middle-income countries. High-income countries show a lower incidence of AKI than do low-to-middle-income countries, where contaminated water and endemic diseases such as malaria contribute to a high burden of AKI. Outcomes of AKI are similar to or more severe than those of patients in high-income countries. In all resource settings, suboptimal early recognition and care of patients with AKI impede their recovery and lead to high mortality, which highlights unmet needs for improved detection and diagnosis of AKI and for efforts to improve care for these patients.