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Effect of methylprednisolone on acute kidney injury in patients undergoing cardiac surgery with a cardiopulmonary bypass pump: a randomized controlled trial.
Garg, AX, Chan, MTV, Cuerden, MS, Devereaux, PJ, Abbasi, SH, Hildebrand, A, Lamontagne, F, Lamy, A, Noiseux, N, Parikh, CR, et al
CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2019;(9):E247-E256
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Abstract
BACKGROUND Perioperative corticosteroid use may reduce acute kidney injury. We sought to test whether methylprednisolone reduces the risk of acute kidney injury after cardiac surgery. METHODS We conducted a prespecified substudy of a randomized controlled trial involving patients undergoing cardiac surgery with cardiopulmonary bypass (2007-2014); patients were recruited from 79 centres in 18 countries. Eligibility criteria included a moderate-to-high risk of perioperative death based on a preoperative score of 6 or greater on the European System for Cardiac Operative Risk Evaluation I. Patients (n = 7286) were randomly assigned (1:1) to receive intravenous methylprednisolone (250 mg at anesthetic induction and 250 mg at initiation of cardiopulmonary bypass) or placebo. Patients, caregivers, data collectors and outcome adjudicators were unaware of the assigned intervention. The primary outcome was postoperative acute kidney injury, defined as an increase in the serum creatinine concentration (from the preoperative value) of 0.3 mg/dL or greater (≥ 26.5 μmol/L) or 50% or greater in the 14-day period after surgery, or use of dialysis within 30 days after surgery. RESULTS Acute kidney injury occurred in 1479/3647 patients (40.6%) in the methylprednisolone group and in 1426/3639 patients (39.2%) in the placebo group (adjusted relative risk 1.04, 95% confidence interval 0.96 to 1.11). Results were consistent across several definitions of acute kidney injury and in patients with preoperative chronic kidney disease. INTERPRETATION Intraoperative corticosteroid use did not reduce the risk of acute kidney injury in patients with a moderate-to-high risk of perioperative death who had cardiac surgery with cardiopulmonary bypass. Our results do not support the prophylactic use of steroids during cardiopulmonary bypass surgery. Trial registration: ClinicalTrials.gov, no. NCT00427388.
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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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Genome-wide association study of myocardial infarction, atrial fibrillation, acute stroke, acute kidney injury and delirium after cardiac surgery - a sub-analysis of the RIPHeart-Study.
Westphal, S, Stoppe, C, Gruenewald, M, Bein, B, Renner, J, Cremer, J, Coburn, M, Schaelte, G, Boening, A, Niemann, B, et al
BMC cardiovascular disorders. 2019;(1):26
Abstract
BACKGROUND The aim of our study was the identification of genetic variants associated with postoperative complications after cardiac surgery. METHODS We conducted a prospective, double-blind, multicenter, randomized trial (RIPHeart). We performed a genome-wide association study (GWAS) in 1170 patients of both genders (871 males, 299 females) from the RIPHeart-Study cohort. Patients undergoing non-emergent cardiac surgery were included. Primary endpoint comprises a binary composite complication rate covering atrial fibrillation, delirium, non-fatal myocardial infarction, acute renal failure and/or any new stroke until hospital discharge with a maximum of fourteen days after surgery. RESULTS A total of 547,644 genotyped markers were available for analysis. Following quality control and adjustment for clinical covariate, one SNP reached genome-wide significance (PHLPP2, rs78064607, p = 3.77 × 10- 8) and 139 (adjusted for all other outcomes) SNPs showed promising association with p < 1 × 10- 5 from the GWAS. CONCLUSIONS We identified several potential loci, in particular PHLPP2, BBS9, RyR2, DUSP4 and HSPA8, associated with new-onset of atrial fibrillation, delirium, myocardial infarction, acute kidney injury and stroke after cardiac surgery. TRIAL REGISTRATION The study was registered with ClinicalTrials.gov NCT01067703, prospectively registered on 11 Feb 2010.
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ZipFix Versus Conventional Sternal Closure: One-Year Follow-Up.
Nezafati, P, Shomali, A, Kahrom, M, Omidvar Tehrani, S, Dianatkhah, M, Nezafati, MH
Heart, lung & circulation. 2019;(3):443-449
Abstract
BACKGROUND The present study aimed to compare postoperative complications commonly revealed after sternotomy closure by new sternal ZipFix™ (Synthes GmbH, Oberdorf, Switzerland) implant and conventional steel wire. METHODS Among the initial 360 subjects, 326 patients enrolled in this randomised control trial who were candidates for cardiac surgery from April 2014 to March 2015. After the surgery, the sternal closure was randomly done with poly-ether-ether-ketone (PEEK) based sternal ZipFix (ZF) on the sternal body (n=168) or with conventional wires (CWs) (n=158). Patients were followed postoperatively as well as 1, 3, 6, and 12 months after discharge regarding postoperative complications such as pain severity, dehiscence, and infection including incisional infections (superficial or deep), and organ/space infection (mediastinitis or osteomyelitis). RESULTS The mean age of the ZF and CW groups were 63.58±10.9 and 62.42±7.1years, respectively (p=0.262). In addition, there was no significant difference between the two groups' baseline characteristics (p>0.05). Our study showed higher mean pain severity score in the conventional closure group compared with ZipFix closure group at all study time points (p<0.001). Infection was seen in 2.76% of the overall participants with no significant difference of incisional and organ infection between the two groups throughout the study. After 1-month follow-up, five patients in the CW group had sternal dehiscence whereas no patients in ZF had dehiscence (p<0.001). CONCLUSIONS Our trial demonstrates greater clinical advantages in terms of pain and sternal dehiscence post surgery by using sternal ZipFix compared to conventional steel wire.
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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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Heart Rehabilitation in patients awaiting Open heart surgery targeting to prevent Complications and to improve Quality of life (Heart-ROCQ): study protocol for a prospective, randomised, open, blinded endpoint (PROBE) trial.
Hartog, J, Blokzijl, F, Dijkstra, S, DeJongste, MJL, Reneman, MF, Dieperink, W, van der Horst, ICC, Fleer, J, van der Woude, LHV, van der Harst, P, et al
BMJ open. 2019;(9):e031738
Abstract
INTRODUCTION The rising prevalence of modifiable risk factors (eg, obesity, hypertension and physical inactivity) is causing an increase in possible avoidable complications in patients undergoing cardiac surgery. This study aims to assess whether a combined preoperative and postoperative multidisciplinary cardiac rehabilitation (CR) programme (Heart-ROCQ programme) can improve functional status and reduce surgical complications, readmissions and major adverse cardiac events (MACE) as compared with standard care. METHODS AND ANALYSIS Patients (n=350) are randomised to the Heart-ROCQ programme or standard care. The Heart-ROCQ programme consists of a preoperative optimisation phase while waiting for surgery (three times per week, minimum of 3 weeks), a postoperative inpatient phase (3 weeks) and an outpatient CR phase (two times per week, 4 weeks). Patients receive multidisciplinary treatment (eg, physical therapy, dietary advice, psychological sessions and smoking cessation). Standard care consists of 6 weeks of postsurgery outpatient CR with education and physical therapy (two times per week). The primary outcome is a composite weighted score of functional status, surgical complications, readmissions and MACE, and is evaluated by a blinded endpoint committee. The secondary outcomes are length of stay, physical and psychological functioning, lifestyle risk factors, and work participation. Finally, an economic evaluation is performed. Data are collected at six time points: at baseline (start of the waiting period), the day before surgery, at discharge from the hospital, and at 3, 7 and 12 months postsurgery. ETHICS AND DISSEMINATION This study will be conducted according to the principles of the Declaration of Helsinki (V.8, October 2013). The protocol has been approved by the Medical Ethical Review Board of the UMCG (no 2016/464). Results of this study will be submitted to a peer-reviewed scientific journal and can be presented at national and international conferences. TRIAL REGISTRATION NUMBER NCT02984449.
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Perioperative Vitamin C and E levels in Cardiac Surgery Patients and Their Clinical Significance.
Hill, A, Borgs, C, Fitzner, C, Stoppe, C
Nutrients. 2019;(9)
Abstract
BACKGROUND Oxidative stress contributes to organ dysfunction after cardiac surgery and still represents a major problem. Antioxidants, such as vitamins C and E might be organ protective. METHODS The primary objective of this prospective observational study was the description to evaluate the perioperative vitamin C and E levels in 56 patients undergoing cardiac surgery with the use of cardiopulmonary bypass. The association of vitamin C with inflammatory reaction, oxidative stress, organ dysfunctions, and clinical outcomes were evaluated in an explorative approach. RESULTS Vitamin C levels decreased significantly from 6.5 (3.5-11.5) mg/L before surgery to 2.8 (2.0-3.9) mg/L 48 h after surgery (p < 0.0001). Fifty-six percent of patients had a suboptimal vitamin C status even before surgery. In protein-denaturized probes, significantly higher vitamin C concentrations were detected (p = 0.0008). Vitamin E levels decreased significantly from preoperative level 11.6 (9.5-13.2) mg/L to 7.1 (5.5-7.4) mg/L, (p = 0.0002) at the end of cardiopulmonary bypass, remained low during the first day on ICU and recovered to 8.2 (7.1-9.3) mg/L 48 h after surgery. No patient was vitamin E deficient before surgery. Analysis showed no statistically significant association of vitamin C with inflammation, oxidative stress or organ dysfunction levels in patients with previously suboptimal vitamin C status or patients with a perioperative decrease of ≥50% vitamin C after surgery. Patients with higher vitamin C levels had a shorter ICU stay than those who were vitamin C depleted, which was not statistically significant (72 versus 135 h, p = 0.1990). CONCLUSION Vitamin C and E levels significantly declined intraoperatively and remained significantly reduced low for 2 days after cardiac surgery. The influence of reduced serum levels on the inflammatory reaction and clinical outcome of the patients remain unclear in this small observational study and need to be investigated further. Given vitamin C´s pleiotropic role in the human defense mechanisms, further trials are encouraged to evaluate the clinical significance of Vitamin C in cardiac surgery patients.
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Delirium After Cardiac Surgery and Cumulative Fluid Balance: A Case-Control Cohort Study.
Mailhot, T, Cossette, S, Lambert, J, Beaubien-Souligny, W, Cournoyer, A, O'Meara, E, Maheu-Cadotte, MA, Fontaine, G, Bouchard, J, Lamarche, Y, et al
Journal of cardiothoracic and vascular anesthesia. 2019;(1):93-101
Abstract
OBJECTIVE To assess a novel hypothesis to explain delirium after cardiac surgery through the relationship between cumulative fluid balance and delirium. This hypothesis involved an inflammatory process combined with a hypervolemic state, which could lead to venous congestion reaching the brain. DESIGN Retrospective case-control (1:1) cohort study. SETTING University-affiliated tertiary cardiology center. PARTICIPANTS Cardiac surgery intensive care unit (ICU) patients. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Cumulative fluid balance was evaluated at 3 times: (1) upon arrival at the ICU after surgery, (2) 24 hours post-ICU arrival, and (3) 48 hours post-ICU arrival. A generalized estimated equation was used to model the association between cumulative fluid balance and delirium occurrence 24 hours later. Covariates were selected based on the statistical differences between cases and controls on delirium risk factors and clinical characteristics. The cohort included 346 patients, of which 39 (11%), 104 (30%), and 142 patients (41%) presented delirium at 24, 48, and 72 hours post-ICU arrival, respectively. The effect of time had an odds ratio (OR) of 2.14, 95% confidence interval (CI) 1.603 to 2.851, and a p value < 0.001. The cumulative fluid balance was associated with delirium occurrence (OR 1.20, 95% CI: 1.066-1.355, p = .003). History of neurological disorder, having both hearing and visual impairment, type of procedure, perioperative cerebral oximetry, mean pulmonary artery pressure pre-cardiopulmonary bypass (CPB), and mean arterial pressure post-CPB also contributed to delirium in the model. CONCLUSION Delirium is associated with a cumulative fluid balance, but the extent through which this plays an etiologic role remains to be determined.
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Pharmacological and non-surgical renal protective strategies for cardiac surgery patients undergoing cardiopulmonary bypass: a systematic review.
Tan, SI, Brewster, DJ, Horrigan, D, Sarode, V
ANZ journal of surgery. 2019;(4):296-302
Abstract
BACKGROUND Post-operative acute kidney injury after cardiopulmonary bypass (AKI-CPB) for cardiac surgery is a frequent complication. It may require renal replacement therapy (RRT), which is associated with an increased morbidity and mortality. This review explores the efficacy of proposed pharmacological and non-surgical renal protective strategies. METHODS A comprehensive literature search was done using Ovid MEDLINE, Embase and Scopus databases. Keywords included were cardiopulmonary bypass, cardiac surgery, coronary artery bypass, renal protection and renal preservation. Eligible articles consisted of all studies on patients who had undergone cardiac surgery via CPB with an outcome of AKI and/or RRT reported. All studies underwent a quality check via the risk of bias tool. The three most researched interventions (based on number of randomized controlled trials and total patients analysed) and their renal outcomes were then analysed with Review Manager Software. RESULTS Eighty-eight articles were extracted. A total of 26 management strategies for renal protection following CPB were identified. N-acetylcysteine (NAC), remote ischaemic preconditioning (RIPC) and the use of volatile anaesthetic agents (VAAs) were further analysed. NAC, RIPC and VAA had no statistically significant benefit in reducing either AKI-CPB or the need for RRT following CPB. CONCLUSION NAC, RIPC and VAA were found to have no statistical significant benefit in reducing either AKI-CPB or the need for RRT following CPB. There remains clinical uncertainty with all currently proposed pharmacological and non-surgical renal protective strategies for CPB. Future research in this area should analyse the effects of combined interventions or specifically focus on 'at-risk' patients.
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Risk factors of cardiac surgery-associated acute kidney injury: development and validation of a perioperative predictive nomogram.
Guan, C, Li, C, Xu, L, Zhen, L, Zhang, Y, Zhao, L, Zhou, B, Che, L, Wang, Y, Xu, Y
Journal of nephrology. 2019;(6):937-945
Abstract
OBJECTIVE Cardiac surgery-associated acute kidney injury (CSA-AKI), one of the most severe complications in patients with cardiac surgery, is associated with considerable morbidity, mortality and high costs thus placing a heavy burden to society. Therefore, we aimed to build a predictive model based on preoperative features in order to early recognize and intervene for patients with high risk of CSA-AKI. METHODS In this retrospective cohort study, baseline perioperative hospitalization information of patients who underwent cardiac surgery from October 2012 to October 2017 were screened. After multivariate logistic regression, identified independent predictive factors associated with CSA-AKI were incorporated into the nomogram and the discriminative ability and predictive accuracy of the model was assessed by concordance index (C-Index). Additionally, internal validation was performed by using bootstrapping technology with 1000 resamples to reduce the over-fit bias. RESULTS In all 4395 patients with cardiac surgery October 2012-October 2017, no patients were excluded for the continuous renal replacement therapy (CRRT) before surgery while 2495 patients were excluded due to only one or less than one Scr assay post-surgery. In the end, a total of 1900 patients were enrolled in the study, of which 698 patients (74.89%) developed AKI stage 1, 158 (16.96%) AKI stage 2 and 76 (8.15%) AKI stage 3. After multivariate logistic regression, age, perioperative estimated glomerular filtration rate (eGFR), lactate dehydrogenase (LDH), prothrombin time (PT), with a history of surgery, transfusion, cardiac arrhythmia, coronary heart disease (CHD), or chronic kidney disease (CKD), using calcium channel blocker (CCB), proton pump inhibitors (PPI), non-steroidal anti-inflammatory drugs (NSAID), antibiotic or statin before surgery were predictive factors of CSA-AKI. In addition, the nomogram demonstrated a good accuracy in estimating CSA-AKI, with an C-Index and a bootstrap-corrected one of 0.796 (SD = 0.018, 95% CI 0.795-0.797) and 0.789 (SD = 0.015, 95% CI 0.788-0.790), respectively. Moreover, calibration plots showed an optimal consistency with the actual presence of CSA-AKI. CONCLUSION The novel predictive nomogram achieved a good preoperative prediction of CSA-AKI within the Kidney Disease: Improving Global Outcomes (KDIGO) criteria. Though the model, the risk of an individual patient with "subclinical AKI" undergoing cardiac surgery could be determined earlier and such application was helpful for timely intervention in order to improve patient's prognosis.