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Concept: Cardiopulmonary bypass

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OBJECTIVESA sternal-sparing approach for bilateral lung transplantation was recently applied to reoperative lung transplant cases and is compared with the traditional clamshell approach.METHODSA retrospective analysis of 15 consecutive reoperative bilateral lung transplants performed from January 2008 to April 2011 was conducted. Outcomes were compared between the first 11 patients who underwent the traditional clamshell and the most recent 4 patients who underwent the sternal-sparing approach.RESULTSThe indication for retransplantation was obliterative bronchiolitis in all patients. Both groups were similar with regard to age, allograft ischaemic time and operative time. Cardiopulmonary bypass was more frequent in the sternal-sparing group although required for a shorter period of time. The need for postoperative extracorporeal membrane oxygenation for primary graft dysfunction was similar in both groups. The length of ICU care and total hospitalization length of stay were similar for the sternal-sparing group compared with the traditional clamshell approach. Operative mortality and overall survival also did not differ.CONCLUSIONSReoperative bilateral lung transplantation with a sternal-sparing approach is feasible and may yield outcomes similar to those in the traditional clamshell approach. Further analysis with larger numbers of patients is warranted to delineate the benefits of this approach for patients requiring reoperative lung transplantation.

Concepts: Time, Pulmonology, Pleural effusion, Organ transplant, Cardiopulmonary bypass, Lung transplantation, Bronchiolitis obliterans, Extracorporeal

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An air embolus is a recognized but rare complication of a partial hepatectomy. The aim of this report was to describe the diagnosis and management of a large paradoxical air embolus during hepatic resection.

Concepts: Coronary artery bypass surgery, Cardiopulmonary bypass, Embolism, Air embolism

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We investigated early clinical outcomes of a new extracorporeal life support (ECLS) system (Endumo(®) 2000, Heiwa Bussan, Tokyo, Japan), which consists of a ROTAFLOW centrifugal pump, a BIOCUBE oxygenator with plasma-leakage-tight polymer fibers, and a biocompatible coating (T-NCVC(®) coating), in pediatric patients <1 year old. From 2008 to 2011, 31 patients required ECLS. Except for 1 patient who was instituted with a transitional ECLS device, a conventional ECLS system (pediatric Emersave(®), TERUMO, Saitama, Japan) was initiated in 14 patients before December 2009 (6 boys, 63.4 ± 87.1 days old, 3.1 ± 1.0 kg), and the Endumo(®) 2000 was initiated in 16 patients after December 2009 (8 boys, 43.9 ± 78.5 days old, 3.2 ± 0.7 kg). Primary reasons for the institution of ECLS were intraoperative low output syndrome in 11 patients, post-cardiotomy cardiopulmonary collapse in 9 patients, and other reasons in 10 patients. The median support period was 21.7 ± 20.7 days and the total number of circuit exchanges was 83. The median first circuit durability was significantly longer in the Endumo group [8.0 days (range 5.9-13.2) vs. 4.4 days (1.9-8.3)] (p = 0.020). Significant cranial hemorrhage occurred in only 1 patient, who received the Emersave system. The success rate for weaning from ECLS was 14.3 % in the Emersave group and 56.3 % in the Endumo group. Univariate analysis showed that usage of the Endumo(®) 2000 was a predictor for successful weaning from the ECLS (p = 0.017) as well as survival at discharge (p = 0.032). The Endumo(®) 2000 system provided safe and effective cardiopulmonary support without complications.

Concepts: Infant, Patient, Physician, Cardiopulmonary bypass

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Background This study evaluates the impact of gender in dialysis-dependent patients undergoing cardiac surgery.Methods We retrospectively identified 204 dialysis-dependent patients (68.6% male, aged 66.6 ± 9.9 years) with end-stage renal disease undergoing cardiac surgery and compared them to a propensity-score-pair-matched control collective.Results A 30-day mortality was 13.2% (14/106) for coronary artery bypass grafting (CABG), 19.3% (6/31) for aortic valve replacement (AVR), and 23.8% (16/67) for combined procedures. Postoperative chest tube output was significantly higher in men (1,007 ± 946 mL) versus women (687 ± 598 mL, p = 0.014). Compared with a propensity-score-pair-matched control collective of 204 patients, we identified significant differences in terms of 30-day mortality: overall mortality revealed 17.6 versus 4.6% (p = 0.0001), 13.2 versus 3.4% (p = 0.014) for CABG, 19.3 versus 0% (p = 0.051) for AVR, and 23.8 versus 9.1% (p = 0.02) for combined procedures.Conclusion Multivariate analysis identified preoperative myocardial infarction, prolonged extracorporeal circulation time, operation time, and surgical reexploration as independent predictors of 30-day mortality. There was a higher occurrence of bleeding complications in men that remained significant even after correction for body surface area.

Concepts: Myocardial infarction, Atherosclerosis, Angina pectoris, Coronary artery disease, Heart, Artery, Coronary artery bypass surgery, Cardiopulmonary bypass

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Protamine is a protein mainly used to reverse anticoagulant effects of heparin during cardiac or vascular surgery with extracorporeal circulation. Adverse events after protamine administration are rare but if they occur they can be catastrophic. Based on a case report with an elective cardiac surgery patient with known allergy to fish, we discuss the related events and risk factors for an adverse reaction after protamine. The patient management and its outcome are presented.

Concepts: Blood, Medical terms, Patient, Hospital, Physician, Management, Adverse drug reaction, Cardiopulmonary bypass

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Cardiopulmonary bypass has revolutionized the practice of cardiac surgery and allows safe conduct of increasingly complex cardiac surgery. A brief review of the bypass circuit is undertaken in this review. A more thorough review of the anesthetic management is accomplished including choice of anesthetic medications and their effects. The inflammatory response to cardiopulmonary bypass is reviewed along with interventions that may help ameliorate the inflammation.

Concepts: Inflammation, Blood vessel, Endothelium, Anti-inflammatory, Review, Cardiopulmonary bypass, The Practice

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Magnesium is often used to supplement cardioplegic solutions during cardiopulmonary bypass due to its cardioprotective effect during ischemia and reperfusion. The aim of this meta-analysis was to evaluate the effects of magnesium-supplemented cardioplegia versus an inactive (placebo) control cardioplegia on reducing cardiac injury after cardiac arrest surgery, as found by randomized, controlled trials.

Concepts: Randomized controlled trial, Cardiopulmonary bypass

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In patients under extracorporeal membrane oxygenation (ECMO) support requiring renal replacement therapy or plasmapheresis, connecting such extracorporeal therapy device to the ECMO circuit provides many advantages compared with central venous catheterization. However, high pressures of the ECMO circuit limit the usefulness of this technique. We propose a new approach to connect extracorporeal therapy lines to the ECMO circuit. Inlet line is connected to the oxygenator, and outlet line is connected either to the femoral artery antegrade perfusion cannula in case of venoarterial ECMO or to the lateral vent of the return cannula in case of venovenous ECMO. We report the successful management of 21 patients using this connection, with much longer hemofilter average lifetime than previously reported.

Concepts: Cardiopulmonary bypass, Medical equipment, Extracorporeal, Extracorporeal membrane oxygenation

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Background The benefits of coronary-artery bypass grafting (CABG) without cardiopulmonary bypass in the elderly are still undetermined. Methods We randomly assigned patients 75 years of age or older who were scheduled for elective first-time CABG to undergo the procedure either without cardiopulmonary bypass (off-pump CABG) or with it (on-pump CABG). The primary end point was a composite of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy at 30 days and at 12 months after surgery. Results A total of 2539 patients underwent randomization. At 30 days after surgery, there was no significant difference between patients who underwent off-pump surgery and those who underwent on-pump surgery in terms of the composite outcome (7.8% vs. 8.2%; odds ratio, 0.95; 95% confidence interval [CI], 0.71 to 1.28; P=0.74) or four of the components (death, stroke, myocardial infarction, or new renal-replacement therapy). Repeat revascularization occurred more frequently after off-pump CABG than after on-pump CABG (1.3% vs. 0.4%; odds ratio, 2.42; 95% CI, 1.03 to 5.72; P=0.04). At 12 months, there was no significant between-group difference in the composite end point (13.1% vs. 14.0%; hazard ratio, 0.93; 95% CI, 0.76 to 1.16; P=0.48) or in any of the individual components. Similar results were obtained in a per-protocol analysis that excluded the 177 patients who crossed over from the assigned treatment to the other treatment. Conclusions In patients 75 years of age or older, there was no significant difference between on-pump and off-pump CABG with regard to the composite outcome of death, stroke, myocardial infarction, repeat revascularization, or new renal-replacement therapy within 30 days and within 12 months after surgery. (Funded by Maquet; GOPCABE ClinicalTrials.gov number, NCT00719667 .).

Concepts: Death, Myocardial infarction, Atherosclerosis, Gerontology, Old age, Ageing, Coronary artery bypass surgery, Cardiopulmonary bypass

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Extracorporeal membrane oxygenation (ECMO) is a technology capable of providing short-term mechanical support to the heart, lungs or both. Over the last decade, the number of centres offering ECMO has grown rapidly. At the same time, the indications for its use have also been broadened. In part, this trend has been supported by advances in circuit design and in cannulation techniques. Despite the widespread adoption of extracorporeal life support techniques, the use of ECMO remains associated with significant morbidity and mortality. A complication witnessed during ECMO is the inflammatory response to extracorporeal circulation. This reaction shares similarities with the systemic inflammatory response syndrome (SIRS) and has been well-documented in relation to cardiopulmonary bypass. The exposure of a patient’s blood to the non-endothelialised surface of the ECMO circuit results in the widespread activation of the innate immune system; if unchecked this may result in inflammation and organ injury. Here, we review the pathophysiology of the inflammatory response to ECMO, highlighting the complex interactions between arms of the innate immune response, the endothelium and coagulation. An understanding of the processes involved may guide the design of therapies and strategies aimed at ameliorating inflammation during ECMO. Likewise, an appreciation of the potentially deleterious inflammatory effects of ECMO may assist those weighing the risks and benefits of therapy.

Concepts: Immune system, Inflammation, Innate immune system, Immunity, Chemokine, Cardiopulmonary bypass, Extracorporeal, Extracorporeal membrane oxygenation