Abstract: OBJECTIVE: Intra-aortic balloon pump (IABP)-induced pulsatile perfusion has demonstrated that it can preserve organ function during cardiopulmonary bypass (CPB). We evaluated the role of IABP pulsatile perfusion on endothelial response. METHODS: Forty consecutive isolated CABG undergoing preoperative IABP were randomized to receive IABP pulsatile CPB during aortic cross-clamping (group A, 20 patients) or standard linear CPB (group B, 20 patients) during cross-clamp time. Hemodynamic results were analyzed by Swan-Ganz catheter [mean arterial pressure (MAP), cardiac index (CI), indexed systemic vascular resistances (ISVR), indexed pulmonary vascular resistances (IPVR), wedge pressure (PCWP)]. Inflammatory/endothelial response was analyzed by pro-inflammatory (IL-2, IL-6, IL-8), anti-inflammatory cytokines (IL-10), and endothelial markers [vascular endothelial growth factor (VEGF) and monocyte chemotactic protein-1 (MCP-1)]. All measurements were recorded preoperatively (T0), before aortic declamping (T1), at the end of surgery (T2), 12h (T3) and 24h (T4) postoperatively. ANOVA for repeated measures was used to evaluate the differences of means. RESULTS: Hemodynamic response was comparable except for higher MAP (p=0.01 at T1) and lower ISVR (p=0.001 at T1, p=0.003 at T2) in group A. No differences were found in perioperative leakage of IL-2, IL-6, and IL-8 between the two groups (within-group p=0.0001 either in group A and group B; between-groups p=NS at 2-ANOVA). Group A showed significantly lower VEGF (between-groups p=0.001 at 2-ANOVA, p=0.001 at T1, T2) and MCP-1 (between-groups p=0.001 at 2-ANOVA, p=0.001 at T1, T2) with higher IL-10 secretion (between-groups p=0.001 at 2-ANOVA, p=0.01 at T1, T2, T3). CONCLUSIONS: IABP-induced pulsatile perfusion allows lower endothelial activation during CPB and higher anti-inflammatory cytokines secretion.
Abstract: BACKGROUND: We evaluated the association between the preoperative use of intraaortic balloon pumping and in-hospital and long-term outcomes in high-risk patients undergoing coronary artery bypass grafting. METHODS: From 714 total patients undergoing coronary artery bypass grafting during a 4-year period, we compared the clinical, biochemical, and echocardiographic findings up to 1 year after surgery between 111 patients who had a European System for Cardiac Operative Risk Evaluation (EuroSCORE) of 12 or greater and received intraaortic balloon pumping preoperatively (group A) and 130 patients who had a EuroSCORE of 5 or less and received no preoperative intraaortic balloon pumping (group B). RESULTS: Group A patients were significantly older, had significantly more comorbid conditions, and had a significantly lower mean preoperative ejection fraction (all p < 0.001). Intraoperative data were comparable between groups, as were lactate and troponin I levels sampled from the coronary sinus. Lactate, troponin I, creatine kinase, and creatine kinase-MB mass showed comparable leakage at all postoperative times. The incidences of in-hospital mortality, perioperative myocardial damage, and acute myocardial infarction and duration of hospital stay were comparable. High-risk patients showed significant improvements in ejection fraction (p < 0.001) and wall-motion score index (p = 0.06) after surgery, but low-risk patients showed no significant change in these variables. The incidences of death, recurrent angina, myocardial infarction, and repeat coronary procedures did not differ significantly between groups. CONCLUSIONS: The preoperative use of intraaortic balloon pumping appears to shift high-risk patients undergoing coronary artery bypass grafting into a lower-risk category and is associated with comparable perioperative troponin leakage and short-term and long-term outcomes similar to low-risk patients not receiving intraaortic balloon pumping.
Abstract: We evaluated the impact of immediate intra-aortic balloon pumping (IABP) on hospital and mid-term outcome of coronary artery bypass graft (CABG) whenever perioperative acute complications developed. We compared clinical, biochemical, echocardiographic in-hospital results and two-year follow-up outcome of 30 low-risk (EuroSCORE<5) CABG (group A) who immediately received perioperative IABP when acute complications were suspected, to a contemporary, uncomplicated case-matched group (30 patients; Group B). Two in-hospital deaths were recorded in group A with no deaths in controls (P=0.492). Group A showed significantly higher lactate only at ICU arrival (P=0.001). Troponin I was always higher, but never reached values diagnostic for myocardial infarction (P<0.001). Worse left ventricular ejection fraction (P<0.001) and wall motion score index (P=0.008) were recorded at ICU arrival in group A, although an almost complete recovery was registered at discharge. Two-year actuarial survival was similar between the two groups (P=0.598). No differences were observed in freedom from acute myocardial infarction (P=0.503) and from overall cardiac complications (P=0.410). Early IABP should be established whenever cardiac complications are suspected, because of its beneficial impact on enzymatic leakage, myocardial recovery at echocardiography, hospital outcome, mid-term follow-up survival and freedom from cardiovascular events.
Abstract: PURPOSE: To evaluate if the use of an intra-aortic balloon pump (IABP) during cardioplegic arrest improves body perfusion. METHODS: 158 coronary artery bypass graft (CABG) patients were randomized to linear cardiopulmonary bypass (CPB) (n=71, Group A) or automatic 80 bpm intra-aortic balloon pump (IABP) induced pulsatile CPB (n=87, Group B). We evaluated hemodynamic response by Swan-Ganz catheter, inflammation by cytokines, coagulation and fibrinolysis, transaminase, bilirubin, amylase, lactate and renal function (estimated glomerular filtration rate (eGFR), creatinine, and incidence of renal insufficiency and failure). RESULTS: IABP induced Surplus Hemodynamic Energy was 15.8-/+4.9 mmHg, with higher mean arterial pressure during cross-clamping (p=0.001), and lower indexed systemic vascular resistances during cross-clamping (p=0.001) and CPB discontinuation (p=0.034). IL-2 and IL-6 were lower, while IL-10 proved higher in Group B (p<0.05). Group B showed lower chest drainage (p<0.05), transfusions (p<0.05), INR (p<0.05), and AT-III (p=0.001), together with higher platelets, aPTT (p<0.05), fibrinogen (p<0.05) and D-dimer (p<0.05). Transaminases, bilirubin, amylase, lactate were lower in Group B (p<0.05); eGFR was better in Group B from ITU-arrival to 48 hours, both in preoperative kidney disease Stages 1-2 (p<0.03) and Stage 3 (p<0.05), resulting in lower creatinine from ITU-arrival to 48 hours (p<0.03). Incidence of renal insufficiency (p=0.004) and need for renal replacement therapy (p=0.044) was lower in Group B Stage 3. Group B PaO2/FiO2 and lung compliance improved from aortic declamping to the first day (p<0.003) with shorter intubation time (p=0.01). CONCLUSION: Pulsatile flow by IABP improves whole-body perfusion during CPB.
Abstract: AIM: Recent reports have shown anti-inflammatory effects with conventional hemofiltration (CUF) in patients undergoing cardiopulmonary bypass (CPB). The aim of this study was to evaluate the immunological and the hemodynamic response to CUF or metilprednisolone in patients undergoing coronary artery bypass grafting. METHODS: Twenty-four consecutive patients were prospectively randomized to receive CUF (12 patients, Group A) or metilprednisolone (12 patients, Group B). Hemodynamic response was evaluated by Swan-Ganz catheter, immunological response was analyzed by IL-2, IL-4, IL-6, TNF-alfa, IFN-gamma, IL-10 before anesthetic induction (T0), at aortic-declamping (T1), at the end of surgery (T2), ITU admission (T3) and 24 hours (T4). Troponin I was measured at the same time-points. Hematological and coagulative controls were performed. RESULTS: Morbidity and mortality were comparable between the two groups. Group A demonstrated lower cardiac index at T1 (2.1+/-0.69 L/min m2 vs. 3.917+/-1.28, P=0.034) without significantly higher indexed-systemic-vascular-resistances at the end of surgery (1 101+/-434.3dyne s cm(-5) m(-2) vs. 797.7+/-316.67, P=0.233). When proinflammatory and anti-inflammatory cytokines were considered, all improved during the postoperative time course, without differences between the 2 Groups (P=NS). Hematological and coagulative data were similar in the two groups, in terms of white blood cells, platelets, prothrombin time, and activated partial thromboplastin time (P=NS). CONCLUSIONS: Anti-inflammatory action of CUF was comparable to steroids, thus determining a similar proinflammatory response to CPB. However, hemodynamics was slightly impaired by CUF. Therefore, there is no reason to prefer CUF to steroids in patients undergoing elective CABG.
Abstract: We report the cases of five consecutive patients undergoing coronary artery bypass grafting (CABG) who required a transbrachial approach for 7-Fr catheter intra-aortic balloon pumping (IABP) insertion because of unsuitable femoral arteries. No adverse outcomes occurred in any patient during a mean 72 h of IABP support. Our experience with 7-Fr catheters appears to confirm previous reports of the safety and efficacy of transbrachial IABP assistance and suggests that such support can be provided safely for an extended duration with the use of these smaller catheters. Keywords: Coronary artery bypass grafting; Medical technology; Assisted circulation; Counterpulsation; Intra-aortic balloon pumping.
Abstract: Background: Despite restrictive mitral annuloplasty (RMA) being considered effective for chronic ischaemic mitral regurgitation (CIMR), few data exist on mid-term echocardiographic results with different prosthetic rings. Therefore, comparative echocardiographic analysis has been performed. Methods: Sixty-four consecutive coronary artery bypass graft surgery (CABG)+RMA (downsizing by two-ring sizes; median size: 26mm) for CIMR with a follow-up of at least 6 months were prospectively followed-up with serial echocardiograms (preoperative, discharge, 6 months, follow-up ending). Hospital mortality, follow-up clinical and echocardiographic results were analysed and compared between three groups (group A: semi-rigid band, 17 patients; group B: complete symmetric semi-rigid, 22 patients; group C: complete asymmetric semi-rigid, 25 patients). Results: Hospital mortality was 6.3%; 22.8+/-14.7 standard deviation (SD) months (range: 6-55) survival was 96.5+/-2.5%; freedom from re-intervention was 94.2+/-4.2%, from re-revascularisation 87.5+/-11.7%, from >/=grade-2 mitral regurgitation 58.2+/-9.8% and from heart failure (CHF) 71.6+/-10.5%. Recurrent (>/=grade-2) CIMR resulted in lower freedom-from-CHF (p=0.0001), worsened New York Heart Association (NYHA) classification (p=0.0001) and absence of reverse remodelling of the left ventricular end-diastolic diameter (LVEDD; p=0.004), systolic diameter (LVESD; p=0.014), indexed mass (LVMi; p=0.005) and coaptation depth (p=0.0001). Group A showed significant worse freedom from CHF (group A: 42.8+/-19.5% vs group B: 88.9+/-10.5% vs group C: 92.3+/-7.5%; p=0.049) and from recurrent CIMR (17.4+/-13.8% vs 82.1+/-11.7% vs 94.1+/-5.7%, respectively; p=0.0001). Complete rings decreased the hazard of recurrent CIMR (Physio=0.141; Adams=0.089). Higher NYHA during follow-up was found in group A (p=0.002 for group B and p=0.001 for group C) with a progressive reduction of trans-mitral mean gradient (p=0.001), and a lower degree of reverse remodelling of LVEDD (p=0.009 and p=0.010) and coaptation depth (p=0.040 and p=0.002). Conclusions: Recurrent CIMR correlates with absent ventricular reverse remodelling. Despite a higher trans-mitral gradient, complete rings achieve better results in the treatment of CIMR.
Abstract: BACKGROUND: We sought to investigate the role of the bidirectional Glenn with antegrade pulmonary blood flow in the surgical history of children with univentricular hearts. METHODS: A series of 246 patients, from three joint institutions, having univentricular heart with restricted but not critical pulmonary blood flow received a bidirectional cavopulmonary shunt with additional forward pulmonary blood flow. All patients have been studied according to their progression, or not, to Fontan operation. Two hundred and eight (84.5%) patients underwent bidirectional cavopulmonary anastomosis as primary palliation. Twenty patients (8.1%) with previous pulmonary artery banding were also enrolled in the study. Patients who had received additional pulmonary blood flow through a previous systemic to pulmonary artery shunt for the critical pulmonary blood flow were excluded. RESULTS: No in-hospital death occurred. Follow-up was complete at 100%. Mean follow-up was 4.2 +/- 2.8 years (range, 6 months to 7 years). During the observational period 73 (29.7%) patients, considered optimal candidates, underwent Fontan completion for increasing cyanosis and (or) hematocrit and (or) fatigue with exertion. Three patients expired after total cavopulmonary connection (3 of 73; 4.1% mortality rate). The remaining 173 (70.3%) patients are alive with initial palliation. All patients were still well palliated with an arterial oxygen saturation at rest about 90%. CONCLUSIONS: According to our experience and results, bidirectional Glenn with antegrade pulmonary blood flow may be an excellent temporary palliation prior to a Fontan operation, which can be performed at the onset of symptoms. Bidirectional Glenn may also be the best possible palliation for a suboptimal candidate for Fontan.
Abstract: The clinical management of ventricular failure after the Fontan operation presents a formidable challenge to surgeons. We report our experience with successful implantation of a Berlin Heart EXCOR ventricular assist device as a bridge to transplantation in a child with Fontan circulation.
