Shock management for cardio-surgical intensive care unit patient: the silver days

Shock in cardio-surgical intensive care unit (ICU) patients requires prompt identification of the underlying condition and timely therapeutic interventions. Management during the first 6 hours, also referred to as “the golden hours”, is of paramount importance to reverse the shock state and improve the patient’s outcome. The authors have previously described a state-of-the-art diagnostic work-up and discussed how to optimise preload, vascular tone, contractility, heart rate and oxygen delivery during this phase. Ideally, shock can be reversed during this initial period. However, some patients might have developed multiple organ dysfunction, which persists beyond the first 6 hours despite the early haemodynamic treatment goals having been accomplished. This period, also referred to as “the silver days”, is the focus of this review. The authors discuss how to reduce vasopressor load and how to minimise adrenergic stress by using alternative inotropes, extracorporeal life-support and short acting beta-blockers. The review incorporates data on fluid weaning, safe ventilation, daily interruption of sedation, delirium management and early rehabilitation. It includes practical recommendations in areas where the evidence is scarce or controversial. Although the focus is on cardio-surgery ICU patients, most of the considerations apply to critical ill patients in general

Repair of post-infarction left ventricular free wall rupture using an extracellular matrix patch

Several techniques for surgical treatment of acute or subacute left ventricular free wall rupture (LVFWR) have been described using a sutured or sutureless patch with different currently available materials. We present a case report of a 50-year-old male with acute LVFWR, who was treated with a simple surgical technique using an ‘off-pump' epicardially sutured LV patch consisting of an acellular xenogeneic extracellular matrix (ECM). ECM patches are structurally more surgeon-friendly and have shown to be bioactive, and capable of activating remodelling and even tissue regeneration. Compared with conventional pericardial patches, the advantage of this material is excellent pliability and very easy stitching owing to the thin composition of the material. In addition, and most importantly, in case of complex structural reconstructions, the patch is highly tear-proo

Tricuspidisation of the aortic valve with creation of a crown-like annulus is able to restore a normal valve function in bicuspid aortic valves

Objective: To evaluate the early results of a new method to repair malfunctioning bicuspid aortic valves by creating a tricuspid valve with a crown-like (i.e. anatomic) annulus. Material and methods: Twelve patients (ages from 10 to 27 years) with chronic regurgitation (and flow-dependent stenosis) of a bicuspid aortic valve underwent repair with the principle of creating a tricuspid valve and a crown-like annulus. The fused leaflets were trimmed and reinserted underneath the existing aortic annulus to create one new native cusp. The third leaflet was fashioned out of a xenopericard patch and was inserted underneath the existing annulus as well to restore the crown-like anatomy of a normal aortic annulus. A tricuspid aortic valve with a morphologically normal annulus was thus created, which resulted in improved coaptation of the leaflets. The repair was immediately assessed by transesophageal echocardiography (TEE) with the heart loaded at 50%. In two patients, a second run helped fine-tune the repair. Median cross-clamping time was 82 min. Follow-up ranged from 3 to 46 months (median 13 months). Results: No significant complication occurred. The function of the aortic valve was excellent with trivial or mild regurgitation in 11 patients and moderate regurgitation in 1 patient. There was no stenosis across the valve. The repair remained stable over time. Remodelling of the left ventricle occurred as expected. Conclusions: Aortic valve repair is feasible in some dysfunctioning bicuspid aortic valves. Tricuspidisation of the valve can result in excellent systolic and diastolic functions. The creation of a crown-like annulus results in improved coaptation of the cusps and could lead to more reliable outcome. Although long-term results are needed, this anatomic correction seems to be a good alternative to valvular replacement in certain sub-groups of patient

Anatomic reconstruction of recurrent aortic arch obstruction in children

Objective: Anatomical reconstruction of the aortic arch following aortic arch surgery is challenging. The placement of an extra-anatomical aortic bypass has been proposed for these difficult cases. This approach is not ideal in children due to possible long-term complications. This study presents the results of our policy to reconstruct the aortic arch in recurrent obstruction in children, which are not amenable to balloon dilatation. Methods: Seven children with a median age of 8 years (range 1 month-15 years) were operated for aortic arch obstruction following correction of an aortic coarctation. Six children presented another intra-cardial lesion (2 subaortic membranes; 2 VSDs, 1 ostium stenosis of the left main coronary artery, and 1 mitral valve insufficiency). The surgical approach involved a sternotomy, cardiopulmonary support using two arterial inflow cannulas (one above and one below the aortic arch), and moderate hypothermia. Enlargement of the aortic arch was performed by a sliding plasty in four patients and by a patch plasty in three patients. Associated cardiac defects were corrected as well. Results: It was technically possible to perform the planned operation in all patients. All patients survived and none presented significant postoperative complications. There were no residual gradients in six patients and a gradient of 10 mmHg in one patient postoperatively. One patient showed transient recurrent nerve palsy which recovered within 6 weeks. Follow-up echocardiographic and MRI studies revealed a normal appearing aortic arch with laminar flow. Conclusions: Although more demanding, an anatomical reconstruction of the aortic arch can be performed in infants and children with recurrent obstruction of the aortic arch with excellent initial results. This approach may prove superior to an extra-anatomic bypass in the long-ter

Mid-term results of right axillary incision for the repair of a wide range of congenital cardiac defects

Objective: We evaluated the mid-term results of the right axillary incision used for the repair of various congenital heart defects. Methods: All the patients who were operated with this incision between March 2001 and December 2007 were reviewed. There were 123 patients (median age 4.7 {0.4-19.4} years and median weight 16.6 {3.8-62} kg) undergoing atrial septal defect (ASD) closure (62), repair of partial anomalous pulmonary venous connection (PAPVC) (22), correction of partial atrioventricular septal defect (AVSD) (19), and restrictive perimembranous ventricular septal defect (VSD) (20). Additional procedures involved tricuspid valve plasty (10), mitral annuloplasty (3), reduction plasty of the aortic sinus (2), resuspension of the aortic valve cusp (2), sub aortic membrane resection (1), or reimplantation of Scimitar vein (1). The surgical technique involved peripheral (groin) and central (SVC ± aorta) cannulation for institution of cardiopulmonary bypass. Fibrillatory arrest was used for repair of ASDs and cardioplegic arrest for repairs involving the atrioventricular valves as well as VSDs. The median CPB and aortic clamp times were 72 (35-232) and 0 (0-126) min, respectively. Results: There was no need for conversion to another approach in any patient. Early morbidity included transient paresis of left upper arm (1), stenting of SVC after repair of a sinus venosus defect (1) and revision for bleeding (1). Follow-up echo showed no residual defect in 116 patients and minor residual defects in 7 patients: tiny ASD (2), tiny VSD (1) and mitral regurgitation (4). One patient developed stenosis in the right external iliac artery used for cannulation, necessitating surgical intervention. All the patients are in excellent condition after a median follow-up of 4.1 (0.4-7.1) years. The incision healed well and the thorax and the breast showed no deformity on follow-up. Conclusions: The right axillary incision provides a quality of repair for various congenital defects similar to that obtained by using standard surgical approaches. Because of its deceitful location, and the camouflaging effect of being hidden by the resting arm, it has superior cosmetic appeal compared to conventional incisions. The incision does not interfere with subsequent development of the thorax or the breast (in case of females

Levosimendan Efficacy and Safety: 20 Years of SIMDAX in Clinical Use

Levosimendan was first approved for clinical use in 2000, when authorization was granted by Swedish regulatory authorities for the hemodynamic stabilization of patients with acutely decompensated chronic heart failure (HF). In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitization and promotes vasodilatation through the opening of adenosine triphosphate-dependent potassium channels on vascular smooth muscle cells, has been approved in more than 60 jurisdictions, including most of the countries of the European Union and Latin America. Areas of clinical application have expanded considerably and now include cardiogenic shock, takotsubo cardiomyopathy, advanced HF, right ventricular failure, pulmonary hypertension, cardiac surgery, critical care, and emergency medicine. Levosimendan is currently in active clinical evaluation in the United States. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and noncardiac disease states. A levosimendan oral form is at present under evaluation in the management of amyotrophic lateral sclerosis. To mark the 20 years since the advent of levosimendan in clinical use, 51 experts from 23 European countries (Austria, Belgium, Croatia, Cyprus, Czech Republic, Estonia, Finland, France, Germany, Greece, Hungary, Italy, the Netherlands, Norway, Poland, Portugal, Russia, Slovenia, Spain, Sweden, Switzerland, the United Kingdom, and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute HF arena in recent times and charts a possible development trajectory for the next 20 years

Repair of post-infarction left ventricular free wall rupture using an extracellular matrix patch

Several techniques for surgical treatment of acute or subacute left ventricular free wall rupture (LVFWR) have been described using a sutured or sutureless patch with different currently available materials. We present a case report of a 50-year-old male with acute LVFWR, who was treated with a simple surgical technique using an 'off-pump' epicardially sutured LV patch consisting of an acellular xenogeneic extracellular matrix (ECM). ECM patches are structurally more surgeon-friendly and have shown to be bioactive, and capable of activating remodelling and even tissue regeneration. Compared with conventional pericardial patches, the advantage of this material is excellent pliability and very easy stitching owing to the thin composition of the material. In addition, and most importantly, in case of complex structural reconstructions, the patch is highly tear-proof

European Association of Cardiothoracic Anesthesiology and Intensive Care (EACTAIC) Fellowship Curriculum: Second Edition

This document represents the first update of the Cardiothoracic and Vascular Anaesthesia Fellowship Curriculum of the European Association of Cardiothoracic Anaesthesiology and Intensive Care. After obtaining feedback from exit interviews with fellows in training, graduate fellows, and program directors, 2 modified online Delphi procedures with questionnaires were conducted. A consensus was reached when two-thirds of responding committee members gave green or yellow ratings on a traffic light system, and >70% indicated strong agreement or agreement on a 5-point Likert scale. The new regulations include the following: (1) more flexibility in the fellows` rotation, as long as the total number of days, rotations, and cases are completed during the training year; (2) recommendation for strict compliance with national working-time guidelines; (3) no extension of fellowship training to compensate for annual and/or sick leave, unless the required minimum number of cases and rotations are not reached; (4) interruption of fellowship training for >12 months is allowed for personal or medical reasons; (5) introduction of a checklist for quantitative assessment of standard clinical skills; (6) recommendations for a uniform structure of exit interviews; (7) possibility of a 1-month training rotation in a postanesthesia care unit instead of an intensive care unit; and (8) provided all other requirements have been met, the allowance of progression from the basic training year to the advanced fellowship training year without first passing the transesophageal echocardiography examination

Transmyocardial laser revascularisation in acutely ischaemic myocardium

Objective: Although recent experience suggests that transmyocardial laser revascularisation (TMLR) relieves angina, its mechanism of action remains undefined. We examined its functional effects and analysed its morphological features in an animal model of acute ischaemia. Methods: A total of 15 pigs were randomised to ligation of left marginal arteries (infarction group, n=5), to TMLR of the left lateral wall using a holmium:yttrium-aluminium garnet (Ho:YAG) laser (laser group, n=5), and to both (laser-infarction group, n=5). All the animals were sacrificed 1 month after the procedure. Haemodynamics and echocardiography with segmental wall motion score were carried out at both time intervals (scale 0-3: 0, normal; 1, hypokinesia; 2, akinesia; 3, dyskinesia). Histology of the involved area was analysed. Results: Laser group showed no change of the segmental wall motion score of the involved area 30 min after the laser channels were made (score: 0±0). Infarction and laser-infarction groups both showed a persistent and definitive increase of the segmental wall motion score (at 30 min: 1.6±0.3 and 2±0, respectively; at 1 month: 1.8±0.2 and 1.8±0.4, respectively). These increases were all statistically significant in comparison with baseline values (P<0.5), however comparison between infarction and laser-infarction groups showed no significant difference. On macroscopic examination of the endocardial surface, no channel was opened. On histology, there were signs of neovascularisation around the channels in the laser group, whereas in the laser-infarction group the channels were embedded in the infarction scar. Conclusions: In this acute pig model, TMLR did not provide improvement of contractility of the ischaemic myocardium. To the degree that the present study pertains to the clinical setting, the results suggest that mechanisms other than blood flow through the channels should be considered, such as a laser-induced triggering of neovascularisation or neural destructio

Repair of postinfarction dyskinetic LV aneurysm with either linear or patch technique

Objectives: Controversy still exists regarding the optimal surgical technique for postinfarction dyskinetic left ventricular aneurysm (LVA) repair. We compared the efficacy of two established techniques, linear vs. patch remodeling, for repair of dyskinetic LVA. Patients and methods: From 1989 to 1998, 95 (16 women, 79 men) consecutive patients were operated on for postinfarction dyskinetic LVA. Thirty-four patients underwent patch remodeling (R) and 61 linear (L) repair. The mean age was 61.1±8.5 years. Indications for surgery alone or in combination included angina in 72 patients, dyspnea in 64 and ventricular tachycardia in 41. Thirty-seven patients had a history of congestive heart failure (R 13 (38%), L 24 (39%), NS). The mean ejection fraction (EF) with aneurysm was 0.29±0.09 in R vs. 0.35±0.10 in L (P≪0.04), whereas the mean EF without aneurysm was 0.43±0.11 in R vs. 0.46±0.08 in L (P=0.3). Seventy-one aneurysms were anterior (R 30 (88%), L 41 (68%), P≪0.05). Concomitant coronary artery bypass grafting was performed in 84 patients (R 29 (85%), L 55 (90%), NS). Follow-up ranged from 1 to 12 years (mean 5.6±3.4 years, median 6.1 years). Results: Early mortality was 8% (n=8) (R 4, L 4, NS). Survival at 1, 5 and 10 years was 88, 73, and 44%, respectively. It did not differ significantly between R (1 and 5 year survival 85, 66%) and L (90, 76%, P=0.58). Preoperative risk factors for mortality were history of congestive heart failure (1 and 5 year survival 81 and 57% vs. 90 and 78%, respectively, hazard ratio (HR)=1.95, P≪0.05), non-anterior localization of the aneurysm (86 and 49% vs. 86 and 77%, HR=2.06, P≪0.05), history of thromboembolic events (57 and 19% vs. 89 and 74%, HR=3.27, P≪0.05), and left ventricular EF (HR=0.97 per %, P=0.05). At late follow-up the mean functional class was 1.8±0.6 in long-term survivors (preoperative 2.9±0.9, P≪0.001) with no difference between the groups. Conclusions: The technique of repair of postinfarction dyskinetic LVA should be adapted in each patient to the cavity size and extent of the scarring process into the septum and subvalvular mitral apparatus. Applying these considerations to the choice of the technique of repair, both techniques achieved satisfactory results with respect to perioperative mortality, late functional status and surviva