Feasibility and safety of continuous retrograde administration of Del Nido cardioplegia: a case series.

Background Del Nido (DN) cardioplegia, a calcium-free, hyperkalemic solution containing lidocaine and magnesium has been developed to help reduce intracellular calcium influx and the resulting myocyte damage in the immediate postischemic period following cardiac arrest. DN cardioplegia has been used for pediatric cardiac surgery but its use in complex reoperative surgery has not been studied. We specifically report the outcomes of patients undergoing reoperative cardiac surgery after previous coronary artery bypass grafting with a patent internal mammary artery (IMA). Methods Patients undergoing reoperative cardiac surgery with prior coronary bypass grafting surgery were studied between 2010 and 2013. Fourteen patients were identified who required continued retrograde cardioplegia administration. In all cases, an initial antegrade dose was given, followed by continuous retrograde administration. Demographics, co-morbidities, intra-operative variables including cardioplegia volumes, post-operative complications, and patient outcomes were collected. Results The mean age of all patients was 73.3+/−6.7 years, and 93 % were male. Aortic cross clamp time and cardiopulmonary bypass times were 81+/−35 and 151+/−79 mins, respectively. Antegrade, retrograde and total cardioplegia doses were 1101+/−398, 3096+/−3185 and 4367+/−3751 ml, respectively. An average of 0.93+/−0.92 inotropes and 1.50+/−0.76 pressors were used on ICU admission after surgery. ICU and total hospital lengths of stay were 5.5+/−7.4 and 9.6+/−8.0 days, respectively. Complications occurred in two patients (14 %) (pneumonia and prolonged mechanical ventilation) and new arrhythmias occurred in five patients (36 %) (four new-onset atrial fibrillation and one pulseless electrical activity requiring 2 min of chest compression). No perioperative myocardial infarctions were noted based on electrocardiograms and cardiac serum markers. Postoperatively, left ventricular function was preserved in all patients whereas two patients (14 %) had mild decrease in right ventricular function as assessed by echocardiography. No mortality was observed. Conclusion Del Nido cardioplegia solution provides acceptable myocardial protection for cardiac surgery that requires continuous retrograde cardioplegia administration. DN cardioplegia’s administration in a continuous retrograde fashion with a patent IMA is believed to provide adequate myocardial protection while avoiding injuring the IMA through dissection and clamping

Predictors of contemporary coronary artery bypass grafting outcomes

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Early mobilization of patients receiving extracorporeal membrane oxygenation: a retrospective cohort study

Introduction: Critical illness is a well-recognized cause of neuromuscular weakness and impaired physical functioning. Physical therapy (PT) has been demonstrated to be safe and effective for critically ill patients. The impact of such an intervention on patients receiving extracorporeal membrane oxygenation (ECMO) has not been well characterized. We describe the feasibility and impact of active PT on ECMO patients. Methods: We performed a retrospective cohort study of 100 consecutive patients receiving ECMO in the medical intensive care unit of a university hospital. Results: Of the 100 patients receiving ECMO, 35 (35%) participated in active PT; 19 as bridge to transplant and 16 as bridge to recovery. Duration of ECMO was 14.3 ± 10.9 days. Patients received 7.2 ± 6.5 PT sessions while on ECMO. During PT sessions, 18 patients (51%) ambulated (median distance 175 feet, range 4 to 2,800) and 9 patients were on vasopressors. Whilst receiving ECMO, 23 patients were liberated from invasive mechanical ventilation. Of the 16 bridge to recovery patients, 14 (88%) survived to discharge; 10 bridge to transplant patients (53%) survived to transplantation, with 9 (90%) surviving to discharge. Of the 23 survivors, 13 (57%) went directly home, 8 (35%) went to acute rehabilitation, and 2 (9%) went to subacute rehabilitation. There were no PT-related complications. Conclusions: Active PT, including ambulation, can be achieved safely and reliably in ECMO patients when an experienced, multidisciplinary team is utilized. More research is needed to define the barriers to PT and the impact on survival and long-term functional, neurocognitive outcomes in this population

Del Nido Cardioplegia can be safely administered in high-risk coronary artery bypass grafting surgery after acute myocardial infarction: a propensity matched comparison

Del Nido (DN) cardioplegia solution provides a depolarized hyperkalemic arrest lasting up to 60 minutes, and the addition of lidocaine may limit intracellular calcium influx. Single-dose DN cardioplegia solution may offer an alternative myocardial protection strategy to multi-dose cold whole blood (WB) cardioplegia following acute myocardial infarction (AMI). We retrospectively reviewed 88 consecutive patients with AMI undergoing coronary artery bypass (CABG) surgery with cardioplegic arrest between June 2010 to June 2012. Patients exclusively received WB (n = 40, June 2010-July 2011) or DN (n = 48, August 2011-June 2012) cardioplegia. Preoperative and postoperative data were retrospectively reviewed and compared using propensity scoring. No significant difference in age, maximum preoperative serum troponin level, ejection fraction, and STS score was present between DN and WB. A single cardioplegia dose was given in 41 DN vs. 0 WB patients (p < 0.001), and retrograde cardioplegia was used 10 DN vs. 31 WB patients (p < 0.001). Mean cardiopulmonary bypass and cross clamp times were significantly shorter in the DN group versus WB group. Tranfusion rate, length of stay, intra-aortic balloon pump requirement, post-operative inotropic support, and 30-day mortality was no different between groups. One patient in the WB group required a mechanical support due to profound cardiogenic shock. DN cardioplegia may provide equivalent myocardial protection to existing cardioplegia without negative inotropic effects in the setting of acute myocardial infarction

Review of Deep Hypothermia and Circulatory Arrest Techniques For Surgical Repair of Giant Cerebral Aneurysms

Early experience in the 1960s with the repair of giant cerebral aneurysms utilizing cardiopulmonary bypass (CPB) with deep hypothermia and circulatory arrest was reviewed. However, due to the complications associated with CPB, its use was abandoned in the early 1970's. Surface cooling alone with open chest cardiac massage was then employed successfully in a series of neurosurgical patients. Reintroduction of bypass techniques for core cooling using peripheral cannulation combined with neurosurgical advances has decreased the morbidity associated with this technique in the 1980s. However, some centers continue to perform these procedures with open chest cardiopulmonary bypass. Although there are advantages to the open chest technique, it is no longer necessary in most patients. With a long thin-walled venous cannula advanced from the femoral vein to the right atrium, combined with a centrifugal pump in the venous line, adequate venous return and cardiac decompression can be achieved without the need for a sternotomy. Advances in perfusion techniques and anesthetic monitoring are the hallmarks of the successful outcome in neurosurgical repairs of giant cerebral aneurysms in the 1990s

A Conversation with the Richmonds on Their 30 Years of Service with the American Board of Cardiovascular Perfusion

Beth A. Richmond, PhD, and Mark G. Richmond, EdD, Co-Executive Directors serving for the ABCP, have assumed this role for the past 30 years. Their experience working with a variety of perfusionists in the field influenced the profession and some of the professionals we view as perfusion leaders. Anyone with time working as a clinical perfusionist acknowledges the role they have had establishing the certification process and influencing perfusion education. The goal of this article is simply to highlight the Board’s history through the words of both Co-Directors. Our profession, young in years, has a unique history. The names have not been changed and many of the stories have yet to be told. During the winter of 2009, we sat down with Beth and Mark Richmond to talk about their experience working with different Boards over the past 30 years. The following article is their story in their words

Women in Perfusion: A Survey of North American Female Perfusionists

Perfusion as a career has long been dominated by men (American Board of Cardiovascular Perfusion, Booklet of information since 1975). Women represent 33.3% of the present workforce in North America (1187 certified women). In the 1900s, fewer than 20% of women participated in the labor force compared with 75% today and growing (1). In addition women make only 77 cents for every dollar that men earn and the more education a woman has, the greater the disparity in her wages (2). Only 53% of employers provide at least some replacement pay during periods of maternity leave (2). The purpose of this survey was to poll women in perfusion to evaluate concerns and opinions in their careers and to compare this with the female labor force. In October 2011, a 40-question survey (surveymonkey.co

Heparin Washout in the Pediatric Cell Saver

The possibility of residual heparin in washed red cells transfused to neonatal or pediatric cardiac patients following bypass prompted a measurement of heparin concentrations. Samples were taken during 10 adult and 10 neonatal and pediatric bypass cases. Sample A was from the bypass circuit, Sample B from the Haemonetics Cell Saver bowl inlet before washing, Sample C from the Cell Saver bowl outlet after washing, and Sample D from the patient ten minutes after protamine. Heparin concentrations were measured by a chromogenic assay using activated Factor X. There was no significant difference between the adult and pediatric groups in the levels of heparin concentration on bypass, pre-washing and post-washing, and in the patients following protamine. In the pediatric group, only .002% of the pre-washed heparin remained after washing. This extremely low level of heparin (.0027 units/ml) is only 0.34 units in a 125 ml pediatric unit of Cell Saver blood. Based on post bypass patient samples, this has no clinical significance. Therefore, the Cell Saver can be used safely with neonates and pediatric patients without concern regarding residual heparin when properly processed

Laboratory Evaluation of a Low Prime ClosedCircuit Cardiopulmonary Bypass System

We have explored the potential advantages of a low prime closed-circuit cardiopulmonary bypass (CPB) system using a non-human primate model. Although manufacturers have reduced priming volumes in individual CPB components, the standard circuit volume remains high because of the tubing diameter and length necessary for gravity drainage. By replacing gravity drainage with the negative pressure generated by a centrifugal pump, we can realize significant tubing volume reduction. Closed-circuit bypass was conducted on 13 baboons ranging from 5-15 kg. The circuit consisted of a centrifugal pump, a hollow fiber oxygenator, and l/4" arterial and venous tubing. The design of the circuit included the capacity to remove a limited amount of venous air. Circulatory arrest during deep hypothermia with volume displacement into a reservoir was also accomplished with this circuit. The potential benefits of this low prime closed-circuit bypass system include blood conservation and reduction in blood surface area contact. The future safe clinical use of this type of closed-circuit bypass for routine open heart surgery will depend upon the incorporation of a device in the venous line to remove air. This is the greatest threat to patient safety in a closed circuit system and its use for open chest surgery must wait until an efficient venous air elimination device is available