Transbrachial insertion of a 7.5-Fr intra-aortic balloon pump in a severely atherosclerotic patient

Objective: Preoperative intra-aortic balloon pumping (IABP) improves the results of complex coronary surgery. However, its insertion may be harmful or contraindicated in cases of severe and diffuse atherosclerosis of the descending aorta and peripheral arteries. We sought to evaluate the efficacy and safety of transbrachial insertion of the new 7.5-Fr IABP to support a severely ill patient with eggshell distal aorta and femoro-iliac arteries undergoing coronary artery bypass grafting (CABG).Design. Case report.Setting: An 18-bed adult cardiac surgery unit at a university hospital.Patient A 68-yr-old man with ongoing unstable angina, left main disease, and eggshell calcification in the abdominal aorta and iliacofemoral arteries, needing IABP for CABG.Intervention., Percutaneous sheathless right transbrachial insertion of 7.5-Fr IABP, followed by CABG.Measurements and Main Results. Fluoroscopy and chest radiograph were used to confirm the exact position of the IABP, in the preoperative and postoperative time, respectively. A digital pulse oximeter was applied to monitor distal perfusion. Anticoagulation consisted of nadroparin 4000 lU daily until the second postoperative day, followed by 150 mg of aspirin daily thereafter. Transbrachial IABP support allowed uneventful CABG and postoperative course, without IABP-related complications. Pulse oximetry demonstrated constant good values, the radial artery pulse was always present, and the hand appeared constantly warm. IABP was withdrawn 20 hrs following surgery, and the patient was discharged home on the ninth postoperative day.Conclusions. The miniaturization of IABP, with the recent introduction of a 7.5-Fr balloon catheter, opens the door for the safe, effective transbrachial method of insertion in patients with severe peripheral atherosclerosis

Troponin I and lactate from coronary sinus predict cardiac complications after myocardial revascularization

Background. Postoperative troponin I and lactate elevation are related to cardiac complications after myocardial revascularization. We sought to evaluate earlier predictive value for acute myocardial infarction (AMI) and myocardial damage of troportin I and lactate after myocardial revascularization.Methods. In all, 183 consecutive isolated myocardial revascularizations were prospectively enrolled in the study. Troportin I and lactate were sampled preoperatively and intraoperatively from the coronary sinus, and at 12, 24, 48, and 72 hours. Hospital outcome was recorded. Receiver operating curves for coronary sinus troponin I and lactate were constructed to differentiate patients with or without AMI and myocardial damage.Results. Acute myocardial infarction developed in 6 patients (3.2%), with higher troponin I and lactate at all time points (p < 0.05), longer intubation time (p = 0.003), intensive care unit stay (p = 0.001), hospital stay (p = 0.001), higher atrial fibrillation (p = 0.001), and worse ventricular function (p = 0.001). Myocardial damage developed in 6 patients (3.2%), showing higher troponin I at all time points (p < 0.001), higher intraoperative lactate (P = 0.04), longer intubation time (p = 0.005), and intensive care unit stay (p = 0.03). Receiver operating characteristic curves demonstrated coronary sinus troponin I greater than 0.94 mu g/L (area under the curve [AUCI 0.820 +/- 0.075; sensitivity 90.0%, specificity 68.9%) as a better discriminator between patients with or without AMI than lactate level greater than 2.85 mmol/L (AUC 0.686 +/- 0.090; sensitivity 80.0%; specificity 72.9%); troponin I greater than 0.65 mu g/L was a better discriminator between patients with or without myocardial damage (AUC 0.834 +/- 0.061; sensitivity 93.8%, specificity 71.5%), than lactate greater than 2.05mmol/L (AUC 0.627 +/- 0.067; sensitivity 87.5%; specificity 70.7%).Conclusions. Coronary sinus troponin I and lactate are predictive for cardiac complications after myocardial revascularization. Intraoperative biochemical assays should be routinely performed to establish preventative strategies to reduce further myocardial damage

Preoperative intraaortic balloon pumping improves outcomes for high-risk patients in routine coronary artery bypass graft surgery

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

Early intra-aortic balloon pumping following perioperative myocardial injury improves hospital and mid-term prognosis

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

Coupled plasma filtration adsorption reduces serum bilirubine in a case of acute hypoxic hepatitis secondary to cardiogenic shock

Hypoxic hepatitis (HH) is a severe complication of postoperative low output syndrome, associated with high mortality rates despite appropriate drug therapy. Recently several extracorporeal supportive techniques have become available. We describe the case of a 70-year-old woman who developed HH secondary to cardiogenic shock after cardiac surgery. CPFA proved to be a valid tool for concomitant hemodynamic support and organ replacement therapy

Impact of clonidine administration on delirium and related respiratory weaning after surgical correction of acute type-A aortic dissection: results of a pilot study

Delirium and transient neurologic dysfunctions (TND) often complicate the postoperative course after surgery for acute type-A aortic dissection (AAD). We evaluated the role of clonidine on neurological outcome and respiratory function in 30 consecutive patients undergoing surgery for AAD. Patients were prospectively randomized to receive either clonidine (0.5 microg/kg bolus, followed by continuous infusion at 1-2 microg/kg/h) or placebo (NaCl 0.9%) in on starting and throughout the weaning period from the mechanical ventilation. Incidence of delirium and TND, Delirium Detection Score (DDS), weaning parameters [respiratory rate to tidal volume ratio - f/VT; pressure-frequency product (PFP); partial pressure of arterial oxygen to fractional inspired oxygen concentration (PaO(2)/FiO(2)); partial pressure of carbon dioxide (PaCO(2))], weaning duration and intensive care unit (ICU) length of stay were recorded. The two groups were similar for preoperative and operative variables and also for the incidence of postoperative complications. DDS was lower in the clonidine group (P<0.001). Patients weaned with clonidine showed lower f/VT and PFP, higher PaO(2)/FiO(2) and PaCO(2), lower DDS, weaning period and the related ICU length of stay (P<0.001). This was further confirmed in patients developing delirium/TND. Intravenous clonidine after surgery for AAD reduces the severity of delirium, improves the respiratory function, shortens the weaning duration and the ICU length of stay

Pulsatile perfusion with intra-aortic balloon pumping ameliorates whole body response to cardiopulmonary bypass in the elderly

Objective: The growing life expectancy has led the elderly to be increasingly referred to coronary artery bypass grafting. Preexisting comorbidities may benefit from theoretical advantages of pulsatile perfusion during cardiopulmonary bypass (CPB).Design: Prospective randomized trial.Setting: Cardiac surgery unit in a university hospital.Patients. Eighty consecutive patients older than 70 years.Interventions: Elective coronary artery bypass grafting on CPB, randomizing to conventional linear CPB (40 patients, group A) or intra-aortic balloon pump (IABP)-induced pulsatile CPB (40 patients, group B).Measurements and Main Results: We evaluated hemodynamic response by pulmonary artery flotation catheter, metabolic/splanchnic response by lactate and transaminase, bilirubin, amylase, and renal function (creatinine clearance, creatinine, incidence of renal insufficiency and failure), respiratory response by Pao(2)/Fio(2), respiratory compliance, scoring of chest radiograph, intubation time, and need for noninvasive positive-pressure ventilation, hematologic response by chest drainage, hemocoagulative and fibrinolytic cascades, and transfusions. IABP-related complications were recorded. Two minor IABP-related complications (2.5%) were registered. Hemodynamics was comparable, except for a slightly better cardiac index and indexed systemic vascular resistances at the end of CPB and at intensive therapy unit (ITU) admission (p &lt; 0.05). Transaminases, bilirubin, amylase, proved lower in group B (p &lt; 0.05 from ITU admission to 48 hours). Creatinine clearance, serum creatinine, and lactate were better in group B (p &lt; 0.05), and acute renal insufficiency was accordingly lower (p = 0.02). Respiratory response demonstrated better Pao(2)/Fio(2) and respiratory compliance from aortic declamping to 48 hours, with better scoring of chest radiograph (p &lt; 0.05 from ITU admission to 48 hours), lower noninvasive positive-pressure ventilation (p = 0.002) and intubation time (p = 0.031) in group B. Lower chest drainage (p &lt; 0.05 at first and second day), transfusions (p &lt; 0.05), activated partial thromboplastin time, international normalized ratio, white blood cells, and D-dimer (p &lt; 0.05 from ITU admission to 48 hours), together with higher platelets, fibrinogen, and antithrombin III (p &lt; 0.05 from ITU admission to 48 hours) were demonstrated in the pulsated group.Conclusions. IABP-induced pulsatile flow significantly improves whole body perfusion in the elderly undergoing CPB. (Crit Care Med 2009; 37:902-911

Prosafe: a european endeavor to improve quality of critical care medicine in seven countries

BACKGROUND: long-lasting shared research databases are an important source of epidemiological information and can promote comparison between different healthcare services. Here we present ProsaFe, an advanced international research network in intensive care medicine, with the focus on assessing and improving the quality of care. the project involved 343 icUs in seven countries. all patients admitted to the icU were eligible for data collection. MetHoDs: the ProsaFe network collected data using the same electronic case report form translated into the corresponding languages. a complex, multidimensional validation system was implemented to ensure maximum data quality. individual and aggregate reports by country, region, and icU type were prepared annually. a web-based data-sharing system allowed participants to autonomously perform different analyses on both own data and the entire database. RESULTS: The final analysis was restricted to 262 general ICUs and 432,223 adult patients, mostly admitted to Italian units, where a research network had been active since 1991. organization of critical care medicine in the seven countries was relatively similar, in terms of staffing, case mix and procedures, suggesting a common understanding of the role of critical care medicine. conversely, icU equipment differed, and patient outcomes showed wide variations among countries. coNclUsioNs: ProsaFe is a permanent, stable, open access, multilingual database for clinical benchmarking, icU self-evaluation and research within and across countries, which offers a unique opportunity to improve the quality of critical care. its entry into routine clinical practice on a voluntary basis is testimony to the success and viability of the endeavor