Clinical review: Practical recommendations on the management of perioperative heart failure in cardiac surgery

Acute cardiovascular dysfunction occurs perioperatively in more than 20% of cardiosurgical patients, yet current acute heart failure (HF) classification is not applicable to this period. Indicators of major perioperative risk include unstable coronary syndromes, decompensated HF, significant arrhythmias and valvular disease. Clinical risk factors include history of heart disease, compensated HF, cerebrovascular disease, presence of diabetes mellitus, renal insufficiency and high-risk surgery. EuroSCORE reliably predicts perioperative cardiovascular alteration in patients aged less than 80 years. Preoperative B-type natriuretic peptide level is an additional risk stratification factor. Aggressively preserving heart function during cardiosurgery is a major goal. Volatile anaesthetics and levosimendan seem to be promising cardioprotective agents, but large trials are still needed to assess the best cardioprotective agent(s) and optimal protocol(s). The aim of monitoring is early detection and assessment of mechanisms of perioperative cardiovascular dysfunction. Ideally, volume status should be assessed by 'dynamic' measurement of haemodynamic parameters. Assess heart function first by echocardiography, then using a pulmonary artery catheter (especially in right heart dysfunction). If volaemia and heart function are in the normal range, cardiovascular dysfunction is very likely related to vascular dysfunction. In treating myocardial dysfunction, consider the following options, either alone or in combination: low-to-moderate doses of dobutamine and epinephrine, milrinone or levosimendan. In vasoplegia-induced hypotension, use norepinephrine to maintain adequate perfusion pressure. Exclude hypovolaemia in patients under vasopressors, through repeated volume assessments. Optimal perioperative use of inotropes/vasopressors in cardiosurgery remains controversial, and further large multinational studies are needed. Cardiosurgical perioperative classification of cardiac impairment should be based on time of occurrence (precardiotomy, failure to wean, postcardiotomy) and haemodynamic severity of the patient's condition (crash and burn, deteriorating fast, stable but inotrope dependent). In heart dysfunction with suspected coronary hypoperfusion, an intra-aortic balloon pump is highly recommended. A ventricular assist device should be considered before end organ dysfunction becomes evident. Extra-corporeal membrane oxygenation is an elegant solution as a bridge to recovery and/or decision making. This paper offers practical recommendations for management of perioperative HF in cardiosurgery based on European experts' opinion. It also emphasizes the need for large surveys and studies to assess the optimal way to manage perioperative HF in cardiac surgery

Reading Across Cultures: Global Narratives, Hotels and Railway Stations

This is the final version of the article. Available from Springer Verlag via the DOI in this record.This article takes its cue from the English critic, novelist and painter John Berger. He argues that what we know determines what we see. Hotels and railway stations, though they differ in size, design and appearance, are places of temporary national and international congress that are recognized by everyone. They become visible or even iconic once their history or their role is turned into at least part of a wider narrative—in literature, film or in other arts. This provides a representative focus by which we may read a city’s or a nation’s past. In exemplifying such connections I focus first on the long-term history of Friedrichstraße station and some of the surrounding hotels in the context of the history of Berlin, situating them within the national and, by implication, also the international context. Secondly, I will consider the outbreak of the First World War in 1914 as an event in which the role of railway stations generated both personal and collective memories across cultures and over several decades

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

Levosimendan was first approved for clinic use in 2000, when authorisation was granted by Swedish regulatory authorities for the haemodynamic stabilisation of patients with acutely decompensated chronic heart failure. In the ensuing 20 years, this distinctive inodilator, which enhances cardiac contractility through calcium sensitisation 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 heart failure, right ventricular failure and pulmonary hypertension, cardiac surgery, critical care and emergency medicine. Levosimendan is currently in active clinical evaluation in the US. Levosimendan in IV formulation is being used as a research tool in the exploration of a wide range of cardiac and non-cardiac 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, UK and Ukraine) contributed to this essay, which evaluates one of the relatively few drugs to have been successfully introduced into the acute heart failure arena in recent times and charts a possible development trajectory for the next 20 years

Accelerometry-based classification of circulatory states during out-of-hospital cardiac arrest

Objective: During cardiac arrest treatment, a reliable detection of spontaneous circulation, usually performed by manual pulse checks, is both vital for patient survival and practically challenging. Methods: We developed a machine learning algorithm to automatically predict the circulatory state during cardiac arrest treatment from 4-second-long snippets of accelerometry and electrocardiogram data from real-world defibrillator records. The algorithm was trained based on 917 cases from the German Resuscitation Registry, for which ground truth labels were created by a manual annotation of physicians. It uses a kernelized Support Vector Machine classifier based on 14 features, which partially reflect the correlation between accelerometry and electrocardiogram data. Results: On a test data set, the proposed algorithm exhibits an accuracy of 94.4 (93.6, 95.2)%, a sensitivity of 95.0 (93.9, 96.1)%, and a specificity of 93.9 (92.7, 95.1)%. Conclusion and significance: In application, the algorithm may be used to simplify retrospective annotation for quality management and, moreover, to support clinicians to assess circulatory state during cardiac arrest treatment.Comment: 15 pages, 10 figure

Tranexamic acid for treatment and prophylaxis of bleeding and hyperfibrinolysis

Uncontrolled massive bleeding with subsequent derangement of the coagulation system is a major challenge in the management of both surgical and seriously injured patients. Under physiological conditions activators and inhibitors of coagulation regulate the sensitive balance between clot formation and fibrinolysis. In some cases, excessive and diffuse bleeding is caused by systemic activation of fibrinolysis, i.e. hyperfibrinolysis (HF). Uncontrolled HF is associated with a high mortality. Polytrauma patients and those undergoing surgical procedures involving organs rich in plasminogen proactivators (e.g. liver, kidney, pancreas, uterus and prostate gland) are at a high risk for HF. Antifibrinolytics, such as tranexamic acid (TXA) are used for prophylaxis and treatment of bleeding caused by a local or generalized HF as well as other hemorrhagic conditions. TXA is a synthetic lysine analogue that has been available in Austria since 1966. TXA is of utmost importance in the prevention and treatment of traumatic and perioperative bleeding due to the resulting reduction in perioperative blood loss and blood transfusion requirements. The following article presents the different fields of application of TXA with particular respect to indications and dosages, based on a literature search and on current guidelines.(VLID)354393

Prophylactic levosimendan in patients with low ejection fraction undergoing coronary artery bypass grafting: A pooled analysis of two multicentre randomised controlled trials

International audienceAbstractObjectivesTo assess the effect of preoperative levosimendan on mortality at day 90 in patients with left ventricular ejection fraction (LVEF) ≤ 40%, and to investigate a possible differential effect between patients undergoing isolated coronary artery bypass grafting (CABG) versus CABG combined with valve replacement surgery.DesignPooled analysis of two multicentre randomised controlled trials (RCT) investigating prophylactic levosimendan versus placebo prior to CABG surgery on mortality at day 90 in patients with LVEF ≤ 40%. A meta-analysis of all RCT investigating the same issue was also conducted.ResultsA cohort of 1084 patients (809 isolated CABG, and 275 combined surgery) resulted from the merging of LEVO-CTS and LICORN databases. Seventy-two patients were dead at day 90. The mortality at day 90 was not different between levosimendan and placebo (Hazard Ratio (HR): 0.73, 95% CI: 0.41–1.28, p = 0.27). However, there was a significant interaction between the type of surgery and the study drug (p =  0.004). We observed a decrease in mortality at day 90 in the isolated CABG subgroup (HR: 0.39, 95% CI: 0.19–0.82, p = 0.013), but not in the combined surgery subgroup (HR: 1.73, 95% CI: 0.77–3.92, p = 0.19). The meta-analysis of 6 RCT involving 1441 patients confirmed the differential effect on mortality at day 30 between the 2 subgroups.ConclusionsPreoperative levosimendan did not reduce mortality in a mixed surgical population with LV dysfunction. However, the subgroup of patients undergoing isolated CABG had a reduction in mortality at day 90, whereas there was no significant effect in combined surgery patients. This finding requires confirmation with a specific prospective trial

Perioperative Use of Levosimendan: Best Practice in Operative Settings

LEVOSIMENDAN HAS BEEN USED in clinical practice since 2000, especially in the care of heart-failure patients. It probably is the most studied inotropic agent ever, with 83 randomized controlled trials published about adult critically ill patients1 (PubMed search updated January 6, 2012). The molecular mechanisms of levosimendan action recently have been described in detail elsewhere2 and are based on, but not limited to, the Ca2-sensitizing effect in the cardiac myofilaments. Pleiotropic effects include activation of adenosine triphosphate– sensitive sarcolemmal K channels of smooth muscle cells (linked to vasodilation) and activation of adenosine triphosphate– sensitive K channels in cardiovascular mitochondria (involved in a cardioprotective effect). The active long-lived metabolite OR-1896, also an inodilator,3,4 allows the cardiovascular effects of levosimendan to persist up to 7 to 9 days after the discontinuation of a 24-hour infusion of the drug.