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Normothermic Regional Perfusion, or NRP, is a method of donated organ reperfusion using cardiopulmonary bypass or a modified extracorporeal membrane oxygenation (ECMO) circuit after circulatory death while leaving organs in the dead donor's corpse. Despite its potential, several key ethical issues remain unaddressed by this technology. [ABSTRACT FROM AUTHOR]

Background: Acute type A aortic dissection (ATAAD) is a cardiovascular emergency and has high mortality and morbidity. We retrospectively compared the effects on outcomes of single arterial cannulation via axillary artery (AAC) with double arterial cannulation via axillary and femoral artery (DAC) in patients who underwent cardiopulmonary bypass (CPB) for ATAAD. Methods: Between January 2017 and May 2021, four hundred 29 patients who underwent aortic arch repair with circulatory arrest for ATAAD were divided into AAC group (n = 283) and DAC group (n = 146). The propensity score-matched (PSM) analysis were performed to compare the characteristics and outcomes of the groups. Results: After PSM (n = 137 in each), the DAC group had a longer duration of CPB (229 vs 244, p = 0.011), aortic cross-clamp time (121 vs 149, p < 0.001), durations of Intensive Care Unit (ICU) stay (7 vs 8, p = 0.014) and hospital stay (19 vs 25, p < 0.001) compared with AAC group. The incidences of dialysis (21% vs. 31%, p = 0.073), postoperative stroke (9% vs 15%, p = 0.143), ECMO support (2% vs 7%, p = 0.077), in-hospital mortality (7% vs 14%, p = 0.071) and follow-up mortality (10% vs 19%, p = 0.059) showed no significant difference between two groups. Multivariate logistic regression analysis showed postoperative ECMO (OR: 16.69, 95% CI: 1.78–156.29; p = 0.014) or stroke (OR: 11.34, 95% CI: 2.64–48.72; p < 0.001) were associated with in-hospital mortality. Univariate Cox regression results showed stroke history (OR: 4.61, 95% CI: 1.90–11.16; p = 0.001), aortic valvuloplasty (OR: 0.21, 95% CI: 0.07–0.59; p = 0.003), postoperative ALT day1 (OR: 1.00, 95% CI: 1.00–1.00; p = 0.008), ECMO (OR: 16.30, 95% CI: 4.78–55.61; p < 0.001), tracheotomy (OR: 3.78, 95% CI: 1.08–13.20; p = 0.037), postoperative stroke (OR: 4.61, 95% CI: 1.90–11.16; p < 0.001) and re-exploration for bleeding (OR: 3.52, 95% CI: 1.01–12.27; p = 0.048) were associated to follow-up mortality. Conclusions: For surgical treatment of ATAAD with CPB when compared to double axillary and femoral artery, single axillary cannulation was associated with shorter durations of CPB and ACC as well as ICU and hospital stays but no with significant difference in mortality. [ABSTRACT FROM AUTHOR]

Introduction: Bloodless cardiac surgery refers to open-heart surgery without blood or blood products. The cardiopulmonary bypass (CPB) circuits are primed with crystalloid solely, and there is no intraoperative blood transfusion. Methods: Our program considers bloodless congenital cardiac surgery with a minimal invasive extracorporeal circulation (MiECC) system for patients above 10 kg of weight. We performed a single-center retrospective cohort study of all consecutive patients undergoing bloodless cardiac surgery for congenital heart defects between January 2016 and December 2018. Results: A total of 164 patients were reviewed (86 male and 78 female) at a median age of 9.6 years (interquartile range (IQR), 4.5–15), a weight of 32 kg (IQR, 16–55), preoperative hemoglobin 13.7 g/dl (IQR, 12.6–14.9), and preoperative hematocrit of 40.4% (IQR, 37.2–44.3). Median CPB time was 81.5 min (IQR, 58–125), and median hematocrit coming off CPB was 26% (IQR, 23–29.7). The congenital heart surgery risk (STAT) category was distributed in STAT 1 for 70, STAT 2 for 80, STAT 3 for 9, and STAT 4 for 5 patients. Most patients (95%) were extubated in the operating room with a low complication rate during the hospital stay (14.6%). Only 6 (4%) patients needed a blood transfusion during the postoperative period, with a higher incidence of complications during the hospital course (p < 0.001). Conclusions: Bloodless congenital heart surgery with MiECC system is safe in low-surgical-risk patients. Our patients had a low rate of complications and short hospital stays. [ABSTRACT FROM AUTHOR]

Background: Myocardial protection during operations with cardiopulmonary bypass (CPB) and aortic cross clamping is vital. For this purpose, Del Nido (DN) and Custodiol cardioplegia (CC) solutions are used for single-dose cardioplegia in cardiac surgical procedures with CPB. Present study aimed to compare the effects of DN and CC on peri-operative clinical outcomes in pediatrics with Tetralogy of Fallot (TF) undergoing cardiopulmonary bypass. Methods: Present randomized clinical trial was performed in two trial groups with parallel design. One group received DN and another group received CC. We assessed circulatory Troponin-I (cTnI) and coronary sinus lactate level as primary outcomes. Secondary outcomes were ventilation time, electrolytes levels, pump time, cross-clamp time and other clinical parameters. Results: Duration of CPB and cross-clamp were the same in both groups. There were no significant differences in hemodynamic parameters, left ventricular ejection fraction after the surgery and discharge time between the two trial groups. Ventilation time (8.5 vs. 18; p = 0.001), ICU stay, Troponin-I in ICU admission and Coronary sinus lactate level (p = 0.001) were significantly higher among patients of Custodiol group compared to other trial group. Electrolytes Na, Cl and K levels, during CPB, were significantly less in Custodiol group. Conclusion: When used for inducing cardiac arrest during CPB, DN solution offers better maintenance of the electrolyte balance during CPB, and is associated with less circulatory cTnI and coronary sinus lactate level compared with the CC. [ABSTRACT FROM AUTHOR]

Venovenous extracorporeal membrane oxygenation is increasingly used as a bridging strategy in decompensating patients awaiting lung transplantation. Various approaches for continuing support intraoperatively have been previously described. A two-circuit strategy that uses the in situ venovenous extracorporeal membrane oxygenation circuit supplemented with peripheral cardiopulmonary bypass allows for diversion of native cardiac output away from the transplanted lung as well as seamless continuation of venovenous extracorporeal membrane oxygenation postoperatively. [ABSTRACT FROM AUTHOR]

Open in new tab Download slide OBJECTIVES The aim of this study was to assess the safety of early chest tube removal (CTR) protocol on the 1st postoperative day (POD1) of our Enhanced Recovery After Surgery (ERAS) programme by comparing the risk of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. METHODS All consecutive patients undergoing elective coronary revascularization and/or valve surgery between 2015 and 2021 were assessed in terms of their perioperative management pathways: conventional standard of care (control group) versus standardized systematic perioperative ERAS programme including an early CTR on POD1 (ERAS group). A propensity score matching was applied. The primary end-point was a composite of postoperative pneumothorax, pleural and pericardial effusion requiring intervention and hospital mortality. RESULTS A total of 3153 patients were included. Propensity score analysis resulted in 2 groups well-matched pairs of 1026 patients. CTR on POD1 was significantly increased from 29.5% in the control group to 70.3% in the ERAS group (P  < 0.001). The incidence of the primary end-point was 6.4% in the control group and 6.9% in the ERAS group (P  = 0.658). Patients in the ERAS group, as compared with control group, had significant lower incidence of bronchopneumonia (9.0% vs 13.5%; P  = 0.001) and higher incidence of mechanical ventilation ≤6 h (84.6% vs 65.2%; P  < 0.001), length of intensive care unit ≤1 day (61.2% vs 50.8%; P  < 0.001) and hospital ≤6 days (67.3% vs.43.2%; P  < 0.001). CONCLUSIONS CTR on POD1 protocol can be safely incorporated into a standardized systematic ERAS programme, enabling early mobilization, and contributing to the improvement of postoperative outcomes. Clinical trial registration number Ethics committee of the French Society of Thoracic and Cardio-Vascular Surgery (CERC-SFCTCV-2022-09-13_23140) [ABSTRACT FROM AUTHOR]

(1) Background: Growing evidence suggests impairment of ocular blood flow in open-angle glaucoma (OAG) pathology, but little is known about the effect of an impaired cardiovascular supply on the structural and vascular parameters of the retina. This study aims to investigate the variations of these parameters in OAG patients compared to patients undergoing cardiac surgery (CS) with cardiopulmonary bypass. (2) Methods: Prospective observational study with 82 subjects (30 controls, 33 OAG patients, and 19 CS patients) who underwent ophthalmological assessment by swept-source OCT and CDI in one randomly selected eye. (3) Results: In the CS group, OA and SPCA PSV and EDV were significantly lower, OA and SPCA RI were significantly higher compared to the OAG and healthy subjects (p = 0.000–0.013), and SPCA EDV correlated with linear CDR (r = −0.508, p = 0.027). Temporal ONH sectors of GCL++ and GCL+ layers in the CS group did not differ significantly compared to the OAG patients (p = 0.085 and p = 0.220). The CS patients had significantly thinner GCL++ and GCL+ layers in the inner sectors (p = 0.000–0.038) compared to healthy subjects, and these layers correlated with the CRA PSV, EDV, and RI and SPCA PSV (p = 0.005–0.047). (4) Conclusions: CS patients had lower vascular and structural parameters in the ONH, and macula compared to the healthy controls that were similar to persons with OAG. [ABSTRACT FROM AUTHOR]

Background: Bleeding after cardiac surgery is common and continues to require 10–20% of the national blood supply. Transfusion of allogeneic blood is associated with increased morbidity and mortality. Excessive protamine in the absence of circulating heparin after weaning off CPB can cause anticoagulation and precipitate bleeding. Hence, adequate dose calculation of protamine is crucial yet under evaluated. Study Design: Retrospective cohort study. Methods: We conducted a retrospective bi‐institutional analysis of cardiac surgical patients who underwent cardiopulmonary bypass (CPB)‐assisted cardiac surgery to assess the impact of protamine dosing in transfusion practice. Total 762 patients were identified from two institutions using electronic medical records and the Society of Thoracic Surgery (STS) database who underwent cardiac surgery using CPB. Patients were similar in demographics and other baseline characteristics. We divided patients into two groups based on mg of protamine administered to neutralize each 100 U of unfractionated heparin (UFH)—low‐ratio group (Protamine: UFH ≤ 0.8) and high‐ratio group (Protamine: UFH > 0.8). Results: We observed a higher rate of blood transfusion required in high‐ratio group (ratio >0.8) compared with low‐ratio group (ratio ≤0.8) (p <.001). The increased requirement was consistently demonstrated for intraoperative transfusions of red blood cells, plasma, platelets, and cryoprecipitate. Conclusion: High protamine to heparin ratio may cause increased bleeding and transfusion in cardiac surgical patients. Protamine to heparin ratio of 0.8 or lower is sufficient to neutralize circulating heparin after weaning off cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

Patent ductus arteriosus stenting (PDAS) for ductal-dependent pulmonary blood flow (DDPBF) provides a new paradigm for managing neonates with single ventricles (SV). Currently, sparse data exist regarding outcomes for subsequent palliation. We describe our experience with inter-stage care and stage 2 (S2P) conversion with PDAS in comparison to a prior era of patients who received surgical aorto-pulmonary shunts (APS). Retrospective review of 18 consecutive DDPBF SV patients treated with PDAS between 2016 and 2021 was done and compared with 9 who underwent APS from 2010 to 2016. Patient outcomes and pulmonary artery (PA) growth were analyzed. S2P was completed in all 18 with PDAS with no cardiac arrests and one post-S2P mortality. In the 9 APS patients, there was one cardiac arrest requiring ECMO and one mortality inter-stage. Off cardiopulmonary bypass strategy was utilized in 10/18 in the PDAS and 1/9 in the APS group (p = 0.005) at S2P. Shorter ventilation time, earlier PO feeding, and shorter hospital stay were noted in the PDAS group (p = 0.01, p = 0.006, p = 0.03) (S2P). Median Nakata index increase inter-stage was not significant between the PDAS and APS at 94.1 mm2/m2 versus 71.7 mm2/m2 (p = 0.94). Median change in pulmonary artery symmetry (PAS) was − 0.02 and − 0.24, respectively, which was statistically significant (p = 0.008). Neurodevelopmental outcomes were better in the PDAS group compared to the APS group (p = 0.02). PDAS provides excellent PA growth, inter-stage survival, progression along multistage single-ventricle palliation, and potentially improved neurodevelopmental outcomes. Most patients can be transitioned through 2 stages of palliation without CPB. [ABSTRACT FROM AUTHOR]

Necrotizing enterocolitis (NEC) is a relatively common complication in neonates with single ventricle physiology following heart surgery. Near-infrared spectroscopy (NIRS) is used to measure regional oxygen saturations in neonates in the postoperative period. We sought to investigate the association of somatic regional oxygen saturation (srSO2) and cerebral regional oxygen saturation (crSO2) in the early postoperative period and the subsequent development of NEC. We performed a retrospective cohort study of neonates who underwent cardiac surgery with cardiopulmonary bypass from October 2017 to September 2021 at the University of Virginia Children's Hospital. Values of srSO2 and crSO2 were captured over the first 48 h following surgery. 166 neonates were included and the median age at time of surgery was 8 days. NEC was diagnosed in 18 neonates following heart surgery with a median interval from surgery to diagnosis of 7 days. Neonates with single ventricle physiology had lower average crSO2 (62% vs 78%, p < 0.001), average srSO2 (72% vs 86%, p < 0.001), average crSO2 to srSO2 ratio (0.874 vs 0.913, p < 0.001), and an increased average srSO2–crSO2 difference (10% vs 8%, p = 0.03). Adjusting for single ventricle physiology, lower average crSO2 was associated with the development of definite NEC (modified Bell's criteria stage IIa and higher) (OR = 0.86, 95% CI 0.78–0.96, p = 0.007). Lower crSO2 values in the early postoperative period in neonates following cardiac surgery was associated with an increased risk in the subsequent development of NEC. [ABSTRACT FROM AUTHOR]

Background The effect of continuous myocardial perfusion (CMP) on the surgical results of acute type A aortic dissection (ATAAD) remains unclear. Methods From January 2017 to March 2022, 141 patients who underwent ATAAD (90.8%) or intramural hematoma (9.2%) surgery were reviewed. Fifty-one patients (36.2%) received proximal-first aortic reconstruction and CMP during distal anastomosis. Ninety patients (63.8%) underwent distal-first aortic reconstruction and were placed in traditional cold blood cardioplegic arrest (CA; 4°C, 4:1 blood-to-Plegisol) throughout the procedure. The preoperative presentations and intraoperative details were balanced using inverse probability of treatment weighting (IPTW). Their postoperative morbidity and mortality were analyzed. Results The median age was 60 years. The incidence of arch reconstruction in the unweighted data was higher in the CMP compared with the CA group (74.5 vs 52.2%, p = 0.017) but was balanced after IPTW (62.4 vs 58.9%, p = 0.932, standardized mean difference = 0.073). The median cardiac ischemic time was lower in the CMP group (60.0 vs 130.9 minutes, p < 0.001), but cerebral perfusion time and cardiopulmonary bypass time were similar. The CMP group did not demonstrate any benefit in the reduction of the postoperative maximum creatine kinase-MB ratio (4.4 vs 5.1% in CA, p = 0.437) or postoperative low cardiac output (36.6 vs 24.8%, p = 0.237). Surgical mortality was comparable between groups (15.5% in CMP vs 7.5% in the CA group, p = 0.265). Conclusion Application of CMP during distal anastomosis in ATAAD surgery, irrespective of the extent of aortic reconstruction, reduced myocardial ischemic time but did not improve cardiac outcome or mortality. [ABSTRACT FROM AUTHOR]

Background We evaluate the outcome of aortic root surgery via an upper J -shaped mini-sternotomy (MS) versus full sternotomy (FS) in an intermediate-volume center. Methods Between November 2011 and February 2019, 94 consecutive patients underwent aortic root surgery: 62 (66%) patients were operated via a J -shaped MS (group A) and 32 (34%) patients via FS (group B). The primary endpoints were mortality, major adverse cardiac and cerebral events (MACCE), and reoperation in a 2-year follow-up. The secondary endpoints were perioperative complications and patient's satisfaction with the procedural results. Results Valve sparing root replacement (David procedure) was performed in 13 (21%) of the MS and 7 (22%) of the FS patients. The Bentall procedure in MS versus FS was 49 (79%) versus 25 (78%), respectively. Both groups presented similar mean operation, cardiopulmonary bypass, and cross-clamp times. Postoperative bleeding was 534 ± 300 and 755 ± 402 mL (p = 0.01) in MS and FS, respectively, erythrocyte concentrate substitution was 3 ± 3 and 5.3 ± 4.8 (p = 0.018) in MS and FS, respectively, and pneumonia rates were 0 and 9.4% (p = 0.03) in MS and FS, respectively. The 30-day mortality was 0% in both groups, whereas MACCE was 1.6 and 3% (p = 0.45) in MS and FS, respectively. After 2 years, the mortality and MACCE were 4.6 and 9.5% (p = 0.11) and 4.6 and 0% (p = 0.66) in MS and FS, respectively. The number of patients who were satisfied with the surgical cosmetic results in groups A and B was 53 (85.4%) and 26 (81%), respectively. Conclusion Aortic root surgery via MS is a safe alternative to FS even in an intermediate-volume center. It offers a shorter recovery time and similar midterm results. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) is a crucial component of cardiac surgery, yet it often leads to postoperative pulmonary dysfunction (PPD). Various modes of ventilation during CPB have been employed, but their comparative effects on PPD remain unclear. Materials and Methods: This study aimed to compare different modes of ventilation--namely, conventional ventilation (CV) and protective ventilation (PV)--during CPB and assess their impact on PPD. A total of 100 patients undergoing cardiac surgery were randomly assigned to either the CV group or the PV group. Demographic data, intraoperative variables, and postoperative outcomes were recorded. PPD was assessed through pulmonary function tests (PFTs) postoperatively. Results: In the CV group, PPD was observed in 45% of patients, with a mean reduction in forced vital capacity (FVC) of 25% and forced expiratory volume in one second (FEV1) of 30%. Contrastingly, in the PV group, PPD occurred in only 20% of patients, with a mean reduction in FVC of 15% and FEV1 of 20%. The incidence of pneumonia was also significantly lower in the PV group (p < 0.05). Conclusion: Protective ventilation during CPB appears to mitigate the incidence and severity of postoperative pulmonary dysfunction compared to conventional ventilation. Employing protective ventilation strategies may contribute to improved postoperative outcomes and reduced pulmonary complications following cardiac surgery. [ABSTRACT FROM AUTHOR]

Background: Cardiopulmonary bypass (CPB) ensures tissue oxygenation during cardiac surgery. New technology allows continuous registration of CPB variables during the operation. The aim of the present investigation was to study the association between CPB management and the risk of postoperative acute kidney injury (AKI). Methods: This observational study based on prospectively registered data included 2661 coronary artery bypass grafting and/or valve patients operated during 2016–2020. Individual patient characteristics and postoperative outcomes collected from the SWEDEHEART registry were merged with CPB variables automatically registered every 20 s during CPB. Associations between CPB variables and AKI were analyzed with multivariable logistic regression models adjusted for patient characteristics. Results: In total, 387 patients (14.5%) developed postoperative AKI. After adjustments, longer time on CPB and aortic cross‐clamp, periods of compromised blood flow during aortic cross‐clamp time, and lower nadir hematocrit were associated with the risk of AKI, while mean blood flow, bladder temperature, central venous pressure, and mixed venous oxygen saturation were not. Patient characteristics independently associated with AKI were advanced age, higher body mass index, hypertension, diabetes mellitus, atrial fibrillation, lower left ventricular ejection fraction, estimated glomerular filtration rate <60 or >90 mL/min/m2, and preoperative hemoglobin concentration below or above the normal sex‐specific range. Conclusions: To reduce the risk of AKI after cardiac surgery, aortic clamp time and CPB time should be kept short, and low hematocrit and periods of compromised blood flow during aortic cross‐clamp time should be avoided if possible. [ABSTRACT FROM AUTHOR]

Cardiac surgery induces systemic inflammatory response syndrome (SIRS), leading to higher morbidity and mortality. There are no individualized predictors for worse outcomes or biomarkers for the multifactorial, excessive inflammatory response. The interest of this study was to evaluate whether a systematic use of the SIRS criteria could be used to predict postoperative outcomes beyond infection and sepsis, and if the development of an exaggerated inflammation response could be observed preoperatively. The study was observational, with prospectively enrolled patients. This was a single institution study in a hospital setting combined with laboratory findings. The study included a cohort of 261 volunteer patients. Patients underwent cardiac surgery with cardiopulmonary bypass, and were followed up to 90 days. Biomarker profiling was run preoperatively. Altogether, 17 of 261 (6.4%) patients had prolonged SIRS, defined as fulfilling at least 2 criteria on 4 consecutive postoperative days. During hospitalization, postoperative atrial fibrillation (POAF) was found in 42.2% of patients, and stroke and transient ischemic attack in 3.8% of patients. Prolonged SIRS was a significant predictor of POAF (odds ratio [OR] 4.5, 95% CI 1.2-17.3), 90-day stroke (OR 4.5, 95% CI 1.1-18.0), and mortality (OR 10.7, 95% CI 1.7-68.8). Biomarker assays showed that preoperative nerve growth factor and interleukin 5 levels were associated with prolonged SIRS (OR 5.6, 95%, CI 1.4-23.2 and OR 0.7, 95%, CI 0.4-1.0, respectively). Nerve growth factor and interleukin 5 can be used to predict prolonged systemic inflammatory response, which is associated with POAF, stroke, and mortality. [Display omitted] [ABSTRACT FROM AUTHOR]

Microcirculation is essential for cellular life and its functions. It comprises a complex network of capillaries, arterioles, and venules, which distributes oxygenated blood across and within organs based on regional metabolic demands. Because previous research indicated that organ function is linked to microcirculatory function, it is crucial to maintain sufficient and effective microcirculatory function during major surgery. Impaired microcirculation can lead to inadequate tissue perfusion, potentially resulting in perioperative complications and an unfavorable outcome. Indeed, changes in microcirculation in cardiovascular disease and cardiac surgery have a direct correlation with prolonged stays in the postoperative intensive care unit and high mortality rates within 30 days. Additionally, cardiopulmonary bypass, a regularly employed method in cardiac surgery, has been proven to induce microcirculatory malfunction and, thus, lead to postoperative multiple organ dysfunction. As global hemodynamic parameters can remain stable or improve, whereas microcirculation is still compromised, tracking microcirculatory variables could lead to the development of targeted microcirculatory treatment within hemodynamic management. Therefore, it is necessary to enhance the use of microcirculatory monitoring in the medical domain to assist physicians in the therapeutic management of patients undergoing cardiac surgery. This potentially can lead to better hemodynamic management and outcomes. This review article concentrates on the use of handheld video microscopes for real-time microcirculatory assessment of cardiac surgery patients in the immediate and early postoperative period. Emphasis is placed on integrating microcirculatory monitoring with conventional hemodynamic monitoring in the therapeutic management of patients undergoing cardiac surgery. [ABSTRACT FROM AUTHOR]

To report early outcomes of blood conservation in neonatal open-heart surgery. Ninety-nine patients undergoing neonatal open-heart surgery during the implementation of a blood conservation program between May 2021 and February 2023 were reviewed. Patients either received traditional blood management (blood prime, n = 43) or received blood conservation strategies (clear prime, n = 56). Baseline characteristics and outcomes were compared between groups. There was no difference in body weight (median, 3.2 kg vs 3.3 kg; P =.83), age at surgery (median, 5 days vs 5 days; P =.37), distribution of The Society of Thoracic Surgeons–European Association for Cardio-Thoracic Surgery Congenital Heart Surgery Mortality Categories categories or duration of cardiopulmonary bypass. Patients in the clear prime group had higher preoperative hematocrit (median, 41% vs 38%; P <.01), shorter postoperative mechanical ventilation time (median, 48 hours vs 92 hours; P =.02) and postoperative intensive care unit length of stay (median, 6 days vs 9 days; P <.01) than patients in the blood prime group. Fourteen patients (25%) in the clear prime group, including 1 Norwood patient, were discharged without any transfusion. Among patients within the clear prime group, hospitalizations without blood exposure were associated with higher preoperative hematocrit (median, 43% vs 40%; P =.02), shorter postoperative mechanical ventilation times (median, 22 hours vs 66 hours; P =.01) and shorter postoperative hospital stays (median, 10 days vs 15 days; P =.02). Bloodless surgery is possible in a significant proportion of neonates undergoing open-heart surgery, including the Norwood operation, even in the early stages of experience. Early clinical results are favorable but long-term follow-up and continued efforts are warranted to prove safety and reproducibility. [Display omitted] [ABSTRACT FROM AUTHOR]

The Norwood procedure can be performed with several variations including a sustained total all-region (STAR) perfusion technique, introduced at our institution 5 years ago and well described in a prior Operative Techniques article. Regardless of technique heterogeneity, national outcomes continue to demonstrate that the Norwood procedure carries one of the highest mortalities of all congenital heart operations. Our technique of STAR perfusion provides total body perfusion during the entire Norwood reconstruction, avoiding coagulopathy associated with significant cooling and ischemic time to end-organs. Over the past few years, we have refined the technique, and describe key variations and modifications in this article. [ABSTRACT FROM AUTHOR]

The purpose of cardiopulmonary bypass is to maintain perfusion and oxygenation of the vital organs in the absence of heart and lung function, usually to facilitate surgery on the heart, but occasionally in other situations. Although the intricacies of the modern extracorporeal circuit and the conduct of cardiopulmonary bypass are the domain of the clinical perfusion scientist ('perfusionist'), safe surgery mandates a good understanding of some fundamentals by the anaesthetist and the surgeon. This review is aimed at the anaesthetist. First, we will systematically examine the main components of the extracorporeal circuit, travelling in the direction that blood travels, from the venous cannula to the arterial cannula. Then we will describe the process of preparing for bypass, 'going on', conducting a bypass run, and weaning and separation from bypass. It is crucial to have clear communication between the surgeon, perfusionist and anaesthetist. This can be difficult for the novice because a quite specific language has evolved in cardiac operating theatres to signal key events in the cardiopulmonary bypass sequence. As we go through this article, we will highlight commonly used terminology and expressions used. [ABSTRACT FROM AUTHOR]

Aim: Acute aortic dissection type A (AADA) is a life-threatening emergency with high mortality rates. Surgical intervention is the preferred and potentially life-saving treatment, but perioperative mortality remains a significant concern. Identifying the risk factors associated with surgical mortality, morbidity, and survival rates is essential. Therefore, this study aimed to characterize the preoperative and intraoperative risk factors for death during surgical repair of AADA. Material and Methods: We included 64 consecutive patients who underwent surgical repair between April 2013 and March 2021 in a tertiary heart center. Perioperative characteristics and variables were collected and analyzed to find any correlation between them and in-hospital Outcomes. Results: Aortic dissection surgery was performed on an average of 8 patients annually, accounting for approximately 1.7% (64/3757) of all openheart surgery cases. The in-hospital mortality rate was 28% (18/64). The main predisposing factors for in-hospital death were cardiac failure (11.1%), stroke (16.7%), uncontrollable hemorrhage (27.8%), renal failure (11.1%), respiratory failure (11.1%), and postoperative multi-organ failure (22.2%). We found no associations between cardiopulmonary bypass duration and mortality. During the routine use of cerebral protective perfusion, we did not encounter any cases of coma. Left ventricular hypertrophy, a short distance of intimal tear to the aortic valve, and renal failure were associated with postoperative bleeding tendency. Conclusion: Our study showed that multiple factors such as heart failure, uncontrolled bleeding, and respiratory failure increase in-hospital mortality of patients with dissection of aorta type A, but duration of surgery does not have any association with in-hospital death. [ABSTRACT FROM AUTHOR]

(1) Background: Near-infrared spectroscopy (NIRS) is a noninvasive tool frequently used during cardiac surgery and postoperatively in the cardiac intensive care unit to monitor regional tissue oxygen saturation. A relationship between trends of intraoperative renal oxygenation and the risk of developing cardiac surgery-associated acute kidney injury (AKI) post-operatively has not yet been established in the neonatal population. The objective of this study is to evaluate the relationship of cerebral and renal oxygenation during cardiopulmonary bypass with cardiac surgery-associated AKI in the first 72 h post-operation in neonates < 30 days of age. (2) Methods: A prospective cohort study at a tertiary care children's hospital was performed. Renal and cerebral oxygenation measured were collected intraoperatively from neonates < 30 days of age who underwent cardiopulmonary bypass for the correction of congenital heart disease. AKI was defined accordance with the Kidney Disease: Improving Global Outcomes criteria modified for neonates. Variables were compared between groups. (3) Results: 32 neonates with 35 cardiopulmonary bypass cases were included. AKI was diagnosed in 60% of cases. Intra-operative renal oxygenation, both on- and off-bypass, did not differ among the three AKI groups (p > 0.19). Renal oxygenation after coming off, but not during, cardiopulmonary bypass steadily decreased with increasing levels of AKI (Jonckheere's test, one-sided p = 0.024). (4) Conclusions: Renal oxygenation decreased in proportion to AKI severity after coming off, but not during, cardiopulmonary bypass. [ABSTRACT FROM AUTHOR]

Cardiopulmonary bypass has been speculated to elicit systemic inflammation to initiate acute lung injury (ALI), including acute respiratory distress syndrome (ARDS), in patients after cardiac surgery. We previously found that post-operative patients showed an increase in endothelial cell-derived extracellular vesicles (eEVs) with components of coagulation and acute inflammatory responses. However, the mechanism underlying the onset of ALI owing to the release of eEVs after cardiopulmonary bypass, remains unclear. Plasma plasminogen-activated inhibitor-1 (PAI-1) and eEV levels were measured in patients with cardiopulmonary bypass. Endothelial cells and mice (C57BL/6, Toll-like receptor 4 knockout (TLR4−/−) and inducible nitric oxide synthase knockout (iNOS−/−)) were challenged with eEVs isolated from PAI-1-stimulated endothelial cells. Plasma PAI-1 and eEVs were remarkably enhanced after cardiopulmonary bypass. Plasma PAI-1 elevation was positively correlated with the increase in eEVs. The increase in plasma PAI-1 and eEV levels was associated with post-operative ARDS. The eEVs derived from PAI-1-stimulated endothelial cells could recognize TLR4 to stimulate a downstream signaling cascade identified as the Janus kinase 2/3 (JAK2/3)-signal transducer and activator of transcription 3 (STAT3)-interferon regulatory factor 1 (IRF-1) pathway, along with iNOS induction, and cytokine/chemokine production in vascular endothelial cells and C57BL/6 mice, ultimately contributing to ALI. ALI could be attenuated by JAK2/3 or STAT3 inhibitors (AG490 or S3I-201, respectively), and was relieved in TLR4−/− and iNOS−/− mice. eEVs activate the TLR4/JAK3/STAT3/IRF-1 signaling pathway to induce ALI/ARDS by delivering follistatin-like protein 1 (FSTL1), and FSTL1 knockdown in eEVs alleviates eEV-induced ALI/ARDS. Our data thus demonstrate that cardiopulmonary bypass may increase plasma PAI-1 levels to induce FSTL1-enriched eEVs, which target the TLR4-mediated JAK2/3/STAT3/IRF-1 signaling cascade and form a positive feedback loop, leading to ALI/ARDS after cardiac surgery. Our findings provide new insight into the molecular mechanisms and therapeutic targets for ALI/ARDS after cardiac surgery. [ABSTRACT FROM AUTHOR]

Cardiopulmonary bypass cause microcirculatory alterations. Near infrared spectroscopic measurement of tissue oxygen saturation and vascular occlusion test are novel technologies for assessing the microcirculatory function of peripheral tissue specifically in patients undergoing cardiac surgery with cardiopulmonary bypass.Our study aimed to evaluate dynamic microcirculatory function using the vascular occlusion testing during cardiac surgery in pediatric patients. 120 pediatric patients were scheduled. Children had continuous regional oxygen saturation monitoring using near infrared spectroscopy and vascular occlusion test. Vascular occlusion test was performed five times; before induction (T1), after induction (T2), then during cardiopulmonary bypass with full flow (T3), after the termination of CPB (T4) and after sternum closure (T5). Basal value was the lowest at T3 and this value was significantly different among measurements (p < 0,01).Values for maximum and minimum tissue oxygen saturation were the lowest at T3 (83,4 and 52,9%).The occlusion slope varied significantly among measurements (p < 0,01).Reperfusion slopes were significantly different among measurements (p < 0,01) with a further progressive decrease in reperfusion slope with duration of cardiopulmonary bypass. Microcirculatory function can assessed using VOT with forearm Near-infrared spectroscopy derived variables during cardiopulmonary bypass in pediatric cardiac surgery. Noninvasive assessment of microcirculatory perfusion during cardiopulmonary bypass can further help evaluate and improve circulatory support techniques. The research Project was registered at ClinicalTrials.gov (NCT06191913) [ABSTRACT FROM AUTHOR]

Introduction: Along with cardiopulmonary bypass time, aortic cross-clamping time is directly related to the risk of complications after heart surgery. The influence of the time difference between cardiopulmonary bypass and cross-clamping times (TDC-C) remains poorly understood. Objective: To assess the impact of cardiopulmonary bypass time in relation to cross-clamping time on immediate results after coronary artery bypass grafting in the Registro Paulista de Cirurgia Cardiovascular (REPLICCAR) II. Methods: Analysis of 3,090 patients included in REPLICCAR II database was performed. The Society of Thoracic Surgeons outcomes were evaluated (mortality, kidney failure, deep wound infection, reoperation, cerebrovascular accident, and prolonged ventilation time). A cutoff point was adopted, from which the increase of this difference would affect each outcome. Results: After a cutoff point determination, all patients were divided into Group 1 (cardiopulmonary bypass time < 140 min., TDC-C < 30 min.), Group 2 (cardiopulmonary bypass time < 140 min., TDC-C > 30 min.), Group 3 (cardiopulmonary bypass time > 140 min., TDC-C < 30 min.), and Group 4 (cardiopulmonary bypass time > 140 min., TDC-C > 30 min.). After univariate logistic regression, Group 2 showed significant association with reoperation (odds ratio: 1.64, 95% confidence interval: 1.01-2.66), stroke (odds ratio: 3.85, 95% confidence interval: 1.99-7.63), kidney failure (odds ratio: 1.90, 95% confidence interval: 1.32-2.74), and in-hospital mortality (odds ratio: 2.17, 95% confidence interval: 1.30-3.60). Conclusion: TDC-C serves as a predictive factor for complications following coronary artery bypass grafting. We strongly recommend that future studies incorporate this metric to improve the prediction of complications. [ABSTRACT FROM AUTHOR]

Objective: To determine the risk factors for early post-operative arrhythmias in children undergoing congenital heart surgeries at a tertiary care hospital. Study Design: Prospective longitudinal study. Place and Duration of Study: National Institute of Cardiovascular Disease, Karachi Pakistan, from Jan to Jul 2020. Methodology: We included 143 patients of both genders undergoing open heart surgery for congenital heart diseases. We noted all patients' pre-operative, intra-operative, and post-operative clinical characteristics. Patients were monitored in the pediatric cardiac intensive care unit. We analyzed the development of postoperative arrhythmias and the factors associated with them. Results: In 143 patients, the mean age at the time of surgery was 7.52±6.0 years. There were 83(58.0%) male patients. Tetralogy of Fallot was the most common type of congenital heart disease noted in 57(39.0%) patients. The mean cardiopulmonary bypass time was 83.9±25.5 minutes, while the mean aortic cross-clamp time was 58.1±21.9 minutes. Post-operatively, arrhythmia was observed in 39(27.3%) children. Intra-operative arrhythmias (p

BackgroundTo identify the risk factors for postoperative delirium (POD) after cardiac surgery in frail elderly patients and develop a receiver operating characteristic (ROC) prediction model to confirm the effectiveness.MethodsThis was a prospective observational study, patients were assessed preoperatively according to the frailty index (FI) scale. Cerebral (SctO2) was assessed at different time points using near-infrared spectroscopy (NIRS). On the basis of the occurrence of POD within 7 days after surgery, patients were divided into POD and non-POD groups. Risk factors were analyzed using logistic regression analysis, while their predictive values were evaluated using the receiver operating characteristic curve analysis.ResultsPOD was significantly associated with frailty, lower preoperative MMSE scores, hyperlipidemia, diabetes, cerebrovascular disease, lower hemoglobin level, lower albumin level, longer operation time, longer CPB time, lower SctO2 at T5, and lower SctO2baseline (P

Cardiopulmonary bypass (CPB) initiates an intense inflammatory response due to various factors: conversion from pulsatile to laminar flow, cold cardioplegia, surgical trauma, endotoxemia, ischemia-reperfusion injury, oxidative stress, hypothermia, and contact activation of cells by the extracorporeal circuit. Redundant and overlapping inflammatory cascades amplify the initial response to produce a systemic inflammatory response, heightened by coincident activation of coagulation and fibrinolytic pathways. When unchecked, this inflammatory response can become maladaptive and lead to serious postoperative complications. Concerted research efforts have been made to identify technical refinements and pharmacologic interventions that appropriately attenuate the inflammatory response and ultimately translate to improved clinical outcomes. Surface modification of the extracorporeal circuit to increase biocompatibility, miniaturized circuits with sheer resistance, filtration techniques, and minimally invasive approaches have improved clinical outcomes in specific populations. Pharmacologic adjuncts, including aprotinin, steroids, monoclonal antibodies, and free radical scavengers, show real promise. A multimodal approach incorporating technical, circuit-specific, and pharmacologic strategies will likely yield maximal clinical benefit.

Objective: To observe the effect of the lung-protective ventilation strategy, static lung expansion, during cardiopulmonary bypass (CPB) on pulmonary function and tracheal intubation time following cardiac surgery in children. Methods: A total of 48 child patients (aged 1–3) with ventricular septal defect (VSD) were enrolled, and all underwent CPB cardiac surgery for the first time. The patients were divided into two groups using the random number table method: the experimental group (Group A, n = 30) and the control group (Group B, n = 18). After terminating the mechanical ventilation during CPB, the adjustable pressure limiting valve of the anesthesia machine was adjusted in the experimental group to maintain the pressure of the breathing circuit at 5 cmH2O, such that both lungs remained in a static expansion state. In the control group, routine mechanical ventilation was terminated as usual. Results: When static lung expansion with a continuous positive airway pressure of 5 cmH2O was employed in the VSD children during CPB, compared with termination of mechanical ventilation, the partial pressure of oxygen in the arterial blood increased, while the respiratory index decreased and the oxygenation index increased following the surgery. Conclusion: In child patients undergoing VSD reparation under CPB, lung injury occurs following the procedure, and the pulmonary oxygenation function and pulmonary oxygen diffusion function decrease. When static lung expansion of 5 cmH2O is performed during CPB, the improvement in lung function is better than that of apnea without lung expansion pressure.

BackgroundPostoperative delirium (POD) is a common anesthetic side effect in cardiac surgery. However, the role of oxygen saturation monitoring in reducing postoperative delirium has been controversial. Therefore, this meta-analysis aimed to analyze whether NIRS monitoring during cardiac surgery under cardiopulmonary bypass could reduce the incidence of postoperative delirium.MethodsPubMed, Web of Science, Cochrane Library, Embase and China National Knowledge Infrastructure (CNKI) databases were systematically searched using the related keywords for randomized-controlled trials (RCTs) published from their inception to March 16, 2024. This review was conducted by the Preferred Reporting Project and Meta-Analysis Statement (PRISMA) guidelines for systematic review. The primary outcome was postoperative delirium, and the second outcomes included the length of ICU stay, the incidence of kidney-related adverse outcomes, and the incidence of cardiac-related adverse outcomes.ResultsThe incidence of postoperative delirium could be reduced under the guidance of near-infrared spectroscopy monitoring (OR, 0.657; 95% CI, 0.447–0.965; P = 0.032; I2 = 0%). However, there were no significant differences in the length of ICU stay (SMD, 0.005 days; 95% CI, −0.135–0.146; P = 0.940; I2 = 39.3%), the incidence of kidney-related adverse outcomes (OR, 0.761; 95% CI, 0.386–1.500; P = 0.430; I2 = 0%), and the incidence of the cardiac-related adverse outcomes (OR, 1.165; 95% CI, 0.556–2.442; P = 0.686; I2 = 0%) between the two groups.ConclusionNear-infrared spectroscopy monitoring in cardiac surgery with cardiopulmonary bypass helps reduce postoperative delirium in patients.Systematic Review RegistrationPROSPERO, identifier, CRD42023482675

An intramyocardial dissection hematoma is a rare event usually caused by hemorrhagic dissection among the spiral myocardial. Herein, we reported a senile man with Intramyocardial dissection hematoma who presented with neglected myocardial infarction

BackgroundUsing a pig model of cardiopulmonary bypass, we compared outcomes after cardioplegia either with our in-house “Huaxi-1” solution containing natural blood and crystalloid or with the entirely crystalloid, commercially available “histidine-tryptophan-ketoglutarate” solution.MethodsCardiopulmonary bypass was established in 13 healthy male pigs. Twelve of those animals were randomized to receive a single dose of either Huaxi-1 or entirely crystalloid cardioplegia, while the remaining animal was assigned to receive Huaxi-1 without randomization. All animals were then subjected to whole-heart ischemia for 90 min, followed by 2 h of reperfusion, after which myocardial injury was assessed in terms of cardiac function, myocardial pathology and levels of biomarkers in plasma, while levels of high-energy phosphate in myocardium were assayed using liquid chromatography.ResultsAnimals given Huaxi-1 cardioplegia required significantly less time to be weaned off bypass, they received significantly lower doses of norepinephrine, and they showed significantly higher levels (mean ± SD) of adenosine triphosphate (14 ± 4 vs. 8 ± 2 µg/mg, P = 0.005), adenosine diphosphate (16 ± 2 vs. 13 ± 2 µg/mg, P = 0.046), and total adenine nucleotide (37 ± 4 vs. 30 ± 3 µg/mg, P = 0.006) in myocardium after 2 h of reperfusion. They also showed less severe bleeding, edema and injury to mitochondria and myofibers in myocardium. The two groups did not differ significantly in doses of inotropic drugs received, cardiac output or levels of biomarkers in plasma.ConclusionsIn this animal model of healthy hearts subjected to 90 min of ischemia, Huaxi-1 cardioplegia may be superior to entirely crystalloid cardioplegia for promoting energy generation and attenuating ischemia/reperfusion injury in myocardium.

Abstrct: Objectives: The FUWAI-SAVE system is a modified low-priming cardiopulmonary bypass (CPB) system. The study aimed to explore whether the FUWAI-SAVE system can reduce the perioperative blood transfusion and its impact on other postoperative complications during cardiac surgery. Metohds: This study was a single-center, single-blind, randomized controlled trial, registered at the Chinese Clinical Trial Registry (identifier: ChiCTR2100050488). Adult patients undergoing cardiac surgery with CPB and intermediate risk for transfusion risk stratification were randomly assigned to an intervention group (FUWAI-SAVE group) or a control group (conventional group). The primary endpoint of the study was the peri-CPB red blood cell transfusion (RBC) rate. The secondary endpoints included the transfusion rate of other blood products, the amount of blood products transfused, the incidence of major complications, in-hospital mortality, and others. Results: 360 patients were randomized from December 9, 2021, to January 30, 2023. The rate of the primary endpoint was significantly lower in the FUWAI-SAVE group compared to the control group [ OR (95%CI): 0.649 (0.424–0.994)]. Meanwhile, the amount of RBC transfusion during the peri-CPB period was significantly lower in the FUWAI-SAVE group compared to the control group, with a mean difference of −0.626 (−1.176 to −0.076) units. The occurrence rate of major complications did not differ significantly between the two groups. Conclusions: Among adult patients undergoing cardiac surgery with CPB, the application of the FUWAI-SAVE system significantly reduced RBC transfusion rate and amount. The FUWAI-SAVE system can be considered an important component of comprehensive blood management strategies in cardiac surgery.

Infants with concurrent severe hypertriglyceridemia and complex congenital heart disease are a rare occurrence and can have life-threatening consequences when undergoing surgical intervention. This case series outlines two instances involving infants undergoing total anomalous pulmonary venous connection repair and surgical closure of a ventricular septal defect. The study explores troubleshooting the effects of hypertriglyceridemia on perioperative outcomes.

Up to 57% of patients develop postoperative delirium after surgery for congenital heart defects (CHD). To reduce cerebral damage in pediatric patients during CHD surgery it is important to find out what inflicts the worse damage: would it be a systemic inflammatory response (SIR) triggered by transfusion, or hypoxia developed in non-transfused patients? In vitro evaluation of hypoxia and SIR effects on the neurovascular unit (NVU) cells might contribute to finding the answer.The aim of the study was to compare the effect of varying severity hypoxia and SIR on the functional activity of NUV cells in vitro.Materials and methods. An in vitro NVU model was designed including neurons, astrocytes and endotheliocytes. The effect of hypoxia on NVU was evaluated in the control (C) and 4 study groups (H 1–4), formed based on O₂ content in the medium. The C group NVU were cultivated in standard conditions: N₂ — 75%, O₂ — 20%, CO₂ — 5%; H1: N₂ — 99%, O₂ — 1%; H2: N₂ — 98%, O₂ — 2%; H3: N₂ — 97%, O₂ — 3%; H4: N₂ — 96%, O₂ — 4%. The significance of the differences was 0.0125. The effect of interleukin-6 (IL-6) content on NVU was measured by adding to culture medium pediatric patients’ serum with known minimal or maximal SIRS-response. The assessment was made in the Control — an intact NVU model, and 2 study groups — «Minimum» and «Maximum», i. e. samples with minimum or maximum IL-6 content in culture, respectively. The significance of the differences was 0.017. The cells were incubated at a normothermia regimen for 30 minutes. Then, the functional activity of NVU cells was evaluated by measuring transendothelial resistance (TER) for 24 hours and Lucifer Yellow (LY) permeability test at 60 and 90 minutes after the start of the experiment.Results. After incubation under hypoxic conditions, TER changes occurred in all studied groups. However, they were statistically significant only in the group with 1% oxygen content in the medium. TER decrease in this group was observed after 2, 4 and 24 hours. LY permeability also changed at 60 and 90 minutes, similarly — in NVU cultivated with 1% oxygen in the medium. Minimal TER values were documented at 4 hours after patients’ serum was added to NVU cells culture medium, and TER increased at 24 hours in both study groups. Cellular permeability to LY changed significantly after 1 hour exposure in both groups — with minimum and maximum IL-6 content in the medium. Although at 90 minutes, there was no difference between the 3 groups in LY permeability tests.Conclusion. Intensive SIR demonstrated short-term but more deleterious than hypoxia, effect on cells in the NVU model. Hypoxia disrupted functional activity of NUV cells only at 1% O₂ concentration in the medium.

Abstract Background Up to 42% of patients develop acute kidney injury (AKI) after cardiac surgery. The aim of this study was to describe the relationship between preoperative microcirculatory function and postoperative AKI after cardiac surgery using cardiopulmonary bypass (CPB). Methods The prospective observational cohort MONS enrolled 60 patients scheduled for valvular (n = 30, 50%) or coronary (n = 30, 50%) surgery using CPB. Preoperative microcirculation was assessed during preoperative consultation from January 2019 to April 2019 at the University Hospital of Angers, France, using endothelium-dependent and endothelium-independent reactivity tests on the forearm (iontophoresis of acetylcholine (ACh) and sodium nitroprusside (SNP), respectively). Skin blood flow was measured by laser speckle contrast imaging. The primary endpoint was the occurrence of AKI according to the KDIGO classification during the hospital stay. Results Forty-three (71.7%) patients developed AKI during the in-hospital follow-up, and 15 (25%) were classified as KDIGO stage 1, 20 (33%) KDIGO stage 2, and 8 (13%) KDIGO stage 3. Regarding preoperative microcirculation, a higher peak amplitude of vasodilation in response to iontophoresis of ACh was found in patients with postoperative occurrence of AKI (35 [20–49] vs 23 [9–44] LSPU, p = 0.04). Iontophoresis of SNP was not significantly different according to AKI occurrence (34 [22–49] vs 36 [20–50] LSPU, p = 0.95). In a multivariable model, the preoperative peak amplitude at iontophoresis of ACh was independently associated with postoperative AKI (OR 1.045 [1.001–1.092], p = 0.045). Conclusions The preoperative peak amplitude of endothelium-dependent vasodilation is independently associated with the postoperative occurrence of AKI. Trial registration Clinical-Trials.gov, NCT03631797. Registered 15 August 2018, https://clinicaltrials.gov/ct2/show/NCT03631797

Abstract Background The ProMPT-2 trial (Propofol for Myocardial Protection Trial #2) aims to compare the safety and efficacy of low- and high-dose propofol supplementation of the cardioplegia solution during adult cardiac surgery versus sham supplementation. This update presents the statistical analysis plan, detailing how the trial data will be analysed and presented. Outlined analyses are in line with the Consolidated Standards of Reporting Trials and the statistical analysis plan has been written prior to database lock and the final analysis of trial data to avoid reporting bias (following recommendations from the International Conference on Harmonisation of Good Clinical Practice). Methods/design ProMPT-2 is a multi-centre, blinded, parallel three-group randomised controlled trial aiming to recruit 240 participants from UK cardiac surgery centres to either sham cardioplegia supplementation, low dose (6 µg/ml) or high dose (12 µg/ml) propofol cardioplegia supplementation. The primary outcome is cardiac-specific troponin T levels (a biomarker of cardiac injury) measured during the first 48 h following surgery. The statistical analysis plan describes the planned analyses of the trial primary and secondary outcomes in detail, including approaches to deal with missing data, multiple testing, violation of model assumptions, withdrawals from the trial, non-adherence with the treatment and other protocol deviations. It also outlines the planned sensitivity analyses and exploratory analyses to be performed. Discussion This manuscript prospectively describes, prior to the completion of data collection and database lock, the analyses to be undertaken for the ProMPT-2 trial to reduce risk of reporting and data-driven analyses. Trial registration ISRCTN ISRCTN15255199. Registered on 26 March 2019.

Abstract Background The aim of this study was to identify the risk factors for postoperative delirium (POD) in elderly patients undergoing heart valve surgery with cardiopulmonary bypass (CPB). Methods Elderly patients undergoing elective heart valve surgery with CPB in The First Affiliated Hospital of Wenzhou Medical University between March 2022 and March 2023 were selected for this investigation. They were divided into a POD group and a non-POD group. Their baseline information was collected and recorded, and the patients were subjected to neurocognitive function assessment using the Mini-Mental State Examination and the Montreal Cognitive Assessment scales before surgery. We also recorded their intraoperative indicators such as duration of surgery, duration of CPB, duration of aortic cross-clamp, blood transfusion, and postoperative indicators such as duration of mechanical ventilation, postoperative 24-hour drainage volume, and pain score. Regional cerebral oxygen saturation was monitored intraoperatively by near-infrared spectroscopy based INVOS5100C Regional Oximeter. Patients were assessed for the occurrence of POD using Confusion Assessment Method for the Intensive Care Unit, and logistic regression analysis of risk factors for POD was performed. Results The study finally included 132 patients, with 47 patients in the POD group and 85 ones in the non-POD group. There were no significant differences in baseline information and preoperative indicators between the two groups. However, marked differences were identified in duration of surgery, duration of CPB, duration of aortic cross-clamp, duration of postoperative mechanical ventilation, postoperative length of stay in cardiac intensive care unit, postoperative length of hospital stay, intraoperative blood transfusion, postoperative pain score, and postoperative 24-hour drainage volume between the two groups (p 285 min (OR, 1.021 [95% CI, 1.008–1.035]; p = 0.002), duration of postoperative mechanical ventilation > 23.5 h (OR, 6.210 [95% CI, 1.619–23.815]; p = 0.008), and postoperative CCU stay > 3.5 d (OR, 3.927 [95% CI, 1.046–14.735]; p = 0.043) were independent risk factors of the occurrence of POD while change of rScO2 at T1>50.5 (OR, 0.832 [95% CI 0.736–0.941]; p = 0.003) was a protective factor for POD. Conclusion Duration of surgery duration of postoperative mechanical ventilation and postoperative CCU stay are risk factors for POD while change of rScO2 at T1 is a protective factor for POD in elderly patients undergoing heart valve surgery with CPB.

Abstract Background During cardiac surgery, transcranial Doppler (TCD) represents a non-invasive modality that allows measurement of red blood cell flow velocities in the cerebral arteries. TCD can also be used to detect and monitor embolic material in the cerebral circulation. Detection of microemboli is reported as a high intensity transient signal (HITS). The importance of cerebral microemboli during cardiac surgery has been linked to the increased incidence of postoperative renal failure, right ventricular dysfunction, and hemodynamic instability. The objective of this study is to determine whether the embolic load is associated with hemodynamic instability during cardiopulmonary bypass (CPB) separation and postoperative complications. Methods A retrospective single-centre cohort study of 354 patients undergoing cardiac surgery between December 2015 and March 2020 was conducted. Patients were divided in tertiles, where 117 patients had a low quantity of embolic material (LEM), 119 patients have a medium quantity of microemboli (MEM) and 118 patients who have a high quantity of embolic material (HEM). The primary endpoint was a difficult CPB separation. Multivariate logistic regression was used to determine the potential association between a difficult CPB separation and the number of embolic materials. Results Patients who had a difficult CPB separation had more HITS compared to patients who had a successful CPB separation (p

Objective: We aimed to evaluate the effects of cardiopulmonary bypass (CPB) machines used in coronary artery bypass grafting surgeries on cerebral perfusion by performing cerebral oximetry monitoring [near-infrared spectroscopy (NIRS)], S100-β protein measurements, and neurocognitive function assessment tests using both pulsatile and non-pulsatile modes. Methods: A total of 44 patients, 22 non-pulsatile (Group NP) and 22 pulsatile (Group P), were included in the study. Hemodynamic parameters, arterial blood gas values, NIRS values and blood S100β protein levels were analyzed at five points: pre-induction (T1), initiation of CPB (T2), termination of CPB (T3), end of surgery (T4), and postoperative 24 h (T5). Two different neuropsychological tests were administered to patients in the preoperative and postoperative periods. Results: There were no significant differences between the groups for demographic characteristics such as age, gender, body mass index, aortic cross-clamping, CPB, and operation durations. The mean arterial blood pressure and PaO2 values for the T2 measurements were significantly higher in group NP (P < 0.05). Regional cerebral oxygen saturation (rSO2) (NIRS) values at T3 and T4 were significantly higher in group P (P < 0.05). Serum S100β measurement values at T3 and T5 were significantly higher in group NP than in group P (P < 0.05). Serum S100β protein levels at T3 correlate with rSO2 results. There was no statistically significant difference between the two groups in terms of pH, lactate, glucose, partial pressure of carbon dioxide, and peripheral oxygen saturation values. Conclusion: Despite no difference between the two groups for neurocognitive function tests, we believe that pulsatile perfusion may be more beneficial for cerebral perfusion when S100β protein and NIRS values are considered. Further clinical studies are needed to evaluate the benefits of the pulsatile technique for cerebral perfusion.

Objective: Professional standards recommend stopping cardiotomy suction at the termination of cardiopulmonary bypass before protamine administration based on perceived safety concerns. This study evaluated a multidisciplinary collaborative quality-improvement intervention promoting this agreed-upon cardiotomy suction practice during coronary artery bypass grafting (CABG). Methods: A statewide intervention (eg, unblinded surgeon and perfusionist feedback, evidence-based lectures, evaluating barriers to change) involved 32 centers participating in the PERForm (ie, Perfusion Measures and Outcomes) Registry to standardize cardiotomy suction practices at cardiopulmonary bypass termination during CABG. Four non-Michigan registry participating centers were not exposed to collaborative learning. Cardiotomy suction practice was defined as the absence of or stopping cardiotomy suction before protamine administration. The practice changes attributed to the intervention, including Michigan and non-Michigan comparisons, were evaluated with the change of time effect modeled using splines. Multivariable regression was used to evaluate the intervention's associated impact (eg, mortality, reoperation, transfusion). Results: Among 10,394 patients undergoing CABG at Michigan centers, 80.7% achieved agreed-upon cardiotomy suction practices. The Michigan centers had nonsignificant changes in agreed-upon cardiotomy suction practices during the preintervention period (P = .24), with significant increased monthly change in practice thereafter, absent adjusted morbidity and mortality increases. The Michigan centers achieved a significantly greater adjusted monthly improvement in agreed-upon practices relative to non-Michigan centers within 7 months after the intervention (adjusted odds ratio for change of trends: 2.53, P

Abstract Background Traditionally, novice perfusionists learn and practice clinical skills, during live surgical procedures. The profession’s accrediting body is directing schools to implement simulated cardiopulmonary bypass (CPB) into the curriculum. Unfortunately, no CPB simulation models have been validated. Here we describe the design and application of a CPB simulation model. Methods A CPB patient simulator was integrated into a representative operative theater and interfaced with a simple manikin, a heart-lung machine (HLM), clinical perfusion circuitry, and equipment. Participants completed a simulation scenario designed to represent a typical CPB procedure before completing an exit survey to assess the fidelity and validity of the experience. Questions were scored using a 5-point Likert scale. Results Participants (n = 81) contributed 953 opinions on 40 questions. The participants reported that the model of simulated CPB (1) realistically presented both the physiologic and technical parameters seen during CPB (n = 347, mean 4.37, SD 0.86), (2) accurately represented the psychological constructs and cognitive mechanisms of the clinical CPB (n = 139, mean 4.24, SD 1.08), (3) requires real clinical skills and reproduces realistic surgical case progression (n = 167, mean 4.38, SD 0.86), and (4) would be effective for teaching, practicing, and assessing the fundamental skills of CPB (n = 300, mean 4.54, SD 0.9). Participants agreed that their performance in the simulation scenario accurately predicted their performance in a real clinical setting (n = 43, mean 4.07, SD 1.03) Conclusion This novel simulation model of CPB reproduces the salient aspects of clinical CPB and may be useful for teaching, practicing, and assessing fundamental skills.

Jie Liu,&ast; Xia Li,&ast; Wanli Xie, Yanting Wang, Zhenzhen Xu, Yun-Xiao Bai, Quanjun Zhou, Qingping Wu Department of Anesthesiology, Union Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, People’s Republic of China&ast;These authors contributed equally to this workCorrespondence: Qingping Wu; Quanjun Zhou, Email wqp1968@126.com; quanjunzhou2023@163.comObjective: The risk factors of postoperative pulmonary complications (PPCs) have been extensively investigated in non-cardiac surgery and non-elderly adult patients undergoing cardiac surgery. However, data on elderly patients after cardiopulmonary bypass (CPB) is limited. This study aimed to evaluate the risk factors and short-term outcomes for PPCs in elderly patients undergoing CPB procedures.Patients and Methods: Data from 660 patients who underwent CPB over a six-year period at a tertiary care hospital were collected. The primary outcome encompassed the incidence of PPCs, including re-intubation, postoperative mechanical ventilation exceeding 48 hours, pulmonary infection, pleural effusion requiring thoracic drainage, and acute respiratory distress syndrome. Missing data were managed using multiple imputation. Univariate analysis and the multiple logistic regression method were utilized to ascertain independent risk factors for PPCs.Results: Among the 660 patients, PPCs were observed in 375 individuals (56.82%). Multiple logistic regression identified serum albumin levels < 40 g/L, type of surgery, CPB duration > 150 minutes, blood transfusion, and intra-aortic balloon pump use before extubation as independent risk factors for PPCs. Patients experiencing PPCs had prolonged mechanical ventilation, extended hospitalization and ICU stays, elevated postoperative mortality, and higher tracheotomy rates compared to those without PPCs.Conclusion: Elderly patients following CPB displayed a substantially high incidence of PPCs, significantly impacting their prognosis. Additionally, this study identified five prominent risk factors associated with PPCs in this population. These findings enable clinicians to better recognize patients who may benefit from perioperative prevention strategies based on these risk factors.Keywords: postoperative pulmonary complications, elderly patients, cardiopulmonary bypass, cardiac surgery

Purpose: We aimed to investigate hemodynamic changes in the retina, peripapillary area, and choroid in patients undergoing coronary artery bypass grafting (CABG). Methods: This prospective case series included 35 eyes of 35 patients. Vessel density (VD) of superficial capillary plexus, deep capillary plexus, radial peripapillary capillary, foveal avascular zone area, and subfoveal choroidal thickness changes were evaluated using optical coherence tomography angiography (OCTA) 1 day before and 2 weeks after surgery. The correlation of these parameters with aortic cross-clamp (ACC) duration and cardiopulmonary bypass (CPB) duration was evaluated. Results: There were no differences in the OCTA measurements of the patients after CABG compared to before surgery (P > 0.05). Inside-disc VD showed a negative correlation with both ACC (P = 0.036) and CPB duration (P = 0.048); peripapillary inferior hernia showed a negative correlation with both ACC (P = 0.042) and CPB duration (P = 0.027). Another negative correlation was observed between mean peripapillary VD and CPB duration (P = 0.039). Conclusion: The CPB procedure had no permanent effect on retinal choroid and optic disc blood flow postoperatively. Prolonged ACC and CPB times seem to be important in terms of optic nerve blood flow. Clinicians should be alert for postoperative ocular complications after long surgeries.

Abstract Background Primary malignant cardiac tumors are rare in clinic, and surgical resection under cardiopulmonary bypass (CPB) remains the main treatment. The non-physiological perfusion process of CPB leads to contact activation, and the resulting coagulopathy and systemic inflammatory response syndrome (SIRS) are common complications. However, it is difficult to predict the impact of foreign tumor fragments on this pathophysiological process once they enter the bloodstream, making this phenomenon more complex and challenging. Case Presentation We report a case of cardiac intimal sarcoma who developed severe coagulopathy and widespread inflammation after excision of massive right ventricular tumor and replacement of tricuspid valve by median sternotomy under CPB. Although the procedure was expected to cause tumor cell necrosis and precautions were taken, uncontrolled massive postoperative bleeding, persistent fever, abnormally elevated inflammatory markers, and recurrent malignant arrhythmias occurred after surgery. In addition to common factors, the most possible underlying mechanism is contact activation triggered following surgical procedure for intimal sarcoma with CPB. Conclusion Patients with intracardiac malignant tumors are at a high risk for serious contact activation during CPB. Preventive application of comprehensive anti-inflammatory measures such as drugs and adsorptive CPB technology, as well as point-of-care (POC) monitoring of coagulation status will be helpful for individualized guidance and optimization of CPB management, and improvement of patient prognosis.