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- Systemic microvascular shunting through hyperdynamic capillaries after acute physiological disturbances following cardiopulmonary bypass. [JOURNAL ARTICLE]
- Am J Physiol Heart Circ Physiol 2014 Jul 25.
Introduction: Previously we showed that cardiopulmonary bypass during cardiac surgery is associated with reduced sublingual microcirculatory perfusion and oxygenation. It has been suggested that impaired microcirculatory perfusion may be paralleled by increased heterogeneity of flow in the microvascular bed, possibly leading to arteriovenous shunting. Here we investigated our hypothesis that acute hemodynamic disturbances during extracorporeal circulation indeed lead to microcirculatory heterogeneity with hyperdynamic capillary perfusion and reduced systemic oxygen extraction. Methods: In this single-center prospective observational study, patients undergoing cardiac surgery with (n=18) or without (n=13) cardiopulmonary bypass (CPB) were included. Perioperative microcirculatory perfusion was assessed sublingually with sidestream dark field imaging and recordings were quantified for microcirculatory heterogeneity and hyperdynamic capillary perfusion. The relationship with hemodynamic and oxygenation parameters was analyzed. Results: Microcirculatory heterogeneity index increased substantially after onset of CPB (0.5 [0.0-0.9] to 1.0 [0.3-1.3]; P=0.031) but not during off-pump surgery. Median capillary red blood cell (RBC) velocity increased intraoperatively in the CPB group only (1600 [913-2500 µm/s] versus 380 [190-480 µm/s]; P<0.001), with 31% of capillaries supporting high RBC velocities (>2000 µm/s). Hyperdynamic microcirculatory perfusion was associated with reduced arteriovenous oxygen difference and systemic oxygen consumption during and after CPB. Conclusions: The current study provides the first direct human evidence for a microvascular shunting phenomenon through hyperdynamic capillaries following acute physiological disturbances after onset of cardiopulmonary bypass. The hypothesis of impaired systemic oxygen offloading caused by hyperdynamic capillaries was supported by reduced blood arteriovenous oxygen difference and low systemic oxygen extraction associated with cardiopulmonary bypass.
- Does body mass index impact the early outcome of surgical revascularization? A comparison between off-pump and on-pump coronary artery bypass grafting. [JOURNAL ARTICLE]
- Interact Cardiovasc Thorac Surg 2014 Jul 25.
To investigate the effects of body mass index (BMI) on early outcomes after revascularization using either on-pump or off-pump surgery.Data for 3714 of 4314 patients who underwent surgical revascularization at our institution between 1999 and 2008 were analysed. Patients were divided into two groups [off-pump coronary artery bypass (OPCAB); n = 1958 and on-pump coronary artery bypass (ONCAB); n = 1756] and further assigned into five classes according to their BMI (underweight <20 kg/m(2), normal 20-24.99 kg/m(2), overweight 25-29.99 kg/m(2), obese 30-34.99 kg/m(2) and morbidly obese ≥35 kg/m(2)). Thirty-day mortality, occurrence of major adverse cardiac events (MACEs), occurrence of major non-cardiac adverse events (MNCAEs) and length of in-hospital stay were analysed in relation to BMI only (whole cohort analysis), to BMI and chosen surgical method (ONCAB versus OPCAB) as well as confounding factors.In the whole cohort analysis (n = 3714), no significant differences between BMI classes could be identified with regard to 30-day mortality (P = 0.78), MACEs (P = 0.72), MNCAEs (P = 0.45) or length of in-hospital stay (P = 0.94). With increasing BMI values, 30-day mortality tended to steadily increase (1.8% in BMI class 'underweight' vs 2.6% in BMI class 'morbidly obese'; P = 0.78), whereas MNCAEs tended to decrease with an increasing BMI (17.5% in BMI class 'underweight' vs 12.2% in BMI class 'morbidly obese'; P = 0.45). Compared with ONCAB, in patients with higher BMI values, OPCAB appeared to reduce slightly the frequency of 30-day mortality, MACEs and MNCAEs, while slightly increasing the length of in-hospital stay. Adjustment for other risk factors by covariate analysis in multiple regression models did not change the inferences drawn.Our study did not detect significant differences between BMI classes with regard to mortality and morbidity. However, a slight trend towards a steadily increasing short-term mortality was detectable for patients with higher BMI values. When comparing ONCAB versus OPCAB, patients with higher BMI values appeared to have a weak tendency towards a reduced short-term morbidity and mortality in favour of OPCAB.
- [Late complications and treatment options of aortic coarctation operated in childhood.] [JOURNAL ARTICLE]
- Orv Hetil 2014 Jul 1; 155(30):1189-1195.
Introduction: The prevalence of congenital aortic coarctation is 4 in 10 000 live birth. Aortic coarctation is typically located in the aortic isthmus, but it may occur at atypical sites. Treatment options include both surgical and endovascular interventions. In patients undergoing surgical or endovascular intervention late complications such as recoarctation or aortic aneurysm may develop. Aim: The aim of the authors was to analyse their own experience in late complication and treatment options of aortic coarctation operated in childhood. Method: Retrospective analysis of data of 32 patients treated between 1980 and 2014 for late complications 8-42 years after surgical treatment of aortic coarctation. Results: In 28 patients aneurysm formation after isthmic patch plasty was found. Two patients had aortobronchial fistula, 2 patients showed anastomosis disruption and 2 patients had graft stenosis. During operation hybrid solution was performed in 23 patients, isthmic aorto-aortic inlay graft interposition in 5 patients, aorto-aortic bypass in 2 patients, subclavio-aortic bypass in 2 patients, graft patch plasty in one patient and ilio-renal bypass in one patient. Complications included severe intraoperative bleeding in one patient and pneumothorax in one patient. No early or late mortality occurred. Conclusions: The authors conclude that life long control is mandatory in order to detect late complications in patients who underwent operation of aortic coarctation in childhood. Orv. Hetil., 2014, 155(30), 1189-1195.
- Laparoscopic gastric bypass during left ventricular assist device support and ventricular recovery. [Letter]
- J Heart Lung Transplant 2014 Aug; 33(8):870-1.
- A minimally invasive off-pump implantation technique for continuous-flow left ventricular assist devices: Early experience. [Journal Article]
- J Heart Lung Transplant 2014 Aug; 33(8):851-6.
The HeartWare (HeartWare International, Inc. Framingham, MA) ventricular assist device (HVAD) is approved for implantation through a sternotomy with cardiopulmonary bypass. We report on our initial experience with this device implanted off-pump via thoracotomy.A total of 26 patients were included in this review. All patients were Interagency Registry for Mechanically Assisted Circulatory Support categories 2 or 3 and underwent implantation of an HVAD as an elective procedure via thoracotomy and mini sternotomy approach. Three-dimensional echocardiography was used to assess the ventricle and was also used to facilitate proper pump positioning. Patients were managed during follow-up using anti-coagulants at a target international normalized ratio 2.0 to 2.5 as well as anti-platelet agents.Implantation was performed without the use of cardiopulmonary bypass, but 1 patient did require conversion to on-pump surgery. There were no perioperative deaths or right heart failure events. The mean intensive care unit stay was 1.5 days. Transfusions of 1 to 3 units of packed red blood cells were required in 16 patients, whereas 10 patients maintained a stable perioperative hematocrit of at least 30% and did not require transfusion. Survival through 90 days was 100%, and survival through 180 days was 87%.Our experience was favorable in respect to outcome, safety, and use of blood products. Our technique can be used as an alternative approach for left ventricular assist device implantation using the HVAD.
- Optimization of poly(l-lactic acid)/segmented polyurethane electrospinning process for the production of bilayered small-diameter nanofibrous tubular structures. [JOURNAL ARTICLE]
- Mater Sci Eng C Mater Biol Appl 2014 Sep 1.:489-499.
The present study is focused on the electrospinning process as a versatile technique to obtain nanofibrous tubular structures for potential applications in vascular tissue engineering. A bilayered scaffolding structure composed of poly(L-lactic acid) (PLLA)/bioresorbable segmented polyurethane (SPEU) blends for small-diameter (5mm) vascular bypass grafts was obtained by multilayering electrospinning. Polymer blend ratios were chosen to mimic the media and adventitia layers. The influence of the different electrospinning parameters into the fiber formation, fiber morphology and fiber mean diameter for PLLA, SPEU and two PLLA/SPEU blends were studied. Flat and two-parallel plate collectors were used to analyze the effect of the electrostatic field on the PLLA nanofiber alignment in the rotating mandrel. Membrane topography resulted in random or aligned nanofibrous structures depending on the auxiliary collector setup used. Finally, composition, surface hydrophilicity, thermal properties and morphology of nanofibrous scaffolds were characterized and discussed. Since the development of tissue engineered microvascular prostheses is still a challenge, the prepared scaffolding tubular structures are promising candidates for vascular tissue engineering.
- To adjust, or not to adjust, that is the question. [JOURNAL ARTICLE]
- Int J Cardiol 2014 Jul 12.
- [Replantation of fingertip amputation in lack of availability of intravenous anastomosis]. [English Abstract, Journal Article]
- Zhongguo Gu Shang 2012 Aug; 25(8):648-50.
To discuss the replantation of fingertip amputation in lack of availability of intravenous anastomosis.From November 2009 to November 2010, 86 patients (104 fingers) with fingertip amputation were treated with replantatioin, including 64 males and 22 females, with an average age of 26 years ranging from 2 to 64 years. The time from injury to therapy was from 30 min to 12 h, time of broken finger ischemia was from 2.5 to 12 h. Preoperative examination showed no obvious abnormalities. Four different replantation methods were selectively applied to these 104 amputated fingertips of 86 cases: (1) replantation with anastomosis of single or bilateral proper digital artery in 37 fingers; (2) replantation with arteriovenous bypass in 27 fingers; (3) replantation with exclusive anastomosis of digital artery in 24 fingers; (4) replantation with removing the palmar pocket method in 16 fingers.One hundred and two of 104 amputated fingertips were survived. Among these survived fingers,75 cases (92 fingers) were followed-up for 6 to 24 months. According to the assessment standard of Chinese Medical Association of Hand Surgery, the results were excellent in 52 cases, good in 19, poor in 4.It benefits to expand the indications and improve the survival rate of replantation of fingertip amputation with the correct choice of different replantation methods according to the injury situation of the broken fingertip artery after debridement under the microscope.
- False-positive rates of provocative cardiac testing in chest pain patients admitted to an emergency department observation unit. [Journal Article]
- Crit Pathw Cardiol 2014 Sep; 13(3):104-8.
Emergency department observation units (EDOUs) typically perform routine cardiac stress testing or coronary computed tomography (CCTA) to rule out ischemic cardiac chest pain. Some have questioned the utility of routine stress testing and advanced anatomic imaging in the low-risk chest pain patients. EDOU chest pain patients undergoing stress testing or CCTA prior to cardiac catheterization between June 1, 2009 and May 31, 2012 were studied in a prospective, observational manner. Baseline data, EDOU-related outcomes, and testing results were recorded. Stress tests were treadmill echocardiogram or myocardial perfusion stress tests and were considered positive if a "positive" or "equivocal" interpretation by the reviewing cardiologist prompted cardiac catheterization. CCTA was considered positive if it led to subsequent cardiac catheterization. Cardiac catheterization was considered positive if subsequent stent placement, coronary artery bypass graft (CABG), or change in medical management occurred. Of 1276 patients evaluated, 112 (8.8%) underwent cardiac catheterization of which 56 underwent some modality of prior testing. Forty-two of 56 were subject to stress testing (30 stress echo and 12 myocardial perfusion) and 14 underwent CCTA prior to catheterization. False-positive rate overall was 62.5% (35/56, 95% CI, 48.5%-74.7%). False-positive rate for stress testing was 75% and 66.7% for perfusion and stress echo respectively. False-positive rate for CCTA was 42.9%. It must be acknowledged that while these findings do not directly impugn the utility of stress testing or CCTA, it may indicate the need for more appropriate patient selection to avoid unnecessary cardiac catheterization among EDOU chest pain patient cohorts.
- Should Pediatric Emergency Physicians Be Decentralized in the Medical Community? [JOURNAL ARTICLE]
- Pediatr Emerg Care 2014 Jul 24.
Pediatric emergency physicians (PEPs) are well established as primary emergency department (ED) providers in dedicated pediatric centers and university settings. However, the optimum role of these subspecialists is less well defined in the community hospital environment. This study examined the impact on the ED care of children after the introduction of 10 PEPs into a simulated medical community.A computer-generated community was created, containing 10 community hospitals treating 250,000 pediatric ED patients. Children requiring ED treatment received their care at the closest ED to their location. Ten PEPs were introduced into the community, and their impact on patient care was examined under 2 different models. In a restrictive model, the PEPs established 2 full-time pediatric EDs within the 2 busiest hospitals, whereas, in a distributive model, the PEPs were distributed throughout the 8 busiest hospitals. In the 8-hospital model, the PEPs provided direct patient care along with the general emergency physicians in that facility and also provided educational, administrative, and performance improvement support for the department. In the restrictive model, the PEPs impacted the care of 100% of the children presenting for treatment at their 2 practice sites. In the distributive model, impact included the direct patient care by the PEP but also included changes produced in the care provided by the general emergency physicians at the site. Three different levels of impact were considered for the presence of the PEPs: a low-impact version in which the PEPs' presence only impacted 25% of the children at that site, a moderate-impact version in which the impact affected 50% of the children, and a high-impact version in which the impact affected 75% of the children. A secondary analysis was performed to account for the possibility of patients self-diverting from the closest ED to 1 of the pediatric EDs in the restrictive model.In the restrictive model, the addition of 10 PEPs to the community would impact 27% of the pediatric ED care in the community. In the 3 distributive models, the PEPs would impact 23% of pediatric care in the low-impact version, 46% of pediatric care in the moderate-impact version, and 69% of pediatric care in the high-impact version. If self-diversion were to occur in the restrictive model, then 19% of the patients would need to bypass the closest ED and travel to the pediatric ED to match the same effect on patient care produced in the moderate-impact version of the distributive model and 46% would need to divert to match the effect of the high-impact version.The greatest impact of PEPs on an ED population of children is produced when the PEPs distribute themselves throughout a medical community rather than create individual pediatric EDs in a small number of hospitals.