Factores clínicos y ecocardiográficos asociados al bajo gasto cardíaco posoperatorio en pacientes con tratamiento quirúrgico cardiovascular / Clinical and echocardiographic factors associated with the postoperative low cardiac output in patients with cardiovascular surgical treatment i: en

Introducción: Entre las diferentes complicaciones que surgen en el periodo posoperatorio inmediato, el bajo gasto cardíaco presenta mayor morbilidad y mortalidad asociadas, con una incidencia de hasta 45,0 %. Objetivo: Determinar los factores relacionados con la aparición posoperatoria del bajo gasto cardíaco en pacientes con tratamiento quirúrgico cardiovascular y circulación extracorpórea, según variables demográficas, clínicas y ecocardiográficas. Métodos: Se realizó una investigación analítica, de casos y controles, la cual incluyó a pacientes que recibieron tratamiento quirúrgico cardíaco en el Servicio de Cardiología y Cirugía Cardiovascular del Hospital Provincial Clinicoquirúrgico Docente Saturnino Lora de Santiago de Cuba, desde enero hasta diciembre de 2019. Cada grupo de estudio estuvo conformado por 43 integrantes, para lo cual se consideró la presencia del síndrome de bajo gasto cardíaco (casos) o no (controles). Resultados: En la serie predominaron los pacientes menores de 65 años de edad en ambos grupos de estudio (51,2 y 73,5 % para casos y controles, respectivamente), así como el sexo masculino (60,9 %); de igual modo, resultó más frecuente la intervención quirúrgica de emergencia (80,2 %). La fibrilación auricular y la función sistólica del ventrículo derecho presentaron alta significación estadística (p<0,05). Conclusiones: Algunos elementos clínicos y ecocardiográficos (edad, fibrilación auricular, función sistólica de los ventrículos izquierdo y derecho, así como intervención quirúrgica de emergencia) se asociaron de manera independiente a la aparición del bajo gasto cardíaco.

Introduction: Among the different complications that arise in the immediate postoperative period, the low cardiac output presents higher associated morbidity and mortality, with an incidence of up to 45.0 %. Objective: To determine the factors related to the postoperative emergence of the low cardiac output in patients with cardiovascular surgical treatment and extracorporeal circulation, according to demographic, clinical and echocardiographic variables. Methods: An analytic, cases and controls investigation was carried out, which included patients that received heart surgical treatment in the Cardiology and Cardiovascular Surgery Service of Saturnino Lora Teaching Clinical Surgical Provincial Hospital in Santiago de Cuba, from January to December, 2019. Each study group was conformed by 43 members, for which was considered the presence (cases) or not (controls) of the low cardiac output syndrome. Results: In the series there was a prevalence of the patients under 65 years in both study groups (51.2 and 73.5 % for cases and controls, respectively), as well as the male sex (60.9 %); in a same way, the emergency surgical intervention was the most frequent (80.2 %). The atrial fibrillation and the systolic function of the right ventricle presented high statistical significance (p <0.05). Conclusions: Some clinical and echocardiographic elements (age, atrial fibrillation, systolic function of the left and right ventricles, as well as emergency surgical intervention) were associated in an independent way with the emergence of the low cardiac output.

Complicaciones de la cirugía de revascularización coronaria en pacientes con diabetes mellitus de tipo II / Complications of the coronary revascularization surgery in patients with type II diabetes mellitus

Introducción: La diabetes mellitus y la cardiopatía isquémica están íntimamente relacionadas, puesto que los pacientes con la primera tienen más riesgo de presentar la segunda, así como mayor mortalidad cardiovascular. Objetivo: Identificar las complicaciones posoperatorias en pacientes con diabetes mellitus de tipo II. Método: Se realizó un estudio descriptivo de serie de casos de 203 pacientes con diabetes mellitus de tipo II, expuestos a cirugía de revascularización coronaria en el Cardiocentro del Hospital Provincial Docente Saturnino Lora de Santiago de Cuba, desde enero de 2011 hasta igual periodo de 2020. Resultados: En la casuística resultaron más afectados el sexo masculino (56,1 %) y el grupo etario de 45 - 64 años (53,7 %), quienes tenían más de 10 años con la enfermedad endocrina y se le había detectado la cardiopatía isquémica en el último, con una forma de presentación aguda. Se encontraron varios factores de riesgo, tales como enfermedad coronaria difusa, niveles de glucemia elevada en el periodo perioperatorio y fracción ventricular izquierda baja. En la mayoría de las intervenciones quirúrgicas se empleó la técnica de corazón latiendo (81,8 %), y las complicaciones predominantes fueron arritmias supraventriculares, bajo gasto cardiaco e infecciones de la herida. Conclusiones: La cirugía de coronaria en pacientes con diabetes mellitus de tipo II es el método que logra una revascularización más completa, tanto anatómica como funcional, y la técnica de corazón latiendo alcanza reducir la mortalidad, aunque aún son frecuentes las complicaciones atribuibles a causas multifactoriales.

Introduction: The diabetes mellitus and ischemic heart disease are closely related, since patients with the former have more risk of presenting the latter, as well as higher cardiovascular mortality. Objective: To identify the postoperative complications in patients with type II diabetes mellitus. Method: A serial cases descriptive study of 203 patients with type II diabetes mellitus, exposed to coronary revascularization surgery was carried out in the Heart Center of Saturnino Lora Teaching Provincial Hospital Hospital in Santiago de Cuba, from January, 2011 to the same period in 2020. Results: In the case material the male sex (56.1 %) and the 45 - 64 age group (53.7 %) were more affected, who had more than 10 years with the endocrine disease and the ischemic heart disease had been detected in the latter, with an acute form of presentation. Several risk factors were found, such as diffuse coronary disease, glycemia high levels in the perioperative period and low left ventricular fraction. In most of the surgical interventions the heart beating technique was used (81.8 %), and the predominant complications were supraventricular arrhythmias, low heart output and infections of the wound. Conclusions: The surgery of coronary in patients with type II diabetes mellitus is the method that achieves a more complete revascularization, either anatomical as functional, and the heart beating technique reduces the mortality, although the complications attributable to multifactorial causes are still frequent.

Risk factors of low cardiac output syndrome after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle / 中华心血管病杂志

Objective: To explore the risk factors of low cardiac output syndrome (LCOS) after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. Methods: This was a retrospective study. The clinical data of patients over 60 years old with giant left ventricle who underwent cardiac valvular surgery in Henan Provincial People's Hospital (Fuwai Central China Cardiovascular Hospital) from January 2016 to January 2020 were collected in this study. Patients were divided into LCOS group and non-LCOS group. The clinical data, preoperative echocardiographic results and surgical data of all patients were collected. Taking LCOS as dependent variable and statistically significant variables in univariate analysis as independent variable, multivariate logistic regression equation was constructed to identify the risk factors of LCOS after cardiac valvular surgery in elderly patients with valvular disease complicated with giant left ventricle. On the basis of logistic regression, the risk factors of continuous variables were put into the regression model for trend test. Results: A total of 112 patients were included, among whom 76 patients were male, the mean age was (65.3±3.8) years. There were 21 cases in LCOS group and 91 cases in non LCOS group. Univariate analysis showed that age≥70 years, preoperative NYHA cardiac function class Ⅳ, preoperative renal dysfunction, preoperative cerebrovascular disease, preoperative LVEF<40%, blood loss/total blood volume>20%, cardiopulmonary bypass (CPB) time>130 minutes and aortic cross-clamp time>90 minutes all had statistically significant differences between the two groups (all P<0.05). Multivariate logistic regression analysis showed that age≥70 years (OR=5.067, 95%CI 1.320-19.456, P=0.018), preoperative NYHA cardiac function class Ⅳ (OR=3.100, 95%CI 1.026-9.368, P=0.045), renal dysfunction (OR=3.627, 95%CI 1.018-12.926, P=0.047), CPB time>130 minutes (OR=4.539, 95%CI 1.483-13.887, P=0.008) were the independent risk factors of LCOS after cardiac valvular surgery in elderly patients with giant left ventricle. Risk of LCOS was significantly higher in patients aged from 65 to 70 years (OR=1.784, 95%CI 0.581-5.476) and aged 70 years and above (OR=4.400, 95%CI 1.171-16.531) than in patients aged from 60 to 65 years. The trend test results showed that the risk of LCOS increased significantly in proportion with the increase of age (P for trend=0.024). Risk of LCOS was significantly higher in patients with CPB time between 90 and 110 minutes (OR=1.917, 95%CI 0.356-10.322), 110 and 130 minutes (OR=1.437, 95%CI 0.114-18.076) and 130 minutes and above (OR=5.750, 95%CI 1.158-28.551) than in patients with CPB time ≤ 90 minutes (P for trend=0.009). Conclusions: The risk factors of LCOS after cardiac valvular surgery are age≥70 years, preoperative NYHA cardiac function class Ⅳ, renal dysfunction, CPB time>130 minutes in elderly patients with giant left ventricle.

Valor pronóstico del sistema de calificación APACHE II en el postoperatorio de cirugía cardíaca / Prognostic value of APACHE II score in postoperative of cardiac surgery

Resumen Antecedentes y objetivos: El sistema de calificación APACHE II permite predecir la mortalidad intrahospitalaria en terapia intensiva. Sin embargo, no está validado para cirugía cardíaca, ya que no posee buena capacidad diferenciadora. El objetivo es determinar el valor pronóstico de APACHE II en el postoperatorio de procedimientos cardíacos. Materiales y métodos: Se analizó en forma retrospectiva la base de cirugía cardíaca. Se incluyó a pacientes intervenidos entre 2017 y 2018, de los cuales se calculó la puntuación APACHE II. Se utilizó curva ROC para determinar el mejor valor de corte. El punto final primario fue mortalidad intrahospitalaria. Como puntos finales secundarios se evaluó la incidencia de bajo gasto cardíaco (BGC), accidente cerebrovascular (ACV), sangrado quirúrgico y necesidad de diálisis. Se realizó un modelo de regresión logístico multivariado para ajustar a las variables de interés. Resultados: Se analizó a 559 pacientes. La media del sistema de calificación APACHE II fue de 9.9 (DE 4). La prevalencia de mortalidad intrahospitalaria global fue de 6.1%. El mejor valor de corte de la calificación para predecir mortalidad fue de 12, con un área bajo la curva ROC de 0.92. Los pacientes con APACHE II ≥ 12 tuvieron significativamente mayor mortalidad, incidencia de BGC, ACV, sangrado quirúrgico y necesidad de diálisis. En un modelo multivariado, el sistema APACHE II se relacionó de modo independiente con mayor tasa de mortalidad intrahospitalaria (OR, 1.14; IC95%, 1.08-1.21; p < 0.0001). Conclusiones: El sistema de clasificación APACHE II demostró ser un predictor independiente de mortalidad intrahospitalaria en pacientes que cursan el postoperatorio de cirugía cardíaca.

Abstract Background and objectives: The APACHE II score allows predicting in-hospital mortality in patients admitted to intensive care units. However, it is not validated for patients undergoing cardiac surgery, since it does not have a good discriminatory capacity in this clinical scenario. The aim of this study is to determine prognostic value of APACHE II score in postoperative of cardiac surgery. Materials and methods: The study was performed using the cardiac surgery database. Patients undergoing surgery between 2017 and 2018, with APACHE II score calculated at the admission, were included. The ROC curve was used to determine a cut-off value The primary endpoint was in-hospital death. Secondary endpoints included low cardiac output (LCO), stroke, surgical bleeding, and dialysis requirement. A multivariable logistic regression model was developed to adjust to various variables of interest. Results: The study evaluated 559 patients undergoing cardiac surgery. The mean of APACHE II Score was 9.9 (SD 4). The prevalence of in-hospital death was 6.1%. The best prognostic cut-off value for the primary endpoint was 12, with a ROC curve of 0.92. Patients with an APACHE II score greater than or equal to 12 had significantly higher mortality, higher incidence of LCO, stroke, surgical bleeding and dialysis requirement. In a multivariate logistic regression model, the APACHE II score was independently associated with higher in-hospital death (OR, 1.14; 95CI%, 1.08-1.21; p < 0.0001). Conclusions: The APACHE II Score proved to be an independent predictor of in-hospital death in patients undergoing postoperative cardiac surgery, with a high capacity for discrimination.

Body mass index is associated with low postoperative cardiac output in patients undergoing aortic valve replacement / El índice de masa corporal se asocia a bajo gasto cardiaco postoperatorio de pacientes sometidos a reemplazo valvular aórtico

Abstract Background: Overweight and obesity (O/O) generate lipotoxicity of the cardiac fiber and increase the incidence and progression of aortic valve stenosis. The low cardiac output syndrome (LCOS) is a timing complication after to aortic valve replacement (AVR) surgery. Objective: The objective of the study was to investigate if body mass index (BMI) kg/m2 is a risk factor associated with LCOS and mortality in the post-operative period of AVR. Methods: A historic cohort study was designed, including patients with severe aortic stenosis (SAS), who were subjected to AVR. Results: 152 patients were included, 45 (29.6%), with normal weight (NW), 60 were overweight (39.5%), and 47 obese (30.9%). The prevalence of systemic hypertension (HT) was higher in O/O (p < 0.0001). Incidence of LCOS was 44.7%, being more frequent in the O/O groups compared to the NW group, 43.3%, 68.1%, and 22.2%, respectively, (p < 0.05 in overweight and p < 0.0001 in the obese). Assessing the presence or absence of LCOS associated with BMI as a numerical variable, we found that women, HT, BMI, left ventricular mass, and valve size, were associated with LCOS (p < 0.02, p < 0.02, p < 0.001, p < 0.032, and p < 0.045, respectively). Mortality was higher in patients who had LCOS (p < 0.02). Multivariate model showed that BMI was an independent risk factor for LCOS (odds ratio [OR] 1.21 [95% CI 1.08-1.35], p < 0.001). Conclusion: BMI is a risk factor associated to LCOS in the post-operative period of AVR in patients with SAS.

Resumen Antecedentes: El sobrepeso y la obesidad (O/O) generan lipotoxicidad de la fibra cardíaca y aumentan la incidencia y progresión de la estenosis de la válvula aórtica. El síndrome de bajo gasto cardíaco (SBGC) es una complicación postquirúrgica de la cirugía de reemplazo de válvula aórtica (RVA). Objetivo: Investigar si el índice de masa corporal kg/m2 (IMC) es un factor de riesgo asociado con SBGC y mortalidad en el postoperatorio de RVA. Métodos: Se diseñó un estudio de cohorte histórico, que incluyó pacientes con estenosis aórtica importante (EAI), que fueron sometidos a RVA. Resultados: Se incluyeron 152 pacientes, 45 (29.6%), con peso normal (N), 60 tenían sobrepeso (39.5%) y 47 obesos (30.9%). La prevalencia de hipertensión sistémica (HT) fue mayor en O/O (p < 0.0001). La incidencia de SBGC fue del 44.7%, siendo más frecuente en los grupos O/O en comparación con el grupo N, 43.3%, 68.1%, 22.2% respectivamente, (p < 0.05 en sobrepeso y p < 0.0001 en obesos). Al evaluar la presencia o ausencia de SBGC asociado con el IMC como una variable numérica, encontramos que las mujeres, HT, IMC, masa ventricular izquierda y tamaño de la válvula, se asociaron con SBGC (p < 0.02, p < 0.02, p < 0.001, p < 0.032, p < 0.045, respectivamente). La mortalidad fue mayor en pacientes con SBGC (p < 0.02). El modelo multivariado mostró que el IMC fue un factor de riesgo independiente asociado a SBGC [OR 1.21 (IC 95% 1.08-1.35), p < 0.001]. Conclusión: El IMC es un factor de riesgo asociado a SBGC en el postoperatorio de RVA en pacientes con EAI.

Perioperative use of levosimendan in patients undergoing cardiac surgery: systematic review and meta-analysis / Uso perioperatorio de levosimendán en pacientes sometidos a cirugía cardiaca: revisión sistemática de la literatura y metaanálisis

Abstract Introduction: Patients undergoing cardiac surgery frequently develop low cardiac output syndrome (LCOS). Multiple interventions including levosimendan have been used in the prevention and treatment of LCOS. Preliminary studies reported lower mortality respect to placebo or other inotropes, however, recently, 3 clinical trials found no benefit against this outcome. Objective: Our objective was to evaluate the evidence of levosimendan on mortality and secondary outcomes in patients undergoing cardiac surgery, and to determine the sources of heterogeneity. Methods: We conducted a systematic review and meta-analysis of the clinical trials that evaluated the efficacy of levosimendan in patients undergoing cardiac surgery. We obtained the odds ratio (OR) of mortality and other outcomes such as kidney injury with dialysis requirement and LCOS, using fixed and random effects models. The risk of bias was assessed and the sources of heterogeneity were explored. Results: Of 47 studies identified, 14 studies were selected (n=2752). Regarding the mortality outcome and use of levosimendan, only a decrease was found in the studies of low quality (OR 0,30; CI 95%, 0,18 to 0,51). While high-quality studies, there was no protective effect (OR 0.99,95% CI 0.70-1.40) with an I2 = 0%. The quality of the studies and ejection fraction were the main sources of heterogeneity. Conclusion: In high-quality studies, the use of levosimendan in patients undergoing cardiovascular surgery has no effect on 30-day mortality. There was a protective effect on postoperative renal failure with dialysis.

Resumen Introducción: Los pacientes llevados a cirugía cardiaca tienen riesgo de desarrollar síndrome de bajo gasto cardiaco posoperatorio (SBGC). Estudios previos han encontrado una menor mortalidad con levosimendán respecto a placebo u otros inotrópicos; sin embargo, tres experimentos clínicos no encontraron beneficio frente a este desenlace. Objetivo: Evaluar la evidencia del levosimendán sobre la mortalidad y los desenlaces secundarios en pacientes sometidos a cirugía cardiaca, y determinar las fuentes de heterogeneidad. Métodos: Mediante una revisión sistemática y metaanálisis de los experimentos clínicos que evaluaron la eficacia del levosimendán en los pacientes llevados a cirugía cardiaca, se evaluó la eficacia en la mortalidad y en otros desenlaces, como lesión renal y SBGC, utilizando los modelos de efectos fijos y aleatorios. Resultados: De 47 estudios identificados, fueron seleccionados 14 (n = 2752). Respecto al desenlace de mortalidad y el uso de levosimendán solo se encontró una disminución en los estudios de baja calidad (OR 0.30; IC 95%, 0.18-0.51), mientras que para los de alta calidad no hubo efecto protector (OR 0.99; IC 95%, 0.70-1.40) con un I2=0%. La calidad de los estudios y la fracción de eyección fueron las principales fuentes de heterogeneidad. Conclusión: el uso del levosimendán en los pacientes llevados a cirugía cardiovascular no tiene efectos sobre la mortalidad a 30 días en los estudios de alta calidad. Hubo efecto protector sobre la falla renal postoperatoria con necesidad de diálisis.

Emergency Pulmonary Artery–to-Systemic Artery Shunt to Break the Positive Feedback Loop of a Pulmonary Hypertensive Crisis after Neonatal Coarctation Repair / 대한흉부외과학회지

A 2.5-kg neonate with coarctation of the aorta and a small left ventricle experienced a severe pulmonary hypertensive crisis. An emergency pulmonary artery-to-systemic artery shunt was placed to break the positive feedback loop caused by pulmonary hypertension and functional mitral stenosis. This shunt provided immediate relief of suprasystemic pulmonary hypertension and the resultant low cardiac output.

Performance de enfermeiros não peritos na classificação dos indicadores clínicos do débito cardíaco diminuído / Non-expert nurses' performance in classifying clinical indicators of decreased cardiac output / Rendimiento de enfermeros no expertos en la clasificación de los indicadores clínicos de la disminución del gasto cardíaco

Objetivo: verificar performance de enfermeiros assistenciais em cardiologia, não peritos em diagnóstico de enfermagem, em classificar indicadores clínicos do débito cardíaco diminuído (DCD), tendo por base os achados de um estudo realizado com peritos. Método: estudo quantitativo, transversal, de acurácia diagnóstica. Realizado com 23 enfermeiros atuantes em unidades de cuidados intensivos de hospital público estadual do Rio de Janeiro, especializado em cardiologia. As medidas de performance utilizadas foram: eficiência, taxa de superestimação e taxa de subestimação. Resultados: a taxa média de eficiência de classificação dos indicadores clínicos do DCD foi de 65,9%. Na comparação intergrupos, a taxa de subestimação foi maior para os que usam diagnóstico na prática clínica (26,5%) e a de superestimação para os que não usam (49,9%). Conclusão: há adequação na eficiência dos enfermeiros, com atuação clínica em enfermagem cardiológica, não peritos em classificar um conjunto de indicadores de forma similar a peritos.

Objective: to assess the performance of cardiology nurses, non-experts in nursing diagnosis, in classifying clinical indicators of decreased cardiac output, based on the findings of a study of experts. Method: this quantitative, cross-sectional study of diagnostic accuracy examined 23 nurses working in intensive care units of a Rio de Janeiro State public specialist cardiology hospital. The performance measures used were: efficiency, overestimation rate, and underestimation rate. Results: the average rating for efficiency in classifying clinical indicators of decreased cardiac output was 65.9%. In intergroup comparison, the underestimation rate was higher (26.5%) among those who used diagnosis in clinical practice, while overestimation was higher (49.9%) among those who did not use it. Conclusion: non-expert nurses working in clinical cardiology nursing were adequately efficient in classifying a set of indicators similarly to experts.

Objetivo: verificar el rendimiento del enfermero asistencial en cardiología, no experto en diagnóstico de enfermería, en la clasificación de indicadores clínicos del bajo gasto cardíaco, basado en los hallazgos de un estudio llevado a cabo con expertos. Método: estudio cuantitativo, transversal, de precisión diagnóstica. Realizado junto a 23 enfermeros que trabajan en unidades de cuidados intensivos de un hospital público estadual de Río de Janeiro, especializado en cardiología. Las medidas de rendimiento utilizadas fueron: eficiencia, tasa de sobreestimación y tasa subestimación. Resultados: la tasa media de eficiencia de los indicadores clínicos del bajo gasto cardíaco fue 65,9%. En la comparación intergrupal, la tasa de subestimación fue mayor para aquellos que utilizan el diagnóstico en la práctica clínica (26,5%) y la sobreestimación de los que no lo utilizan (49,9%). Conclusión: existe adecuación de la eficiencia de los enfermeros con el trabajo clínico en enfermería cardiológica, no expertos en clasificar un conjunto de indicadores de manera similar a los expertos.

Predictores de bajo gasto cardíaco perioperatorio en pacientes operados de cirugía cardíaca valvular / Predictors of low perioperative cardiac output in patients with heart valve surgery

RESUMEN Introducción: El síndrome de bajo gasto cardíaco (BGC) perioperatorio es una complicación frecuente en el postoperatorio de cirugía cardíaca la cual disminuye la supervivencia a corto plazo. Objetivo: Determinar las variables que pronostican de manera independiente la incidencia del BGC en el perioperatorio de cirugía cardíaca valvular en el Instituto de Cardiología y Cirugía Cardiovascular, durante el trienio 2012-2014. Método: Se realizó un estudio de cohorte donde se conformaron dos grupos: uno con BGC (46 pacientes) y otro sin él (110 pacientes). Se realizó una curva de Kaplan-Meier para determinar la supervivencia a los 30 días de la cirugía, se compararon los grupos con la prueba de rangos logarítmicos (log-rank). Se efectuó un análisis multivariable para determinar las variables que influyeron de manera independiente en la aparición del BGC. El nivel de significación estadístico empleado fue de p<0,05. Resultados: La muestra fue homogénea según características clínicas y demográficas. La incidencia y la mortalidad del BGC fueron del 29,5% y 28,3%, respectivamente. La disfunción renal preoperatoria (OR=5,13; p=0,005), el tiempo prolongado de circulación extracorpórea (OR=4,89; p=0,001) y la resistencia vascular pulmonar elevada (OR=7,52; p<0,001) fueron las variables que se asociaron de manera independiente a la aparición de bajo gasto. Conclusiones: El BGC reduce significativamente la supervivencia perioperatoria. La disfunción renal preoperatoria, el tiempo prolongado de circulación extracorpórea y la resistencia vascular pulmonar elevada constituyeron variables de peor pronóstico en estos pacientes, asociadas a una mayor probabilidad de sufrir esta complicación.

ABSTRACT Introduction: The perioperative low cardiac output syndrome (LCOS) is a frequent complication in the postoperative period of cardiac surgery which decreases short-term survival. Objective: To determine the variables that independently predict the incidence of LCOS in the perioperative period of heart valve surgery at the Instituto de Cardiología y Cirugía Cardiovascular, during the 2012-2014 triennium. Method: A cohort study was conducted where two groups were formed: one with LCOS (46 patients) and the other without it (110 patients). A Kaplan-Meier curve was performed to determine survival 30 days after surgery. The groups were compared with the log-rank test. A multivariate analysis was carried out to determine the variables that independently influenced the appearance of LCOS. The level of statistical significance used was p<0.05. Results: The sample was homogeneous according to clinical and demographic characteristics. The incidence and mortality of the LCOS were 29.5% and 28.3%, respectively. Preoperative renal dysfunction (OR=5.13, p=0.005), prolonged extracorporeal circulation time (OR=4.89, p=0.001) and elevated pulmonary vascular resistance (OR=7.52, p<0.001) were the variables independently associated with the appearance of low cardiac output. Conclusions: The LCOS significantly reduces perioperative survival. Preoperative renal dysfunction, prolonged extracorporeal circulation and elevated pulmonary vascular resistance were variables of worse prognosis in these patients, associated with a higher probability of suffering this complication.

A avaliação da proteção miocárdica utilizando solução cardioplégica sanguínea versus solução cardioplégica cristalóide: estudo em modelo experimental de coração isolado / The evaluation of myocardial protection using blood cardioplegic solution versus crystalloid cardioplegic solution: study in an isolated heart model

Resumo: INTRODUÇÃO: O efeito deletério provocado pela isquemia e reperfusão do miocárdio durante a parada cardíaca apresenta-se como uma das principais causas da síndrome de baixo débito cardíaco no período pós-operatório. Neste sentido, a utilização de solução cardioplégica na indução da parada cardíaca eletiva tem sido o método mais utilizado e difundido de proteção do miocárdio. No entanto, a padronização do método ou tipo ideal de solução cardioplégica ainda é controverso devido à escassez de estudos com o delineamento claro das vantagens e desvantagens na comparação entre as soluções utilizadas nos serviços de cirurgia. OBJETIVOS: A avaliação da recuperação contrátil dos corações com a administração em dose única das soluções cardioplégicas del Nido (sanguínea) versus Custodiol (cristalóide), após serem mantidos por longo período em isquemia global. E a avaliação de proteínas relacionadas com a dinâmica do cálcio intracelular, a atividade de proteases envolvidas com a morte celular programada assim como a preservação energética miocárdica. MÉTODOS: Corações de ratos Wistar macho foram perfundidos de forma isolada de acordo com a técnica de Langendorff clássico. A administração das soluções cardioplégicas em dose única (30 ml/Kg) induziram os corações ao período 3 horas de isquemia fria, seguido pelo período de 90 minutos de reperfusão. Os corações foram divididos em dois grupos; (I) del Nido (n = 6) versus (II) Custodiol (n = 6). A avaliação da recuperação contrátil do ventrículo esquerdo foi realizada durante a reperfusão pelas variáveis hemodinâmicas: PSVE, PDVE, dP/dt máxima, dP/dt mínima, PPDFC e RC. Ao fim da reperfusão as amostras de tecido do ventrículo esquerdo foram coletadas para as análises de proteínas envolvidas com a dinâmica do cálcio intracelular (fosfolambam e SERCA2a) de acordo com a técnica de immunoblot, atividade das caspases 3/7 e a concentração de ATP miocárdico de acordo com a técnica de bioluminescência. RESULTADOS: A solução cardioplégica sanguínea del Nido atribuiu aos corações a recuperação da função contráctil superior em comparação com a solução cristalóide Custodiol. As análises das variáveis hemodinâmicas mostraram resultados superiores com a solução sanguínea, conforme apresentam-se respectivamente: PSVE (90 minutos), 28 ± 7% vs. 50 ± 2%; PDVE (90 minutos), 32 ± 6 vs. del 56 ± 2%; dP/dt máxima (30 minutos), 28 ± 12% vs. 66 ± 10%; dP/dt mínima (30 minutos), 24 ± 10% vs. 53 ± 9%; PPDFC (30 minutos), 18 ± 9% vs. 53 ± 11%. A concentração de ATP miocárdico (P <0,05) e a ativação da fosfolambam (P <0,05) também apresentaram resultados superiores nos corações que receberam a solução cardioplégica del Nido. CONCLUSÕES: A solução cardioplégica sanguínea del Nido demonstrou maior capacidade de proteção do miocárdio em comparação com solução cardioplégica Custodiol de acordo com a maior preservação da recuperação contrátil do ventrículo esquerdo. A elevada concentração de ATP no miocárdio e a maior ativação da fosfolambam são dados que atestam o desempenho ventricular superior com a solução cardioplégica del Nido, demonstrando a maior capacidade de proteção do miocárdio por esta solução(AU)

Abstract: INTRODUCTION: The deleterious effect caused by myocardial ischemia and reperfusion during cardiac arrest is one of the main causes of low cardiac output syndrome in the postoperative period. In this sense, the use of cardioplegic solution on induction of elective cardiac arrest has been the most widely used and widespread method of myocardial protection. However, the standardization of the ideal method or type of cardioplegic solution is still controversial due to the scarcity of studies with a clear delineation about the advantages and disadvantages comparing solutions used in the surgery services. OBJECTIVES: The contractile recovery evaluation from hearts induced to long-term of global ischemia with the single dose of cardioplegic solutions administration by del Nido (blood-based) versus Custodiol (crystalloid). In addition, the evaluation of intracellular calcium dynamics proteins, the activity of proteases involved with programmed cell death as well as myocardial energy preservation. METHODS: Male Wistar hearts rats were submitted to isolated perfusion according to the classic Langendorff technique. The single dose of cardioplegic solutions (30 ml/kg), induced the hearts to the period 3-hours of cold ischemia, followed by the 90-minute of reperfusion. The hearts were divided into two groups; (I) del Nido (n = 6) versus (II) Custodiol (n = 6). The evaluation of left ventricular contractile recovery was performed throughout the reperfusion according to hemodynamic variables: LVSP, LVDP, maximum dP/dt, minimum dP/dt, RPP and CR. Subsequently, at the end of reperfusion the left ventricular tissue samples were collected for analysis of proteins involved with intracellular calcium dynamics (phospholamban and SERCA2a) according to the immunoblot technique and the activity of the caspases 3/7 and myocardial ATP concentration according to the bioluminescence technique. RESULTS: Del Nido blood-based cardioplegic solution provided to the hearts higher contractile recovery comparing to the Custodiol crystalloid cardioplegic solution. The hemodynamic variables analysis showed superior results with the blood-based solution as presented respectively: LVSP (90 minutes), 28 ± 7% vs. 50 ± 2%; LVDP (90 minutes), 32 ± 6 vs. 56 ± 2%; dP/dt maximum (30 minutes), 28 ± 12% vs. 66 ± 10%; dP/dt minimum (30 minutes), 24 ± 10% vs. 53 ± 9%; RPP (30 minutes), 18 ± 9% vs. 53 ± 11%. Ultimately, both analysis with myocardial ATP concentration (P <0.05) and the activation of phospholamban (P <0.05) presented higher levels in the hearts which received the del Nido cardioplegic solution(AU)

Early Clinical Outcomes of Tricuspid Valve Repair with a Tri-Ad Annuloplasty Ring in Comparison with the Outcomes Using an MC³ Ring

BACKGROUND: We evaluated the early clinical outcomes of tricuspid valve annuloplasty (TAP) with the Tri-Ad annuloplasty ring for functional tricuspid regurgitation (TR). METHODS: From January 2015 to March 2017, 36 patients underwent TAP with a Tri-Ad ring for functional TR. To evaluate the early clinical outcomes of TAP with the Tri-Ad ring, we conducted a propensity score-matched analysis comparing the Tri-Ad and MC3 tricuspid annuloplasty rings (n=34 in each group). The follow-up duration was 11.0±7.07 months. RESULTS: There was 1 case of operative mortality (2.8%) and no cases of late mortality. Postoperative complications occurred in 15 patients (41%), including acute kidney injury in 6 patients (16%), bleeding requiring reoperation in 4 patients (11%), and low cardiac output syndrome in 4 patients (11%). There were no ring-related complications, such as atrioventricular block or ring dehiscence. The TR grade decreased significantly (from 2.03±1.06 to 1.18±0.92, p < 0.01), as did the systolic pulmonary artery pressure (from 43.53±13.84 to 38.00±9.72 mm Hg, p=0.03). There were no cases of severe residual TR, but moderate TR was observed in 3 patients, all of whom had severe TR preoperatively. Severe preoperative TR was also associated with moderate in the univariate analysis (p < 0.01). In the propensity score-matched analysis comparing the Tri-Ad and MC3 rings, there was no significant difference in early clinical outcomes. CONCLUSION: TAP with the Tri-Ad ring corrected functional TR effectively and provided good early clinical and echocardiographic results without ring-related complications. However, severe preoperative TR was associated with moderate or severe residual TR in the immediate postoperative period. A follow-up study is necessary to confirm the stability of this procedure.

Critical Illness-Related Corticosteroid Insufficiency in Patients with Low Cardiac Output Syndrome after Cardiac Surgery

BACKGROUND: Low cardiac output syndrome (LCOS) after cardiac surgery usually requires inotropes. In this setting, critical illness-related corticosteroid insufficiency (CIRCI) may develop. We aimed to investigate the clinical features of CIRCI in the presence of LCOS and to assess the efficacy of steroid treatment. METHODS: We reviewed 28 patients who underwent a rapid adrenocorticotropic hormone (ACTH) test due to the suspicion of CIRCI between February 2010 and September 2014. CIRCI was diagnosed by a change in serum cortisol of <9 μg/dL after the ACTH test or a random cortisol level of <10 μg/dL. RESULTS: Twenty of the 28 patients met the diagnostic criteria. The patients with CIRCI showed higher Sequential Organ Failure Assessment (SOFA) scores than those without CIRCI (16.1±2.3 vs. 11.4±3.5, p=0.001). Six of the patients with CIRCI (30%) received glucocorticoids. With an average elevation of the mean blood pressure by 22.2±8.7 mm Hg after steroid therapy, the duration of inotropic support was shorter in the steroid group than in the non-steroid group (14.1±2.3 days versus 30±22.8 days, p=0.001). Three infections (15%) developed in the non-steroid group, but this was not a significant between-group difference. CONCLUSION: CIRCI should be suspected in patients with LCOS after cardiac surgery, especially in patients with a high SOFA score. Glucocorticoid replacement therapy may be considered to reduce the use of inotropes without posing an additional risk of infection.

Risk factors for delayed extubation after ventricular septal defect closure: a prospective observational study

Objective: The objective of our study was to determine the feasibility of early extubation and to identify the risk factors for delayed extubation in pediatric patients operated for ventricular septal defect closure. Methods: A prospective, observational study was carried out at our Institute. This study involved consecutive 135 patients undergoing ventricular septal defect closure. Patients were extubated if feasible within six hours after surgery. Based on duration of extubation, patients were divided two groups: Group 1= extubation time ≤ 6 hours, Group 2= extubation time >6 hours. Results: A total of 99 patients were in Group 1 and 36 patients in Group 2. Duration of ventilation was 4.4±0.9 hours in Group 1 and 25.9±24.9 hours in Group 2 (P<0.001). Univariate analysis showed that young age, low weight, low partial pressure of oxygen, trisomy 21, multiple ventricular septal defect, high vasoactive inotropic score, transient heart block and low cardiac output syndrome were associated with delayed extubation. However, regression analysis revealed that only trisomy 21 (OR: 0.248; 95%CI: 0.176-0.701; P=0.001), low cardiac output syndrome (OR: 0.291; 95%CI: 0.267-0.979; P=0.001), multiple ventricular septal defect (OR: 0.243; 95%CI: 0.147-0.606; P=0.002) and vasoactive inotropic score (OR: 0.174 95%CI: 0.002-0.062; P=0.039) are strongest predictors for delayed extubation. Conclusion: Trisomy 21, low cardiac output syndrome, multiple ventricular septal defect and high vasoactive inotropic score are significant risk factors for delay in extubation. Age, weight, pulmonary artery hypertension, size of ventricular septal defect, aortic cross-clamp and cardiopulmonary bypass time did not affect early extubation.

Where Is the “Optimal” Fontan Hemodynamics?

Fontan circulation is generally characterized by high central venous pressure, low cardiac output, and slightly low arterial oxygen saturation, and it is quite different from normal biventricular physiology. Therefore, when a patient with congenital heart disease is selected as a candidate for this type of circulation, the ultimate goals of therapy consist of 2 components. One is a smooth adjustment to the new circulation, and the other is long-term circulatory stabilization after adjustment. When either of these goals is not achieved, the patient is categorized as having “failed” Fontan circulation, and the prognosis is dismal. For the first goal of smooth adjustment, a lot of effort has been made to establish criteria for patient selection and intensive management immediately after the Fontan operation. For the second goal of long-term circulatory stabilization, there is limited evidence of successful strategies for long-term hemodynamic stabilization. Furthermore, there have been no data on optimal hemodynamics in Fontan circulation that could be used as a reference for patient management. Although small clinical trials and case reports are available, the results cannot be generalized to the majority of Fontan survivors. We recently reported the clinical and hemodynamic characteristics of early and late failing Fontan survivors and their association with all-cause mortality. This knowledge could provide insight into the complex Fontan pathophysiology and might help establish a management strategy for long-term hemodynamic stabilization.

Association between fluid overload and acute renal injury after congenital heart disease surgery in infants / 中国当代儿科杂志

<p><b>OBJECTIVE</b>To study the association between fluid overload and acute kidney injury (AKI) after congenital heart disease surgery in infants.</p><p><b>METHODS</b>A retrospective analysis was performed on 88 infants aged less than 6 months who underwent a radical surgery for congenital heart disease. The treatment outcomes were compared between the infants with AKI after surgery and those without. The effect of cumulative fluid overload on treatment outcomes 2 days after surgery was analyzed. The risk factors for the development of AKI after surgery were assessed by logistic regression analysis.</p><p><b>RESULTS</b>Compared with those without AKI after surgery, the patients with AKI had younger age, lower body weights, higher serum creatinine levels and higher vasoactive-inotropic score, as well as longer durations of intraoperative extracorporeal circulation and aortic occlusion (P<0.05). Compared with those without AKI after surgery, the patients with AKI had a higher transfusion volume, a higher incidence rate of low cardiac output syndrome, a longer duration of mechanical ventilation, a longer length of stay in the intensive care unit (ICU), a longer length of hospital stay, a higher application rate of extracorporeal membrane oxygenation, a higher 30-day mortality rate, and higher levels of cumulative fluid overload 2 and 3 days after surgery (P<0.05). The logistic regression analysis showed that fluid overload and low cardiac output syndrome were major risk factors for the development of AKI after surgery. The children with cumulative fluid overload >5% at 2 days after surgery had a higher incidence rate of low cardiac output syndrome, a longer duration of mechanical ventilation, a longer length of stay in the ICU, a longer length of hospital stay, and a higher mortality rate (P<0.05).</p><p><b>CONCLUSIONS</b>Infants with fluid overload after surgery for congenital heart disease tend to develop AKI, and fluid overload may be associated with poor outcomes after surgery.</p>

Experience with Mechanical Circulatory Support for Medically Intractable Low Cardiac Output in a Pediatric Intensive Care Unit

BACKGROUND AND OBJECTIVES: Mechanical circulatory support with extracorporeal membrane oxygenation (ECMO) and ventricular assist device has always been the optimal choice for treating the majority of medically intractable low cardiac output case. We retrospectively investigated our institution's outcomes and variables associated with a high risk of mortality. SUBJECTS AND METHODS: From 1999 to 2014, 86 patients who were of pediatric age or had grown-up congenital heart disease underwent mechanical circulatory support for medically intractable low cardiac output in our pediatric intensive care unit. Of these, 9 grown-up congenital heart disease patients were over 18 years of age, and the median age of the subject group was 5.82 years (range: 1 day to 41.6 years). A review of all demographic, clinical, and surgical data and survival analysis were performed. RESULTS: A total of 45 (52.3%) patients were successfully weaned from the mechanical assist device, and 25 (29.1%) survivors were able to be discharged. There was no significant difference in results between patients over 18 years and under 18 years of age. Risk factors for mortality were younger age (<30 days), functional single ventricle anatomy, support after cardiac operations, longer support duration, and deteriorated pre-ECMO status (severe metabolic acidosis and increased levels of lactate, creatinine, bilirubin, or liver enzyme). The survival rate has improved since 2010 (from 25% before 2010 to 35% after 2010), when we introduced an upgraded oxygenator, activated heart transplantation, and also began to apply ECMO before the end-stage of cardiac dysfunction, even though we could not reveal significant correlations between survival rate and changed strategies associated with ECMO. CONCLUSION: Mechanical circulatory support has played a critical role and has had a dramatic effect on survival in patients with medically intractable heart failure, particularly in recent years. Meticulous monitoring of acid-base status, laboratory findings, and early and liberal applications are recommended to improve outcomes without critical complication rates, particularly in neonates with single ventricle physiology.

Stormy Course of a Huge Submitral Aneurysm Causing Low Cardiac Output State

Submitral aneurysm is a rare structural abnormality of congenital or acquired aetiology. Most reported cases are from Africa. Unless promptly treated surgically this condition is invariably fatal. We report a case of a young Indian male who presented with dyspnea of recent onset, diagnosed to have a massive submitral aneurysm causing low cardiac output and compression of cardiac structures.

Clinical Manifestations and Diagnosis of Right Ventricular Failure / 대한내과학회지

Right ventricular (RV) failure is a complex clinical syndrome characterized by impaired RV filling and ejection. RV function is altered in the setting of either pressure overload or volume overload. RV failure may result from a primary reduction of myocardial contractility caused by ischemia, cardiomyopathy, or arrhythmia, but left ventricular (LV) failure remains the leading cause. As RV dysfunction progresses to RV failure, the RV chamber becomes more spherical and tricuspid regurgitation is aggravated, leading to increasing venous congestion. Ventricular interdependence may result in impaired LV filling, a decrease in LV stroke volume, and low cardiac output. The important clinical manifestations of RV failure are fluid retention, decreased systolic reserve, low cardiac output, or arrhythmias. The initial diagnosis is based on clinical history and physical examination. A chest X-ray, electrocardiogram, and biochemical tests should be routinely obtained to evaluate the underlying causes and comorbidities. Bedside echocardiography provides valuable information on cardiac structure and function. RV ejection fraction is the most commonly used index of RV function although it is a highly load-dependent index.

Ruptured Tricuspid Valve Papillary Muscle in a Neonate with Intractable Persistent Fetal Circulation

Unguarded tricuspid regurgitation (TR) due to a flail tricuspid leaflet is a rare condition of newborn cyanosis. A high perinatal mortality has been associated with this fatal condition. But, there are feasible surgical repairs to improve survival. We report the case of a male full-term neonate with intractable hypoxia. He had profound tricuspid insufficiency and leaflet prolapse caused by a ruptured papillary muscle supporting the anterior leaflet of the tricuspid valve. He presented with severe cyanosis and respiratory distress immediately after birth. Despite medical management, the pulmonary vascular resistance was not decreased and a low cardiac output persisted. Initial stabilization was accomplished with nitric oxide and extracorporeal membrane oxygenation. The tricuspid valve repair surgery was successfully performed subsequently. TR resulting from papillary muscle rupture is a potentially lethal condition. Timely diagnosis and proper surgical treatment can be lifesaving.