Conventional versus minimally invasive extra-corporeal circulation in patients undergoing cardiac surgery: A randomized controlled trial (COMICS).

INTRODUCTION: The trial hypothesized that minimally invasive extra-corporeal circulation (MiECC) reduces the risk of serious adverse events (SAEs) after cardiac surgery operations requiring extra-corporeal circulation without circulatory arrest. METHODS: This is a multicentre, international randomized controlled trial across fourteen cardiac surgery centres including patients aged ≥18 and <85 years undergoing elective or urgent isolated coronary artery bypass grafting (CABG), isolated aortic valve replacement (AVR) surgery, or CABG + AVR surgery. Participants were randomized to MiECC or conventional extra-corporeal circulation (CECC), stratified by centre and operation. The primary outcome was a composite of 12 post-operative SAEs up to 30 days after surgery, the risk of which MiECC was hypothesized to reduce. Secondary outcomes comprised: other SAEs; all-cause mortality; transfusion of blood products; time to discharge from intensive care and hospital; health-related quality-of-life. Analyses were performed on a modified intention-to-treat basis. RESULTS: The trial terminated early due to the COVID-19 pandemic; 1071 participants (896 isolated CABG, 97 isolated AVR, 69 CABG + AVR) with median age 66 years and median EuroSCORE II 1.24 were randomized (535 to MiECC, 536 to CECC). Twenty-six participants withdrew after randomization, 22 before and four after intervention. Fifty of 517 (9.7%) randomized to MiECC and 69/522 (13.2%) randomized to CECC group experienced the primary outcome (risk ratio = 0.732, 95% confidence interval (95% CI) = 0.556 to 0.962, p = 0.025). The risk of any SAE not contributing to the primary outcome was similarly reduced (risk ratio = 0.791, 95% CI 0.530 to 1.179, p = 0.250). CONCLUSIONS: MiECC reduces the relative risk of primary outcome events by about 25%. The risk of other SAEs was similarly reduced. Because the trial terminated early without achieving the target sample size, these potential benefits of MiECC are uncertain.

The role of hemoadsorption in cardiac surgery - a systematic review.

BACKGROUND: Extracorporeal blood purification has been widely used in intensive care medicine, nephrology, toxicology, and other fields. During the last decade, with the emergence of new adsorptive blood purification devices, hemoadsorption has been increasingly applied during CPB in cardiac surgery, for patients at different inflammatory risks, or for postoperative complications. Clinical evidence so far has not provided definite answers concerning this adjunctive treatment. The current systematic review aimed to critically assess the role of perioperative hemoadsorption in cardiac surgery, by summarizing the current knowledge in this clinical setting. METHODS: A literature search of PubMed, Cochrane library, and the database provided by CytoSorbents was conducted on June 1st, 2023. The search terms were chosen by applying neutral search keywords to perform a non-biased systematic search, including language variations of terms "cardiac surgery" and "hemoadsorption". The screening and selection process followed scientific principles (PRISMA statement). Abstracts were considered for inclusion if they were written in English and published within the last ten years. Publications were eligible for assessment if reporting on original data from any type of study (excluding case reports) in which a hemoadsorption device was investigated during or after cardiac surgery. Results were summarized according to sub-fields and presented in a tabular view. RESULTS: The search resulted in 29 publications with a total of 1,057 patients who were treated with hemoadsorption and 988 control patients. Articles were grouped and descriptively analyzed due to the remarkable variability in study designs, however, all reported exclusively on CytoSorb® therapy. A total of 62% (18/29) of the included articles reported on safety and no unanticipated adverse events have been observed. The most frequently reported clinical outcome associated with hemoadsorption was reduced vasopressor demand resulting in better hemodynamic stability. CONCLUSIONS: The role of hemoadsorption in cardiac surgery seems to be justified in selected high-risk cases in infective endocarditis, aortic surgery, heart transplantation, and emergency surgery in patients under antithrombotic therapy, as well as in those who develop a dysregulated inflammatory response, vasoplegia, or septic shock postoperatively. Future large randomized controlled trials are needed to better define proper patient selection, dosing, and timing of the therapy.

Perioperative Care in Cardiac Surgery: A Joint Consensus Statement by the Enhanced Recovery After Surgery (ERAS) Cardiac Society, ERAS International Society, and The Society of Thoracic Surgeons (STS).

Enhanced Recovery After Surgery (ERAS) programs have been shown to lessen surgical insult, promote recovery, and improve postoperative clinical outcomes across a number of specialty operations. A core tenet of ERAS involves the provision of protocolized evidence-based perioperative interventions. Given both the growing enthusiasm for applying ERAS principles to cardiac surgery and the broad scope of relevant interventions, an international, multidisciplinary expert panel was assembled to derive a list of potential program elements, review the literature, and provide a statement regarding clinical practice for each topic area. This article summarizes those consensus statements and their accompanying evidence. These results provide the foundation for best practice for the management of the adult patient undergoing cardiac surgery.

Cost-Effectiveness and Budget Impact Analyses of Patient Blood Management in a Cardiovascular Surgery Department at Ankara Bilkent City Hospital in Turkey.

INTRODUCTION: Anemia and transfusion of blood products are risk factors associated with poor patient outcomes across all elective surgeries. Patient blood management (PBM) is a patient-centered approach to optimize patient's endogenous red cell mass, to minimize blood loss in patients undergoing surgery, and to harness and optimize patient-specific physiological tolerance to anemia. This study aimed to assess (1) the impact of PBM on blood product usage in cardiovascular surgeries in a state hospital setting, (2) cost-effectiveness of PBM with a model based on transfusion of red blood cells (RBCs) in cardiovascular surgeries, and (3) the budget impact of PBM implementation based on transfusion of RBCs. METHODS: Cost-effectiveness and budget impact models, based on the numbers of avoided transfusions and avoided complications after implementation of the PBM program, were compared between pre- and post-PBM periods at the cardiovascular surgery department of Ankara Bilkent City Hospital between February 11, 2019 and July 24, 2022. The probabilities of transfusions and complications with and without PBM were taken from recent meta-analyses. Data from the Ankara Bilkent City Hospital transfusion center informed the pre- and post-PBM calculations. Costs were calculated from the Social Security Institution's perspective. RESULTS: There was a 21% decrease in the use of RBCs and a 23.7% decrease in use of all blood products after the implementation of PBM. The number of RBC packs per patient reduced by 0.88 packs (21%). The cost saving from reduction of RBC transfusions per patient was 518.68 Turkish lira (TRY) and for the hospital it was 1,635,948 TRY. Fewer complications and lower costs in favor of the post-PBM arm were demonstrated in the cost-effectiveness analysis. On the basis of the budget impact model, in 20 months, the hospital's cardiovascular surgery department saved 6,596,934 TRY (€342,302). CONCLUSION: This hospital-based study demonstrated that PBM is a budget-saving and cost-effective option in Turkey.

When undergoing elective surgery, patients who develop anemia or who need a transfusion of blood products may develop further complications. This study aimed to understand the impact of patient blood management on blood usage in cardiovascular surgeries. Patient blood management is a patient-centered approach that aims to optimize a patient's red cell mass, minimize blood loss in patients undergoing surgery, and maximize a patient's tolerance to anemia. In addition, this study assessed the cost-effectiveness of patient blood management using an economic model based on red blood cells in cardiovascular surgeries and assessed the impact of patient blood management on budget. The patient blood management program resulted in a 21% decrease in use of red blood cells and 23.7% decrease in use of all blood products. The cost savings from reduction of red blood cells transfusions per patient were 518.68 Turkish lira and cost savings for the hospital were 1,635,948 Turkish lira. Fewer complications and lower costs were demonstrated after implementation of patient blood management in the cost-effectiveness analysis. Between December 2020 and July 2022, the hospital's cardiovascular surgery department saved 6,596,934 Turkish lira (€342,302). Overall, this hospital-based study has shown that patient blood management is a budget-saving and cost-effective option in Turkey.

The Influence of Pre-operative Pain and Anxiety on Acute Postoperative Pain in Cardiac Surgery Patients Undergoing Enhanced Recovery after Surgery.

Objective: Perioperative multimodal analgesia is an important step in enhanced recovery after surgery (ERAS) care. Many factors, such as preoperative chronic pain and anxiety, may provide information about the expected postoperative pain. In this study, we evaluated preoperative pain and anxiety and investigate their effects on acute postoperative pain in patients undergoing elective cardiac surgery. Methods: After ethics committee approval, 67 consenting patients undergoing on-pump cardiac surgery under the ERAS program were included in our prospective observational study. Pre- and postoperative pain scores were obtained using a numeric rating scale (NRS) at rest and during movement. Preoperative anxiety was assessed on a 0-10 scale, and data were recorded. The relationships between pre-operative pain/anxiety and postoperative pain were evaluated using correlation analysis. Results: In preoperative pain assessment, the percentage of patients with a pain score above 4 with NRS was 1.5%, regardless of whether they were at rest or mobilize. In postoperative pain assessment, there were 20.9% and 34.3% patients with NRS >4 at rest and mobilization, respectively. 7.5% of patients had preoperative anxiety of grade 5 or higher. While preoperative pain was not correlated with postoperative pain, preoperative anxiety had a moderate positive correlation with postoperative pain (r=0.382, P=0.003). Conclusion: The prevalence of preoperative pain in patients who underwent cardiac surgery is quite low and is not associated with postoperative pain. There is also a significant relationship between the severity of preoperative anxiety and postoperative pain.

Redosing of long acting cardioplegic solutions in adult cardiac surgery: A comparative study.

INTRODUCTION: Despite promising results regarding using long-acting cardioplegia in the adult population, little data exists specifically for operations requiring prolonged aortic cross-clamp needing additional doses. In this pilot study, we evaluated the outcomes of patients undergoing surgery with prolonged cross-clamp time based on four different redosing compositions. METHODS: During the period from January 2019 until June 2022, 288 patients undergoing cardiac surgery with an expected cross-clamp time over 60 min were prospectively randomized regarding the type of the cardioplegia used: Group 1 (N = 150)- single-dose del Nido antegrade cardioplegia and Group 2 (N = 138)- single-dose Histidine-Tryptophane-Ketoglutarate (HTK) antegrade cardioplegia. In patients with ischemic time over 60 min, needing a redosing were further analyzed separately in four subgroups: (A) Cold whole blood (CWB) (4:1) (N = 95); (A1: DN-CWB; A2: HTK-CWB) and (B) St Thomas Solution (N = 92) (B1: DN-St Thomas; B2: HTK-St Thomas. Control groups were C1 (DN redosed by DN) and C2 (HTK by HTK). RESULTS: Troponin levels in A1 and B1 groups were significantly lower than in DN-control. Respiratory support time and incidence of atrial fibrillation were significantly lower in Group A1 versus DN-control. CONCLUSIONS: Long-acting cardioplegic techniques are becoming widely utilized in the adult population, with minimal data on redosing methods/compositions for prolonged cases. Due to the small patient population, further investigation is needed to delineate optimal redosing methods, but this report brings to attention the initial success of multiple strategies.

Evaluation of endovascular treatment of chronic limb-threatening ischemia for patients in the PLAN gray zone.

OBJECTIVE: To compare the results of endovascular therapy for chronic limb-threatening ischemia (CLTI) in patients categorized under the gray and yellow zones of the patient risk, limb severity, and anatomic pattern (PLAN) concept over a 2-year follow-up period. METHODS: Patients who underwent endovascular therapy for peripheral artery disease and presented with CLTI from February 2017 to February 2019 were retrospectively reviewed. The patients were grouped into yellow and gray zones based on the PLAN concept. Preoperative and postoperative walking distances, Rutherford classes, and postoperative target vessel patency rates were recorded and compared between the groups. Follow-up evaluations were performed at 1, 6, 12, and 24 months post-procedure. RESULTS: Of the 387 patients evaluated, the yellow and gray groups comprised 88 patients each. The overall patency rates were similar between the groups (84 (95.45%) vs. 81 (92.05%), respectively). The occlusion-/stenosis-free survival times, amputation-free survival time, and mean survival time were not significantly different. However, the gray group had a significantly higher number of atherectomy interventions (74 vs. 59) and crosser devices used (62 vs. 42). CONCLUSION: Endovascular therapy is an effective treatment option for patients in the gray zone of the PLAN color coding system.

Extracorporeal blood purification strategies in sepsis and septic shock: An insight into recent advancements.

BACKGROUND: Despite various therapies to treat sepsis, it is one of the leading causes of mortality in the intensive care unit patients globally. Knowledge about the pathophysiology of sepsis has sparked interest in extracorporeal therapies (ECT) which are intended to balance the dysregulation of the immune system by removing excessive levels of inflammatory mediators. AIM: To review recent data on the use of ECT in sepsis and to assess their effects on various inflammatory and clinical outcomes. METHODS: In this review, an extensive English literature search was conducted from the last two decades to identify the use of ECT in sepsis. A total of 68 articles from peer-reviewed and indexed journals were selected excluding publications with only abstracts. RESULTS: Results showed that ECT techniques such as high-volume hemofiltration, coupled plasma adsorption/filtration, resin or polymer adsorbers, and CytoSorb® are emerging as adjunct therapies to improve hemodynamic stability in sepsis. CytoSorb® has the most published data in regard to the use in the field of septic shock with reports on improved survival rates and lowered sequential organ failure assessment scores, lactate levels, total leucocyte count, platelet count, interleukin- IL-6, IL-10, and TNF levels. CONCLUSION: Clinical acceptance of ECT in sepsis and septic shock is currently still limited due to a lack of large random clinical trials. In addition to patient-tailored therapies, future research developments with therapies targeting the cellular level of the immune response are expected.

The MANTRA study: a new umbrella concept prospectively applied to assess implantable medical devices for heart valve procedures.

BACKGROUND: Clinical evidence is commonly obtained through individual trials that are time-, cost- and resource-consuming, and which often leave unanswered clinically relevant questions. Umbrella studies have been developed to address the need for more efficient and flexible trial structures, predominantly for cancer treatments. The umbrella concept foresees data collection within a unifying trial structure, to which one or more substudies may be added at any time to address product- or therapy-specific questions. To our knowledge, the umbrella concept has not yet been used in the medical device area, but it may offer similar advantages as in other settings, particularly in areas where multiple therapies are available within one large treatment area. METHODS: The MANTRA study (NCT05002543) is a prospective, global, post-marketing clinical follow-up study. The aim is to collect safety and device performance data covering the Corcym cardiac surgery portfolio for the treatment of aortic, mitral, and tricuspid valve diseases. The study uses a master protocol that outlines the main common parameters, and the specific questions are addressed in three substudies. The primary endpoints are device success at 30 days. Secondary endpoints include safety- and device performance-related data at 30 days, 1 year, and then annually through to 10 years. All endpoints are defined according to the more recent guidelines for heart valve procedures. Additionally, procedure and hospitalization information are collected, including Enhanced Recovery after Surgery in sites using such protocols, and patient outcome measures such as New York Heart Association classification and quality-of-life questionnaires. RESULTS: The study started in June 2021. Enrollment in all three substudies is ongoing. CONCLUSIONS: The MANTRA study will provide contemporary information on the long-term outcomes of medical devices for the treatment of aortic, mitral, and tricuspid heart valve diseases in routine clinical practice. The umbrella approach adopted in the study has the potential of longitudinally assessing long-term efficacy of the devices and the flexibility to investigate new research questions as they arise.

Preparation of magnetic poly(ethylene glycol dimethacrylate-N-Methacryloyl-(L)-glutamic acid) particles for thrombin purification.

In this study, magnetic poly(ethylene glycol dimethacrylate-N-methacryloyl-(L)-glutamic acid) (mPEGDMA-MAGA) particles were prepared by the dispersion polymerization in order to purify thrombin effectively. mPEGDMA-MAGA particles were synthesized by adding different ratios of magnetite (Fe3O4) to the medium in addition to the monomer phases EGDMA and MAGA. The characterization studies of mPEGDMA-MAGA particles were used by fourier transform infrared spectroscopy, zeta size measurement, scanning electron microscopy and electron spin resonance. mPEGDMA-MAGA particles were used in thrombin adsorption studies from aqueous thrombin solutions in both batch and magnetically stabilized fluidized bed (MSFB) system. Maximum adsorption capacity in pH 7.4 phosphate buffer solution is 964 IU/g polymer and 134 IU/g polymer in MSFB system and batch system, respectively. The developed magnetic affinity particles enabled the separation of thrombin from different patient serum samples in one step. It has also been observed that magnetic particles can be used repeatedly without significant reduction in adsorption capacity.

Comparative clinical efficacy of novel bidirectional cannula in cardiac surgery via peripheral cannulation for cardiopulmonary bypass.

OBJECTIVES: The aim of this study is to evaluate the safety and efficacy of the novel bidirectional cannula that ensures stable distal perfusion compared to conventional cannula in patients undergoing femoral arterial cannulation for cardiopulmonary bypass (CPB). METHODS: During a 1-year period, 64 patients undergoing surgery via peripheral cannulation were prospectively randomized to receive 19 F bidirectional (Biflow™, LivaNova, Italy) or 19 F conventional (HLS Peripheral cannula, Getinge Group™, Germany) cannula with 6 F downstream line (Bicakcilar™, Turkey) for femoral artery cannulation. The primary outcome included the efficacy (adequacy of antegrade/retrograde comparative flow via cannula measured by doppler ultrasonography) and the secondary outcome was the safety (early/late complications and adverse events). RESULTS: Percent flow (distal/proximal) after cannulation measured by doppler ultrasonography was significantly better in study group (33.1 ± 5 ml/min) versus downstream cannula (16.1 ± 4, p = 0.012). SpO2 measured by near infrared spectroscopy (NIRS) also demonstrated significantly better saturation in distal calf of the cannulated leg in bidirectional cannula group (67.5% ± 10% vs 52.5 ± 8, p = 0.04). The incidence of serious adverse events was seroma on femoral region (one patient), superficial wound infection (one patient), pseudo-hematoma (two patients) in bidirectional cannula group and in-hospital femoral embolectomy/artery repair (two patients), superficial wound infection (three patients), cannulation site hematoma (three patients) in conventional cannula group. CONCLUSIONS: This study demonstrates that in patients undergoing femoral arterial cannulation for CPB during cardiac surgery, the use of a novel bidirectional cannula is safe and easy to insert and provides stable distal perfusion of the cannulated limb.

2021 MiECTiS focused update on the 2016 position paper for the use of minimal invasive extracorporeal circulation in cardiac surgery.

The landmark 2016 Minimal Invasive Extracorporeal Technologies International Society (MiECTiS) position paper promoted the creation of a common language between cardiac surgeons, anesthesiologists and perfusionists which led to the development of a stable framework that paved the way for the advancement of minimal invasive perfusion and related technologies. The current expert consensus document offers an update in areas for which new evidence has emerged. In the light of published literature, modular minimal invasive extracorporeal circulation (MiECC) has been established as a safe and effective perfusion technique that increases biocompatibility and ultimately ensures perfusion safety in all adult cardiac surgical procedures, including re-operations, aortic arch and emergency surgery. Moreover, it was recognized that incorporation of MiECC strategies advances minimal invasive cardiac surgery (MICS) by combining reduced surgical trauma with minimal physiologic derangements. Minimal Invasive Extracorporeal Technologies International Society considers MiECC as a physiologically-based multidisciplinary strategy for performing cardiac surgery that is associated with significant evidence-based clinical benefit that has accrued over the years. Widespread adoption of this technology is thus strongly advocated to obtain additional healthcare benefit while advancing patient care.

Incidentally discovered cold hemagglutinins within autologous blood bag and cardioplegia line in a patient with a recent history of COVID-19 undergoing coronary artery surgery.

INTRODUCTION: Cold agglutinin disease (CAD) is a rare autoimmune disorder characterized by destruction (hemolysis) of erythrocytes. In CAD, autoantibodies that cause agglutination at temperature of optimum +3-+4 ℃ degree cause symptoms. It is known that CAD often occurs after viral infections. Also, it has been reported in case reports that COVID-19 disease can cause CAD. CASE REPORT: 46-year-old male patient with a history of diabetes mellitus and hypertension presented to outpatient clinic in our department to have CABG surgery. He recovered from COVID-19 disease 1.5 months ago. Cardiopulmonary bypass was initiated and the cross-clamp was placed and antegrade Delnido cardioplegia solution was started to be given at +4 ℃. It was observed that the cardioplegia line was agglutinated. On the other hand, it was seen that the autologous blood taken by the anesthesiologist was also agglutinated and formed air bubbles and became unusable. X-clamp was removed and the heart rhythm recovered. The patient was consulted to hematology during postoperative intensive care follow-ups. The cold agglutinin test performed at of +4 ℃ was reported as positive. In this case, we associated the CAD with covid-19 for three main reasons. First one, the patient's complaints about CAD started after COVID-19 disease. Secondly, in the national health archive, the patient's pre-COVID-19 blood tests were completely normal but it was seen that LDH increased and RBC-HCT incompatibility started after COVID-19. As the third, when we search the literature, we have seen the COVID-19 related CAD in many case reports published by hematologists. CONCLUSION: With the rare cold agglutinin disease, it seems that we will encounter it more often after the COVID-19 pandemic. Except for deep hypothermia, the most important problem is seen during cardioplegia administration. Therefore, non-blood cardioplegia can be lifesaving.

Preoperative ultrasound-guided bilateral thoracic erector spinae plane block within an enhanced recovery program is associated with decreased intraoperative lactate levels in cardiac surgery.

INTRODUCTION: In the perioperative period, regional analgesia techniques may play an increasingly important role in "Enhanced Recovery After Surgery (ERAS)" programs, as they can facilitate recovery. We hypothesized that Erector Spinae Plane (ESP) block could improve regional perfusion, thereby limiting blood lactate increase. Therefore, we aimed to evaluate the effect of ESP block on intraoperative blood lactate levels in patients scheduled for elective on-pump cardiac surgery with ERAS protocol. METHODS: A total of 68 adult patients scheduled for on-pump cardiac surgery were included. All patients were randomized to the ESP group and the non-ESP group. Blood lactate analyses were performed at intraoperative five-time points. C-Reactive protein (CRP) values were also measured. RESULTS: Blood lactate values were significantly lower in the ESP group than in the Non-ESP group, at the end of CPB [1.78 (1.23-2.78) mmol L-1 to 2.63 (1.70-3.12) mmol L-1] and during the sternal closure period [1.78 (1.27-2.42) mmol L-1 to 2.40 (2.14-2.80) mmol L-1] (p = 0.039, p = 0.009). In addition, CRP values were significantly lower in the ESP group in the postoperative period [0.048 (0.036-0.105) g L-1 to 0.090 (0.049-0.154) g L-1] (p = 0.035). CONCLUSIONS: This study showed that preoperative bilateral single-shot ESP block significantly reduces intraoperative final blood lactate and postoperative CRP values. We consider that these results are related to the attenuation of intraoperative hypoperfusion and the alleviation of surgery-related postoperative inflammation. ERAS programs aim to achieve the rapid recovery of patients, a decrease in inflammation, and high-quality analgesia with less opioid consumption. Therefore, our results also prove that it is easier to reach the primary goals of ERAS programs with the application of ESP block in cardiac surgery.

Cost-Effectiveness and Budget Impact of Comprehensive Anemia Management, The First Pillar of Patient Blood Management, on the Turkish Healthcare System.

Purpose: Patient blood management (PBM) is a patient-centered, evidence-based, multidisciplinary approach aimed at optimizing hemoglobin concentration, ensuring the continuity of hemostasis and minimizing blood loss in patients undergoing surgery. The aims of this study were: (1) to explore the cost-effectiveness of comprehensive anemia management, the first pillar of PBM, in non-cardiac and cardiac surgery from the Turkish Social Security Institution's (SSI's) perspective; and (2) to explore the potential budget impact of PBM for coronary artery bypass grafting (CABG) and hip and knee arthroplasty to the SSI. Methods: Cost-effectiveness and budget impact models were developed based on the avoided postoperative adverse events following implementation of the first pillar of PBM for non-cardiac and cardiac surgical patients. The probabilities of adverse events (sepsis with and without pneumonia, renal failure, myocardial infarction and stroke) were taken from a recent meta-analysis and the costs of treating these adverse events to the SSI were estimated through expert views and the use of SSI guidelines. Results: The PBM arm dominated the control arm for both non-cardiac and cardiac surgeries in terms of cost-effectiveness in the simulated cohort of patients and was associated with improved outcomes and lower costs (1768 and 1244 avoided adverse events, and incremental cost reductions for non-cardiac and cardiac surgery of 7504 Turkish lira [TRY] and 6102 TRY, respectively). The budget impact analysis showed that PBM is a potential cost-saving option for the SSI, with savings of up to 196,937,705 TRY (€12,841,697) for hip and knee arthroplasty and 24,642,504 TRY (€1,606,861) for CABG surgery. Conclusion: PBM is a cost-effective option with a potential of cost-saving for cardiac and non-cardiac surgery in Turkey.

Molecular imprinted nanoparticle assisted surface plasmon resonance biosensors for detection of thrombin.

In this study, we designed a surface plasmon resonance (SPR) biosensors based on molecular imprinting to detect low amounts of thrombin directly in a short time, both in thrombin aqueous solutions and in patient serum samples. For this purpose, the thrombin imprinted and non-imprinted SPR biosensors were prepared by integrating the synthesized thrombin imprinted and non-imprinted nanoparticles on the allyl mercaptan modified gold SPR chip surface. The kinetic studies were performed with a thrombin concentration range from 0.1 to 400 pM with a detection limit of approximately 0.017 pM in thrombin aqueous solution. Morever, the limit of detection was found to be 0.033 pM in patient serum samples. When the selectivity of the thrombin imprinted SPR biosensors was compared with the competing molecules as bovine serum albumin and lysozyme, it was showed that the thrombin was 4.58 times and 3.99 times more selective than the bovine serum albumin and lysozyme molecules, respectively. The shelf life and reusability of the designed SPR biosensor showed that there was a 12.93% decrease in the performance according to the kinetic analyzes that performed after 8 months. In addition, thrombin detection from the patient serum samples was performed using both SPR biosensor and the enzyme-linked immunosorbent assay methods, and were calculated recoveries.

Pharmacomechanical catheter-directed thrombolysis for acute iliofemoral deep vein thrombosis in a large study population.

BACKGROUND: We have analyzed our single-center immediate and follow-up results in the management of acute iliofemoral deep vein thrombosis (IFDVT) using pharmacomechanical catheter-directed thrombolysis (PMCDT) to determine the safety, accuracy, and effects on quality of life and whether this treatment strategy prevents post-thrombotic syndrome (PTS). METHODS: The cases of 230 patients who had undergone PMCDT to treat IFDVT from January 2017 to December 2018 were retrospectively reviewed. The preoperative, operative, and postoperative variables, Marder scores, outcomes, and follow-up assessments with the Villalta score and venous clinical severity score were investigated. RESULTS: Anatomic success was achieved for 95.2% of the 230 patients. The mean Marder score had decreased from 12.65 ± 2.1 to 2.4 ± 1.3 postoperatively (P < .01). Early recurrent thrombosis had developed in 13 patients (5.65%). The primary patency at the 1-, 6-, and 12-month follow-up visits was 94.0%, 87.2%, and 81.7%, respectively. From 1 to 6 months, the Villalta score had decreased from 8.32 ± 4.14 to 3.43 ± 0.61 and the venous clinical severity score had decreased from 4.0 ± 1.8 to 1.82 ± 0.36 (P < .05). No statistically significant difference was found in the PTS severity scores at 12 months of follow-up compared with at 6 months. The mean change in the venous disease-specific quality of life from baseline to 12 months was 29.41 ± 1.99 (P = .029). The total recurrence rate was 19.63% at 1 year. CONCLUSIONS: For a select group of patients with acute IFDVT, the use of PMCDT and postoperative anticoagulation therapy offered significant reductions in clot burden, leg pain, and swelling, achieving a significant reduction in PTS severity scores at 6 months.

Clinical outcomes of single-dose cardioplegia in high-risk coronary bypass.

BACKGROUND: Despite the increasing popularity of single-dose cardioplegia techniques in coronary artery bypass grafting, the time window for successful reperfusion remains unclear. This study aimed to compare different cardioplegic techniques based on early and 30-day clinical outcomes via thorough monitoring. METHODS: This prospective cohort study included high-risk patients undergoing coronary artery bypass grafting and receiving 3 different types of cardioplegia between January 2017 and June 2019. Group 1 (n = 101) had a single dose of del Nido cardioplegia, group 2 (n = 92) had a single dose of histidine-tryptophane-ketoglutarate, and group 3 (n = 119) had cold blood cardioplegia. Patients were examined perioperatively by memory loop recording and auto-triggered memory loop recording for 30 days, with documentation of predefined events. RESULTS: Interleukin-6 and cardiac troponin levels in group 1 were significantly higher than those in groups 2 and 3. The incidence of predefined events as markers of inadequate myocardial protection was significantly higher group 1, with more frequent atrial fibrillation attacks and more hospital readmissions. The readmission rate was 17.6% in group 1, 9% in group 2, and 8% in group 3. CONCLUSIONS: Our data demonstrate the long-term efficacy of cardioplegic techniques, which may become more crucial in high-risk patients who genuinely have a chance to benefit from adjunct myocardial protection. Patients given del Nido cardioplegia had a significantly more prominent inflammatory response and higher troponin levels after cardiopulmonary bypass. This group had issues in the longer term with significantly more cardiac events and a higher rehospitalization rate.

Comparative Effects of Single-Dose Cardioplegic Solutions Especially in Repeated Doses During Minimally Invasive Aortic Valve Surgery.

OBJECTIVE: This study aims to compare del Nido cardioplegia (DNC) and histidine-tryptophan-ketoglutarate (HTK) cardioplegic solutions in minimally invasive aortic valve replacement (mini-AVR) surgery to discuss the safety level of myocardial protection and rationale for redosing intervals. METHODS: During the period from January 2017 to June 2019, 200 patients undergoing mini-AVR (solely or with concomitant procedures) were prospectively randomized to DNC (n = 100) andHTK (n = 100), both up to 90 minutes ischemic time. Patients with ischemic time over 90 minutes, needing a redosing, were further analyzed in 2 subgroups with DNC-R (n = 30) and HTK-R (n = 36). Sensitive biomarkers, in addition to routine biochemistry, were also documented at baseline (T1), after cessation of cardiopulmonary bypass (T2), and on the first postoperative day (T3). Transmural myocardial biopsies were sampled for staining. RESULTS: No statistical differences could be demonstrated in DNC and HTK groups with up to 90 minutes cross-clamp times in routine biochemical measurements and basic perioperative clinical outcomes. DNC-R showed significantly more arrhythmia/AV block incidence resulting in more extended intensive care unit (ICU) stay. Interleukin-6 and syndecan-1 in DNC and DNC-R groups were substantially higher at T2. Aquaporin-4 levels were significantly lower in the DNC-R group, demonstrating unsatisfactory response of cells to an excessive volume at T2. CONCLUSIONS: DNC and HTK provided acceptable myocardial protection as single-dose applications. DNC-R had significantly unbalanced levels of biomarkers, and more arrhythmia/AV block incidence resulting in more extended ICU stay. For patients who may need redosing HTK may be preferable to DNC.

Predictiveness of different preoperative risk assessments for postoperative bleeding after coronary artery bypass grafting surgery.

AIM: Postoperative bleeding is a significant cause of morbidity and mortality in patients undergoing cardiac surgery. Studies have been conducted, and guidelines have been published regarding patient blood management and aiming to prevent blood loss in the perioperative period. Various bleeding risk assessments were developed for preoperative period. We aimed to examine the correlations of scoring systems in the literature with the amount of postoperative bleeding in patients undergoing first time coronary artery bypass graft surgery, and to show the most suitable preoperative bleeding risk assessment for coronary artery bypass graft patients. METHODS: The study included 550 consecutive patients who underwent coronary artery bypass graft operation. The inclusion criteria were considered as patients to be older than 18 years old and to undergo elective or emergent myocardial revascularization using cardiopulmonary bypass. All variables required for scoring systems were recorded. The initial results of the study were determined as the amount of chest tube drainage, the use of blood products, the change in hematocrit level, reoperation due to bleeding, duration of ventilation, duration of intensive care unit stay, and hospital stay. Mortality which occurred during first 30 days after operation was considered as operative mortality. Operative mortality was accepted as the primary endpoint. Secondary endpoints were massive bleeding and high amount of transfusion. RESULTS: Data were obtained from a series of 550 consecutive patients treated with isolated coronary artery bypass graft. It was seen that PAPWORTH and WILL-BLEED risk assessments responded better for E-CABG grade 2 and 3 bleeding compared to other risk assessments. TRACK, TRUST, and ACTA-PORT scales were found to have low ability to distinguish patients with E-CABG bleeding grade 2 and 3. CONCLUSION: Predicting postoperative bleeding and transfusion rates with preoperative risk scores in patients undergoing coronary artery bypass graft surgery will provide valuable information to physicians for establishing a proper patient blood management protocol and this will decrease excessive transfusions, unnecessary reoperations as well as improve postoperative outcomes.