Amino acids to prevent cardiac surgery-associated acute kidney injury: a randomized controlled trial.

BACKGROUND: This study aimed to examine the preventive effect of amino acids on postoperative acute kidney injury (AKI). METHODS: This was single-center, patient- and assessor-blinded, randomized controlled trial. Patients who underwent aortic surgery with cardiopulmonary bypass were included. The intervention group received 60 g/day of amino acids for up to 3 days. The control group received standard care. The primary outcome was the incidence of AKI. We assessed the effect of amino acids on AKI using a Cox proportional hazards regression model. RESULTS: Sixty-six patients were randomly assigned to the control or intervention group. One patient in the control group withdrew consent after randomization. The incidence of AKI was 10 patients (30.3%) in the intervention group versus 18 patients (56.2%) in the control group (adjusted hazard ratio, 0.44; 95% confidence interval, 0.20-0.95; P = 0.04). CONCLUSIONS: This trial demonstrated a significant reduction in AKI incidence with amino acid supplementation. TRIAL REGISTRATION: jRCT, jRCTs051210154. Registered 31 December 2021, https://jrct.niph.go.jp/re/reports/detail/69916.

Association between intraoperative blood salvage and coagulation disorder after cardiopulmonary bypass.

BACKGROUND: This study investigated whether intraoperative blood salvage was associated with coagulation disorder diagnosed by conventional coagulation tests and thromboelastography (TEG) after cardiopulmonary bypass (CPB). STUDY DESIGN AND METHODS: This was a prospective, observational study. Ninety-two patients who underwent cardiovascular surgery with CPB were enrolled. We evaluated coagulation function in patients with or without cell salvage blood transfusion at the following time points: before CPB, just after protamine administration, and 1 h after protamine administration. We evaluated platelet count, fibrinogen concentration, and TEG parameters. Patients were considered to have coagulation disorder if one or more of the following criteria were present: (1) residual heparin, (2) low platelet count, (3) low fibrinogen level, (4) low clotting factor level, and (5) hyperfibrinolysis. RESULTS: Fifty-three of 92 patients (57.6%) received intraoperative cell salvage. Coagulation disorder was observed in 56 of 92 patients (60.9%) after CPB. There was no significant difference between patients with or without intraoperative blood salvage in terms of the incidence of coagulation disorder (p = 0.542) or the total volume of blood from the drain after CPB (p = 0.437). Intraoperative blood salvage was not associated with coagulation disorder diagnosed by either TEG or conventional coagulation tests (odds ratio 1.329, 95% confidence interval: 0.549-3.213, p = 0.547). There were no significant interactions between patients with or without intraoperative blood salvage regarding coagulation parameters derived from TEG. CONCLUSIONS: The incidence of coagulation disorder and the total blood volume from the drain after CPB did not differ significantly between patients with or without intraoperative blood salvage.

Effect of cerebrospinal fluid drainage pressure in descending and thoracoabdominal aortic repair: a prospective multicenter observational study.

PURPOSE: Cerebrospinal fluid drainage (CSFD) is recommended during open or endovascular thoracic aortic repair. However, the incidence of CSFD complications is still high. Recently, CSF pressure has been kept high to avoid complications, but the efficacy of CSFD at higher pressures has not been confirmed. We hypothesize that CSFD at higher pressures is effective for preventing motor deficits. METHODS: This prospective observational study included 14 hospitals that are members of the Japanese Society of Cardiovascular Anesthesiologists. Patients who underwent thoracic and thoracoabdominal aortic repair were divided into four groups: Group 1, CSF pressure around 10 mmHg; Group 2, CSF pressure around 15 mmHg; Group 3, CSFD initiated when motor evoked potential amplitudes decreased; and Group 4, no CSFD. We assessed the association between the CSFD group and motor deficits using mixed-effects logistic regression with a random intercept for the institution. RESULTS: Of 1072 patients in the study, 84 patients (open surgery, 51; thoracic endovascular aortic repair, 33) had motor deficits at discharge. Groups 1 and 2 were not associated with motor deficits (Group 1, odds ratio (OR): 1.53, 95% confidence interval (95% CI): 0.71-3.29, p = 0.276; Group 2, OR: 1.73, 95% CI: 0.62-4.82) when compared with Group 4. Group 3 was significantly more prone to motor deficits than Group 4 (OR: 2.56, 95% CI: 1.27-5.17, p = 0.009). CONCLUSION: CSFD is not associated with motor deficits in thoracic and thoracoabdominal aortic repair with CSF pressure around 10 or 15 mmHg.

Prevalence and Severity of Aortic Regurgitation Due to a Percutaneous Left Ventricular Assist Device (Impella 5.0): A Retrospective Observational Study.

OBJECTIVES: Placement of the Impella 5.0 percutaneous left ventricular assist device may cause aortic regurgitation (AR) due to malcoaptation of the aortic leaflets. The authors investigated the prevalence and severity of AR during Impella 5.0 support. DESIGN: Retrospective observational study. SETTING: An academic hospital. PARTICIPANTS: A total of forty-two consecutive patients who underwent Impella 5.0 implantation from April 2018 to March 2022. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: To investigate AR prevalence, the authors calculated the AR volume by subtracting left ventricular inflow from left-sided systemic flow, the latter of which consisted of flow through the Impella 5.0 cannula and across the aortic valve. Because it is challenging to estimate flow across the aortic valve as distinct from that through Impella 5.0, the authors analyzed 19 of 42 patients whose aortic valves were closed (ie, those with no spontaneous cardiac output). AR due to Impella 5.0 was considered present if the AR fraction was ≥7%. The median AR volume was 0.6 L/min (interquartile range: 0.4-1.5 L/min), which was 13.5% (interquartile range: 11.0 to 30.6%) of the median Impella 5.0 flow. Seventeen of the 19 patients (89.5%) were diagnosed with AR during Impella 5.0 support, and the severity of AR was mild in 11 patients (57.9%) and moderate in 6 (31.6%). CONCLUSIONS: The authors revealed a high prevalence of AR during Impella 5.0 support in patients with no spontaneous cardiac output. Moreover, 31.6% of patients had moderate AR.

Quantitative regional cerebral blood flow measurement using near-infrared spectroscopy and indocyanine green in patients undergoing superficial temporal to middle cerebral artery bypass for moyamoya disease: a novel method using a frequency filter.

Measuring regional cerebral blood flow (rCBF) after revascularization for moyamoya disease, as a type of ischemic cerebrovascular disease, is crucial. This study aims to validate our novel technology that combines near-infrared spectroscopy (NIRS) with a frequency filter to extract the arterial component. We measured rCBF before and after revascularization for moyamoya disease and at the end of the surgery using NIRO-200NX (Hamamatsu Photonics, Japan) and indocyanine green (ICG). rCBF was calculated using Fick's principle, change in arterial ICG concentrations, and maximum arterial ICG concentration. rCBF measured with NIRS (rCBF_N) was compared with pre- and postoperative rCBF measured with SPECT (rCBF_S). Thirty-four procedures were analyzed. rCBF_N increased from baseline to end of the surgery (mean difference (MD), 2.99 ml/min/100 g; 95% confidence interval (CI), 0.40-5.57 ml/min/100 g on the diseased side; MD, 4.94 ml/min/100 g; 95% CI, 2.35-7.52 ml/min/100 g on the non-diseased side). Similar trends were observed for rCBF_S (MD, 3.98 ml/min/100 g; 95% CI, 2.30-5.67 ml/min/100 g on the diseased side; MD, 2.77 ml/min/100 g; 95% CI, 1.09-4.45 ml/min/100 g on the non-diseased side). Intraclass correlations 3 (ICC3s) between rCBF_N and rCBF_S were weak on the diseased side (ICC3, 0.25; 95% CI, -0.03-0.5; p = 0.07) and the non-diseased side (ICC3, 0.24; 95% CI, -0.05-0.5; p = 0.08). rCBF measurements based on this novel method were weakly correlated with rCBF measurements with SPECT.

Monitoring of Post-Brain Injuries By Measuring Plasma Levels of Neuron-Derived Extracellular Vesicles.

Background: Extracellular vesicles (EV) released from neurons into the blood can reflect the state of nervous tissue. Measurement of neuron derived EV (NDE) may serve as an indicator of brain injury. Methods: A sandwich immunoassay was established to measure plasma NDE using anti-neuron CD171 and anti-EV CD9 ([CD171 + CD9+]). Plasma samples were obtained from commercial sources, cross-country (n = 9), football (n = 22), soccer (n = 19), and rugby (n = 18) athletes over time. Plasma was also collected from patients undergoing total aortic arch replacement (TAR) with selective cerebral perfusion during cardiopulmonary bypass before and after surgery (n = 36). Results: The specificity, linearity, and reproducibility of NDE assay (measurement of [CD171 + CD9+]) were confirmed. By scanning electron microscopy and nanoparticle tracking, spherical vesicles ranging in size from 150 to 300 nm were confirmed. Plasma levels of NDE were widely spread over 2 to 3 logs in different individuals with a significant age-dependent decrease. However, NDE were very stable in each individual within a ± 50% change over time (cross-country, football, soccer), whereas rugby players were more variable over 4 years. In patients undergoing TAR, NDE increased rapidly in days post-surgery and were significantly (P = .0004) higher in those developing postoperative delirium (POD) (n = 13) than non-delirium patients (n = 23). Conclusions: The blood test to determine plasma levels of NDE was established by a sandwich immunoassay using 2 antibodies against neuron (CD171) and exosomes (CD9). NDE levels varied widely in different individuals and decreased with age, indicating that NDE levels should be considered as a normalizer of NDE biomarker studies. However, NDE levels were stable over time in each individual, and increased rapidly after TAR with greater increases associated with patients developing POD. This assay may serve as a surrogate for evaluating and monitoring brain injuries.

Novel brain computed tomography perfusion for cerebral malperfusion secondary to acute type A aortic dissection.

OBJECTIVES: The management of acute type A aortic dissection with malperfusion syndrome remains challenging. To evaluate preoperative condition, symptoms might be subjective and objective evaluation of cerebral artery has not yet been established. For quantitative evaluation, this study focused on brain computed tomography perfusion (CTP), which has been recommended by several guidelines of acute ischaemic stroke. METHODS: In the last 2 years, 147 patients hospitalized due to acute type A aortic dissection were retrospectively reviewed. Among the 23 (16%) patients with cerebral malperfusion, 14 who underwent brain CTP (6 preoperative and 8 postoperative) were enrolled. CTP parameters, including regional blood flow and time to maximum, were automatically computed using RApid processing of Perfusion and Diffusion software. The median duration from the onset to hospital arrival was 129 (31-659) min. RESULTS: Among the 6 patients who underwent preoperative CTP, 4 with salvageable ischaemic lesion (penumbra: 8-735 ml) without massive irreversible ischaemic lesion (ischaemic core: 0-31 ml) achieved acceptable neurological outcomes after emergency aortic replacement regardless of preoperative neurological severity. In contrast, 2 patients with an ischaemic core of >50 ml (73, 51 ml) fell into a vegetative state or neurological death due to intracranial haemorrhage. CTP parameters guided postoperative blood pressure augmentation without additional supra-aortic vessel intervention in the 8 patients who underwent postoperative CTP, among whom 6 achieved normal neurological function regardless of common carotid true lumen stenosis severity. CONCLUSIONS: CTP was able to detect irreversible ischaemic core, guide critical decisions in preoperative patients and aid in determining the blood pressure augmentation for postoperative management focusing on residual brain ischaemia.

Cardiac surgery improves the postoperative frailty score of frail patients.

BACKGROUND: Cardiac surgery in frail patients has been reported to be associated with increased mortality and morbidity but may improve functional status of frail patients. Few studies have investigated the impact of cardiac surgery on the trajectory of postoperative frailty. We hypothesized that cardiac surgery in frail patients would improve frailty postoperatively. METHOD: This study included 71 patients over 65 years old who were scheduled for cardiac surgery via sternotomy or thoracotomy. Frailty was prospectively evaluated using the Kihon Checklist (KCL) at 1 and 3 months postoperatively. Patients were divided into three groups based on the preoperative KCL score: nonfrail, prefrail, and frail. The interaction between the degree of preoperative frailty and the trajectory of postoperative KCL scores was assessed. RESULTS: The KCL score changed significantly over time (P < 0.001), and the KCL score trajectory differed significantly according to the degree of preoperative frailty (P for interaction = 0.003). In the frail group, the KCL score was significantly lower 3 months postoperatively than preoperatively (median 8, interquartile range [5, 9] versus median 9, interquartile range (9, 13), P = 0.029). CONCLUSION: The trajectory of postoperative KCL scores differed significantly depending on the degree of preoperative frailty. At 3 months after cardiac surgery, the KCL score of frail patients was significantly improved, while that in nonfrail patients was significantly deteriorated.

Aortic valve insufficiency after Impella device insertion that required aortic valve replacement after Heart Mate III left ventricular assist device implantation: a case report.

The Impella (Abiomed, Danvers, MA, USA) is a minimally invasive axial-flow catheter used in severe heart failure. We describe a case in which aortic insufficiency occurred after Impella insertion, required extra surgical intervention twice. A 33-year-old man with familial dilated cardiomyopathy was admitted to our hospital due to acute decompensation of heart failure. Despite intensive medical treatment, his hemodynamic status did not improve. Firstly, Impella was emergently implanted, and HeartMate III (Abbott, Plymouth, MN, USA) implantation was performed 2 weeks after. In the HeartMate III implantation, new aortic insufficiency had revealed and central aortic valve closure was performed concomitantly. However, on postoperative Day1, the coaptation stitch had untied, causing severe aortic insufficiency which led to another emergent operation of aortic valve replacement. We suggest that indications for Impella implantation need to be carefully discussed beforehand, especially with patients who may undergo implantation of left ventricular assist device.

Correlation Between Intraventricular Pressure Difference and Indexed Flow of a Left Ventricular Assist Device.

OBJECTIVES: There is no definitive parameter for left ventricular (LV) preload in patients with a continuous-flow left ventricular assist device (LVAD). The intraventricular pressure difference (IVPD) is the maximum pressure difference between the mitral valve and LV apex during diastole; and, in past studies, the IVPD was influenced by volume loading. The authors hypothesized that IVPD in LVAD patients correlates with indexed LVAD flow and that IVPD can serve as a novel parameter of LV preload in this population. DESIGN: A single-center, retrospective, observational study. SETTING: A tertiary-care hospital from August 2019 to July 2020. PARTICIPANTS: Sixteen ramp tests for adjustment of LVAD pump speed in 14 adult patients undergoing continuous-flow LVAD implantation. INTERVENTIONS: Measurement of IVPD during ramp tests. MEASUREMENTS AND MAIN RESULTS: LVAD flow and IVPD were measured at each LVAD pump speed during the ramp test for the adjustment of LVAD pump speed after patients came off cardiopulmonary bypass during LVAD implantation. A straight, longitudinal view of the left atrium and left ventricle was obtained, and the pressure difference between the mitral valve and LV apex during diastole was measured by transesophageal echocardiography. The maximum pressure difference during diastole was recorded as IVPD. The relationship between indexed LVAD flow (LVAD flow/body surface area) and IVPD was assessed by a multivariate nonlinear regression analysis with the Huber-White sandwich estimator. IVPD correlated with indexed LVAD flow (p < 0.001). CONCLUSIONS: IVPD is a useful indicator of LV preload during LVAD implantation.

Association Between Sternotomy Versus Thoracotomy and the Prevalence and Severity of Chronic Postsurgical Pain After Mitral Valve Repair: An Observational Cohort Study.

OBJECTIVE: Investigate differences in the prevalence and severity of chronic postsurgical pain (CPSP) after cardiac surgery via thoracotomy versus sternotomy are not well-understood. DESIGN: An observational cohort study. SETTING: A tertiary care hospital. PARTICIPANTS: Four hundred twenty-eight patients (sternotomy: 192 patients, thoracotomy: 236 patients) who underwent mitral valve repair. INTERVENTIONS: A questionnaire about the severity of surgical wound pain evaluated with a numerical rating scale (NRS) was sent. NRS responses for current pain, peak pain in the last four weeks, and average pain in the last four weeks were evaluated. MEASUREMENTS AND MAIN RESULTS: The main outcomes were the severity of CPSP evaluated using NRS and the prevalence of CPSP. CPSP was defined as pain >0 that developed after a surgical procedure. During the median follow-up of 29 months, 79 patients complained of CPSP. (sternotomy: 15 patients, thoracotomy: 64 patients). Multivariate ordinal logistic regression showed that NRS responses for current pain (adjusted odds ratio [aOR], 3.17; 95% confidence interval [CI] 1.64-6.12; p = 0.001), peak pain in the last four weeks (aOR, 2.00; 95% CI 1.11-3.61; p = 0.021), and average pain in the last four weeks (aOR, 2.21; 95% CI 1.31-3.72; p = 0.003) were significantly higher in patients who underwent thoracotomy. Multivariate logistic regression showed that thoracotomy was an independent predictor of CPSP (aOR, 3.63; 95% CI 1.67-7.88; p = 0.001). CONCLUSIONS: The prevalence and severity of CPSP were higher among patients who underwent mitral valve repair via thoracotomy than sternotomy.

Cerebrospinal fluid drainage to prevent postoperative spinal cord injury in thoracic aortic repair.

BACKGROUND: Cerebrospinal fluid drainage (CSFD) is recommended as a spinal cord protective strategy in open and endovascular thoracic aortic repair. Although small studies support the use of CSFD, systematic reviews have not suggested definite conclusion and a large-scale study is needed. Therefore, we reviewed medical records of patients who had undergone descending and thoracoabdominal aortic repair (both open and endovascular repair) at multiple institutions to assess the association between CSFD and postoperative motor deficits. METHODS: Patients included in this study underwent descending or thoracoabdominal aortic repair between 2000 and 2013 at 12 hospitals belonging to the Japanese Association of Spinal Cord Protection in Aortic Surgery. We conducted a retrospective study to investigate whether motor-evoked potential monitoring is effective in reducing motor deficits in thoracic aortic aneurysm repair. We use the same dataset to examine whether CSFD reduces motor deficits after propensity score matching. RESULTS: We reviewed data from 1214 patients [open surgery, 601 (49.5%); endovascular repair, 613 (50.5%)]. CSFD was performed in 417 patients and not performed in the remaining 797 patients. Postoperative motor deficits were observed in 75 (6.2%) patients at discharge. After propensity score matching (n = 700), mixed-effects logistic regression performed revealed that CSFD is associated with postoperative motor deficits at discharge [adjusted odds ratio (OR), 3.87; 95% confidence interval (CI), 2.30-6.51]. CONCLUSION: CSFD may not be effective for postoperative motor deficits at discharge.

Anatomical and physiological variables influencing measurement of regional cerebral oxygen saturation by near infrared spectroscopy using the Sensmart Model X-100TM.

The Sensmart Model X-100 (Nonin Medical Inc, Plymouth, MN, USA) is a relatively new device that possesses two sets of emitters and detectors and uses near infrared spectroscopy (NIRS) to measure regional cerebral oxygen saturation (rSO2). The value of rSO2 obtained by other NIRS devices is affected by physiological and anatomical variables such as hemoglobin concentration, area of cerebrospinal fluid (CSF) layer and skull thickness. The effects of these variables have not yet been determined in measurement of rSO2 by Sensmart Model X-100. We examined the effects of area of CSF, hemoglobin concentration, and skull thickness on the values of rSO2 measured by Sensmart Model X-100 and tissue oxygen index (TOI) measured by NIRO-200NX (Hamamatsu Photonix, Hamamatsu, Japan). Forty neurosurgical, cardiac and vascular surgical patients who underwent preoperative computed tomographic (CT) scan of the brain were enrolled in this study. Regional cerebral oxygen saturation (rSO2) at the forehead was measured sequentially by NIRO-200NX and by Sensmart Model X-100. Simultaneously, mean arterial pressure, hemoglobin concentration, and partial pressure of carbon dioxide in arterial blood (PaCO2) were measured. To evaluate the effects of anatomical factors on rSO2, we measured skull thickness and area of CSF layer using CT images of the brain. Multiple regression analysis was used to examine the relationships between the rSO2 values and anatomical and physiological factors. The area of the CSF layer and hemoglobin concentration had significant associations with rSO2 measured by the Sensmart Model X-100, whereas none of the studied variables was significantly associated with TOI. The measurement of rSO2 by Sensmart Model X-100 is not affected by the skull thickness of patients. Area of the CSF layer and hemoglobin concentration may be the main biases in measurement of rSO2 by Sensmart Model X-100.

Impact of Balloon Postdilation on Six-Year Mortality After Transcatheter Aortic Valve Replacement.

OBJECTIVES: Balloon postdilation (BPD) is one strategy for decreasing paravalvular leakage, but its effect on long-term mortality remains unclear. The authors sought to clarify whether BPD influences long-term mortality of patients with transcatheter aortic valve replacement (TAVR). DESIGN: Single-center retrospective study. SETTING: National heart center; single institution. PARTICIPANTS: Participants were patients who underwent TAVR in the authors' hospital from January 2014 to December 2016. A balloon-expandable Sapien XT or Sapien3, or self-expandable CoreValve or Evolute R, was implanted according to the decision of the surgeon considering degree of calcification of the aortic valve. INTERVENTIONS: No interventions. MEASUREMENTS AND MAIN RESULTS: Multivariate Cox regression analysis and inverse probability weighted estimation were performed using a propensity score to examine whether BPD influenced six-year mortality. Ultimately, 180 patients were analyzed. During the follow-up period, with a median of 1104 (interquartile range: 730-1463) days, 41 patients died and cumulative incidence of mortality at six years was 22.8%. Society of Thoracic Surgeons score (odds ratio [OR]: 2.257, 95% CI: 1.213-4.197, p = 0.010)], BPD (OR: 0.306, 95% CI: 0.098-0.953, p = 0.041), and paravalvular regurgitation of at least moderate-to-mild severity after deploying (OR: 5.407, 95% CI: 1.626-17.978, p = 0.006) were significant factors of mortality. CONCLUSIONS: BPD is associated with reduced six-year mortality.

Anesthesia for Cesarean Section and Postpartum Cardiovascular Events in Congenital Heart Disease: A Retrospective Cohort Study.

OBJECTIVE: To clarify the association between anesthetic technique and maternal and neonatal outcomes in parturients with congenital heart disease (CHD). DESIGN: Retrospective, observational cohort study. SETTING: An academic hospital. PARTICIPANTS: A total of 263 consecutive parturients with CHD who underwent cesarean section from 1994 to 2019. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: The authors compared postpartum cardiovascular events (composite of heart failure, pulmonary hypertension, arrhythmia, and thromboembolic complications) and neonatal outcomes (intubation and Apgar score <7 at one or five minutes) by anesthetic technique. Among 263 cesarean sections, general anesthesia was performed in 47 (17.9%) parturients and neuraxial anesthesia in 214 (81.3%) parturients. Cardiovascular events were more common in the general anesthesia group (n = 7; 14.9%) than in the neuraxial anesthesia group (n = 17; 7.9%). Generalized linear mixed models assuming a binomial distribution (ie, mixed-effects logistic regression), with a random intercept for each modified World Health Organization classification for maternal cardiovascular risk, revealed that general anesthesia was not significantly associated with cardiovascular events (odds ratio [OR], 1.00; 95% confidence interval [CI], 0.30-3.29). In addition, general anesthesia was associated with composite neonatal outcomes (Apgar score <7 at one or five minutes or need for neonatal intubation; OR, 13.3; 95% CI, 5.52-32.0). CONCLUSION: Anesthetic technique is not significantly associated with postpartum composite cardiovascular events. General anesthesia is significantly associated with increased need for neonatal intubation and lower Apgar scores.

U-Shaped Association Between Intraoperative Net Fluid Balance and Risk of Postoperative Recurrent Atrial Tachyarrhythmia Among Patients Undergoing the Cryo-Maze Procedure: An Observational Study.

OBJECTIVE: The ability of perioperative fluid management to prevent postoperative recurrence of atrial tachyarrhythmia remains controversial. The aim of the present study was to assess if intraoperative net fluid balance was associated with atrial tachyarrhythmia recurrence after the Cryo-Maze procedure. DESIGN: An observational cohort study. SETTING: A tertiary care hospital from April 2007 to May 2019. PARTICIPANTS: Four hundred forty-four patients undergoing the Cryo-Maze procedure in conjunction with other cardiac surgeries. INTERVENTIONS: The Cryo-Maze procedure in conjunction with other cardiac surgeries. MEASUREMENTS AND MAIN RESULTS: The main outcome was early atrial tachyarrhythmia recurrence, consisting of atrial fibrillation, atrial flutter, or atrial tachycardia, within the first three months after surgery. Complete follow-up was achieved in 443 patients (99.8%), of them 127 (28.6%) developed early atrial tachyarrhythmia recurrence. The median intraoperative net fluid balance was 1,627 mL (interquartile range, -215 to 3,557 mL). Multivariate logistic regression showed that intraoperative net fluid balance (p = 0.001), preoperative AF duration (adjusted odds ratio, 1.40; 95% CI, 1.17-1.68; p < 0.001) and left atrial volume index (aOR, 1.61; 95% CI, 1.06-2.45; p = 0.025) were independent predictors of early atrial tachyarrhythmia recurrence. The adjusted log odds were lowest (-1.52) when net fluid balance was 1,557 mL. CONCLUSIONS: There is a significant U-shaped association between intraoperative net fluid balance and early atrial tachyarrhythmia recurrence among patients undergoing the Cryo-Maze procedure.

Association between postoperative changes in the gut microbiota and pseudopsia after cardiac surgery: prospective observational study.

BACKGROUND: Delirium after cardiac surgery affects mortality, but the mechanism remains unclear. Previous studies have reported gut microbiota are associated with brain activity. Systemic inflammation and antibiotics can damage the gut microbiota after cardiac surgery. We aimed to investigate changes in the gut microbiota and the association between the gut microbiota and delirium after cardiac surgery. METHODS: Twenty-one patients who underwent cardiac surgery were enrolled. Microbiota counts and fecal organic acid concentrations were measured in fecal samples harvested before surgery, just after surgery, and before discharge. To quantify the microbiota, we extracted total RNA fractions and examined gut microbiota composition using 16S and 23S rRNA-targeted quantitative-reverse Transcription-PCR. Postoperative delirium, insomnia, and pseudopsia were assessed for 1 week. Postoperative total bacterial counts changed significantly from 10.2 ± 0.2 log10 cells/g of feces to 9.8 ± 0.5 in the first postoperative samples (p = 0.003) and 10.0 ± 0.4 in the samples before discharge (p = 0.039). Fecal pH was 6.9 ± 0.6 before surgery and 7.4 ± 0.7 in the first postoperative samples (p = 0.001). Postoperative Staphylococcus and Pseudomonas counts were significantly higher in patients with postoperative pseudopsia than in patients without pseudopsia (3.2 ± 1.3 vs. 5.4 ± 0.9; p = 0.012 and 1.7 ± 0.8 vs. 4.6 ± 2.7; p = 0.001). CONCLUSIONS: Total bacterial counts were significantly lower after surgery and until discharge. Fecal pH was significantly higher than preoperative levels. Staphylococcus and Pseudomonas counts were significantly higher in patients with postoperative pseudopsia.

Transfusion characteristics and hemostatic conditions in octogenarians undergoing emergency surgery for acute aortic dissection: a retrospective study.

BACKGROUND: The number of elderly patients undergoing elective as well as emergent cardiac surgery is increasing. Octogenarian and older patients undergoing surgery for acute type A aortic dissection (AAD) have a significantly higher risk of postoperative mortality than younger patients. Hemostasis is difficult in octogenarians with AAD. However, few studies have investigated perioperative blood transfusion volumes and hemostatic conditions in patients undergoing AAD surgery. We retrospectively investigated whether these factors differed between octogenarians and younger patients with AAD. METHODS: The records of 207 patients who underwent emergency surgery for AAD were reviewed between 2008 and 2014. We compared the total volumes of transfused blood components (red blood cell concentrate, fresh frozen plasma, platelets concentrate, and cryoprecipitate), perioperative blood coagulation test results (prothrombin time-international normalized ratio, activated partial thrombin time, and activated coagulation time), and intensive care unit and hospital stay durations between octogenarians (n = 33) and patients < 80 years old (n = 170). RESULTS: A significantly greater volume of red blood cell concentrates was transfused in octogenarians than in patients < 80 years old. Isolated prolonged activated partial thromboplastin time was observed in octogenarian patients. Duration of hospital stays was significantly longer in octogenarians than in patients < 80 years old. CONCLUSIONS: Octogenarians required more red blood cells during surgery for AAD and exhibited isolated APTT prolongation.

Transesophageal echocardiography in robot-assisted mitral valve repair for Barlow's disease: usefulness for predicting artificial ring size and artificial chordae length using the loop technique.

BACKGROUND: There is no fully recommended methodology for surgery for Barlow's disease. Various methods have been proposed. The aim of this study was to investigate the effectiveness of transesophageal echocardiography (TEE) measurements for selecting the optimal annuloplasty ring size and determining the length of artificial chordae in patients with Barlow's disease who underwent robot-assisted mitral valvuloplasty (R-MVP). METHODS: Ten patients were included. Before R-MVP, the anesthesiologist used TEE to predict the optimal annuloplasty ring size and artificial chordae lengths that would reduce mitral regurgitation. The anesthesiolosist's predict ring size was not presented to the surgeon intraoperatively. RESULTS: In 70% (7/10) of cases, the surgeon performed mitral valve repair in full match with the anesthesiologist's repair plan. Mitral regurgitation was controlled in 85% (6/7) of cases. In three cases, the predict annuloplasty ring size and artificial chordae length were not match between anesthesiologist and surgeon. After the operation, 90% (9/10) of patients had no residual mitral regurgitation. CONCLUSIONS: Anesthesiologist's TEE measurements were useful for selecting the optimal annuloplasty ring size and artificial chordae length during R-MVP. TEE can play an important role in robot-assisted, minimally invasive cardiac surgery for mitral regurgitation with extensive and complex prolapse, such as in Barlow's disease.