Periprocedural and perioperatory management of patients with tricuspid valve disease.

Tricuspid regurgitation (TR) is a common valvular lesion which may affect morbidity and mortality. It can be related to an intrinsic abnormality of the tricuspid valve leaflets (organic) or secondary to annular dilatation (functional). Often organic and functional TR coexist in the same patient. A long-standing TR is associated with ascites, congestive hepatopathy, peripheral edema, renal failure, and abdominal fullness which significantly affect the outcome. In particular, the perioperative course may be complicated due to both the presence of comorbidities and the development of a severe postoperative right ventricle (RV) dysfunction. In fact, the TR may conceal a preoperative RV dysfunction due to a backflow in in the right atrium, which becomes overt only after the tricuspid valve (TV) repair/replacement (afterload mismatch). In light of this, an appropriate medical treatment before surgery may improve the performance of the RV, maximizing the result of the elective surgical therapy. The perioperative optimization should reduce the right atrial and ventricle overload, decrease the pulmonary vascular resistances, improve RV contractility and treat aggressively the arrhythmias. In doing so, the following rules should be considered: careful fluid administration, ß1-agonists favored over α-agonists to treat hemodynamic instability, and maintenance of a normal-to-elevated heart rate. Since the TV repair/replacement needs mechanical ventilation in both open and percutaneous surgery, a careful volume and pharmacological management should be adopted to counteract the detrimental effect of the mechanical ventilation on the top of an already dysfunctional RV. In fact, in the context of RV failure the cardiac output is strictly dependent on the preload and the increase of the intrathoracic pressure, reducing the venous return, may lead to acute heart failure. The intraoperative administration of volume and vasoactive drugs, titrated on the basis of the transesophageal echocardiography, permit to support the RV intraoperatively. Paracorporeal mechanical hemodynamic support should be always available as "bail out" in the event of intractable RV failure. In conclusion the patients undergoing TV surgery are complex and only a detailed anesthesiologic and surgical workup may decrease the perioperative mortality and morbidity.

Continuous Positive Airway Pressure Versus Oxygen Therapy in the Cardiac Surgical Ward: A Randomized Trial.

BACKGROUND: Noninvasive ventilation (NIV) is a common technique to manage patients with acute respiratory failure in the intensive care unit. However, use of NIV in general wards is less well described. The authors' aim was to demonstrate efficacy of NIV, applied in a cardiac surgery ward, in improving oxygenation in patients who developed hypoxemic acute respiratory failure after being discharged from the intensive care unit. DESIGN: Randomized, open-label trial. SETTING: University hospital. PARTICIPANTS: Sixty-four patients with hypoxemia (PaO2/FIO2 ratio between 100 and 250) admitted to the main ward after cardiac surgery. INTERVENTIONS: Patients were randomized to receive standard treatment (oxygen, early mobilization, a program of breathing exercises and diuretics) or continuous positive airway pressure in addition to standard treatment. Continuous positive airway pressure was administered 3 times a day for 2 consecutive days. Every cycle lasted 1 to 3 hours. All patients completed their 1-year follow-up. Data were analyzed according to the intention-to-treat principle. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the number of patients with PaO2/FIO2<200 48 hours after randomization. Continuous positive airway pressure use was associated with a statistically significant reduction in the number of patients with PaO2/FIO2<200 (4/33 [12%] v 14/31 [45%], p = 0.003). One patient in the control group died at the 30-day follow-up. CONCLUSIONS: Among patients with acute respiratory failure following cardiac surgery, administration of continuous positive airway pressure in the main ward was associated with improved respiratory outcome. This was the first study that was performed in the main ward of post-surgical patients with acute respiratory failure.

Protein C zymogen in severe sepsis: a double-blinded, placebo-controlled, randomized study.

PURPOSE: To determine whether protein C zymogen (protein C concentrates or human protein C) improves clinically relevant outcomes in adult patients with severe sepsis and septic shock. METHODS: This is a randomized, double-blind, placebo-controlled, parallel-group trial that from September 2012 to June 2014 enrolled adult patients with severe sepsis or septic shock and high risk of death and of bleeding (e.g., APACHE II greater than 25, extracorporeal membrane oxygenation or disseminated intravascular coagulopathy). All patients completed their follow-up 90 days after randomization and data were analyzed according to the intention-to-treat principle. Follow-up was performed at 30 and 90 days after randomization. The primary endpoint was a composite outcome of prolonged intensive care unit (ICU) stay and/or 30-day mortality. Secondary endpoints included mortality. RESULTS: The study was stopped early in a situation of futility for the composite outcome of prolonged ICU stay and/or 30-day mortality that was 79 % (15 patients) in the protein C zymogen group and 67 % (12 patients) in the placebo group (p = 0.40) and for a concomitant safety issue: ICU mortality was 79 % (15 patients) in the protein C zymogen group vs 39 % (7 patients) in the placebo group (p = 0.020), and 30-day mortality was 68 vs 39 % (p = 0.072). CONCLUSION: Protein C zymogen did not improve clinically relevant outcomes in severe sepsis and septic shock adult patients. Given its high cost and the potential increase in mortality, the use of this drug in adult patients should be discouraged.

Do patients undergoing MitraClip implantation require routine ICU admission?

OBJECTIVES: Because of its reduced invasiveness, MitraClip (Abbott Vascular, Menlo Park, CA) therapy usually is reserved for patients with extreme left ventricular dysfunction or severe comorbidity contraindicating surgery. The appropriate post-procedural care in this high-risk population is yet to be defined. In this study, the postoperative course of such patients is reported, focusing on early complications and need for intensive care unit (ICU) management. DESIGN, SETTING, AND PARTICIPANTS: A retrospective analysis of patients with severe mitral regurgitation undergoing transcatheter mitral valve repair with the MitraClip system in the authors institution was performed. INTERVENTIONS: One hundred thirty patients underwent MitraClip implantation between 2008 and 2012. At the end of the procedure, all patients were admitted to the ICU. MEASUREMENTS AND MAIN RESULTS: Median ICU stay was 0.98 (0.82-1.87) days. Median mechanical ventilation time was 9.5 (6.8-14.1) hours. One hundred one patients (78%) required inotropic support and 13 patients (10%) suffered cardiogenic shock and required intra-aortic balloon pump support. No patient died during the procedure, but 3 patients died in the ICU. Three postoperative course profiles were identified: Fast-track, overnight stay, and critical illness. Twenty-four patients (18.5%) had an uneventful postoperative course, 89 patients (68.5%) suffered minor complications, and 17 patients (13.1%) required intensive care management and organ support. Preoperative serum creatinine (odds ratio [OR] 1.8; p = 0.014), cardiogenic shock (OR 34,8; p = 0.002), ventricular tachycardia (OR 2.8; p = 0.03), and intra procedural inotropes (OR 4; p = 0.001) were correlated with a complicated postoperative course. CONCLUSIONS: A large number of patients undergoing MitraClip could be managed with a fast-track ICU course; however, it still is difficult to predict the postoperative course based on preoperative characteristics.