PURPOSE: In this prospective study, the effects of fresh frozen plasma (FFP) included in pump priming for congenital heart surgery in infants and children on post-bypass coagulation profiles were evaluated. MATERIALS AND METHODS: Either 20% albumin (50-100 mL) or FFP (1-2 units) was added to pump priming for patients randomly allocated into control or treatment groups, respectively. Hematologic assays, including functional fibrinogen level, and rotational thromboelastometry (ROTEM(R)) were measured before skin incision (baseline), after weaning from cardiopulmonary bypass (CPB) and heparin reversal, and at 24 hours (h) in the intensive care unit (ICU). RESULTS: All the baseline measurements were comparable between the control and treatment groups of infants and children. After heparin reversal, however, significantly higher fibrinogen levels and less reduced ROTEM parameters, which reflect clot formation and firmness, were demonstrated in the treatment groups of infants and children. At 24 h in the ICU, hematologic assays and ROTEM measurements were comparable between the control and treatment groups of infants and children. Transfusion requirements, excluding FFP in pump prime, and postoperative bleeding were comparable between the control and treatment groups of infants and children. CONCLUSION: Although clinical benefits were not clearly found, the inclusion of FFP in pump priming for congenital heart surgery in infants and children was shown to improve the hemodilution-related hemostatic dysfunction immediately after weaning from CPB and heparin reversal.
Adolescent ; *Blood Coagulation ; Cardiac Surgical Procedures ; Cardiopulmonary Bypass/methods ; Child ; Child, Preschool ; Female ; Fibrinogen/*metabolism ; Heart Defects, Congenital/*surgery ; Humans ; Infant ; Male ; *Plasma ; Postoperative Period ; Thrombelastography/methods

BACKGROUND: Hydroxyethylstarch (HES) solutions are commonly used for intravascular volume expansion with varying effect on coagulation depending on molecular weight and mode of hydroxyl substitution.Clopidogrel and aspirin have been shown to reduce cardiovascular complications in patients with coronaryartery occlusive disease which renders patients to higher risk of bleeding complications who require surgery.The purpose of this study was to evaluate the effect of HES 200/0.5, 130/0.4 and crystalloid on blood loss and transfusion requirement in patients with recent antiplatelet therapy undergoing off-pump coronary bypass surgery (OPCAB) in a prospective, randomized trial. METHODS: Sixty patients scheduled for OPCAB, who received clopidogrel and aspirin within 5 days of surgery were randomly allocated into 3 groups:HES 200/0.5 (n = 20), HES 150/0.4 (n = 20), and Crystalloid (n = 20).Routine coagulation profile were measured before and 2 days after the surgery.Amount of perioperative blood loss, transfusion requirement and fluids input and output were recorded until 2 days postoperatively. RESULTS: The 3 groups were similar with regard to patients and operative characteristics.There were no significant differences in the amount of perioperative blood loss and transfusion requirement among the 3 groups. CONCLUSIONS: Both HES solutions were safe to use in terms of blood loss and transfusion requirement in patients undergoing OPCAB who received antiplatelet agents within 5 days of surgery.
Aspirin ; Hemorrhage ; Hetastarch ; Humans ; Isotonic Solutions ; Molecular Weight ; Platelet Aggregation Inhibitors ; Prospective Studies ; Ticlopidine

BACKGROUND: This study was done to evaluate the sole effect of norepinephrine on the regional myocardial perfusion during displacement of the porcine beating heart using thermal diffusion method. METHODS: Thermal diffusion probe was inserted into the anterior myocardial wall during 20 procedures in 10 male pigs (30-35 kg). The measurements of regional myocardial perfusion and hemodynamic parameters were performed after complete instrumentation (baseline), after displacement of the beating heart anteriorly, and 5 and 15 minutes after norepinephrine infusion, titrated to restore baseline mean arterial pressure (MAP). RESULTS: Norepinephrine infusion reversed the decrease in MAP and myocardial perfusion, caused by displacement of the beating heart (62 +/- 3% to 115 +/- 4% of baseline, P < 0.01; 41 +/- 5% to 125 +/- 4% of baseline, P < 0.05, respectively). CONCLUSIONS: Restoration of MAP with norepinephrine infusion without any preload augmentation reversed deterioration in regional myocardial perfusion during displacement of the porcine beating heart.
Arterial Pressure ; Displacement (Psychology) ; Heart ; Hemodynamics ; Humans ; Male ; Norepinephrine ; ortho-Aminobenzoates ; Perfusion ; Swine ; Thermal Diffusion

Although numerous studies have validated the efficacy of intracoronary shunt on reducing left ventricular dysfunction during off-pump coronary artery bypass surgery (OPCAB), there is lack of evidence supporting its role on right ventricular (RV) function during right coronary artery (RCA) revascularization. Therefore, we studied the effect of intracoronary shunt during grafting of dominant RCA without visible collateral supply on global RV function using thermodilution method. Forty patients scheduled for multivessel OPCAB with right dominant coronary circulation without collateral supply confirmed by angiography were randomized to RCA revascularization either with a shunt (n=20) or soft snare occlusion (n=20). RV ejection fraction (RVEF) was recorded at baseline, during RCA grafting, and 15 min after reperfusion. Corresponding RV stroke work index (RVSWI) was calculated. RVEF and RVSWI decreased significantly during RCA grafting and returned to baseline values after reperfusion in both groups without any significant differences between the groups. Intracoronary shunt did not exert any beneficial effect on global RV function during RCA grafting, even in the absence of visible collateral supply. Regarding the possibility of graft failure by intracoronary shunt-induced endothelial damage, routine use of intracoronary shunt during RCA grafting is not recommended in patients with preserved biventricular function.
Aged ; Blood Pressure ; *Collateral Circulation ; Coronary Artery Bypass, Off-Pump/*methods ; Coronary Artery Disease/physiopathology/*surgery ; *Coronary Circulation ; Female ; Heart Rate ; Humans ; Male ; Middle Aged ; Norepinephrine/administration & dosage ; Prospective Studies ; Stroke Volume ; Sympathomimetics/administration & dosage ; Thermodilution ; *Ventricular Function, Right

BACKGROUND: Preserving the subvalvular apparatus after mitral valve replacement (MVR) results in better ventricular function and a better outcome. In conjunction, mitral valve repair (MVr) is associated with a better outcome, yet little is known about the hemodynamics and outcomes between patients undergoing MVr and MVR with chordal preservation. We prospectively evaluated the hemodynamic changes and outcomes of patients undergoing MVr and MVR with chordal preservation. MATERIAL AND METHOD: Fifty-four patients with mitral regurgitation (MR) who underwent MVR with chordal preservation (n=21) or MVr (n=33) were studied. The patients' characteristics, the intra- and postoperative hemodynamics and the use of cardiac medications, the postoperative outcome and the complications were recorded during the hospital stay. All the patients were followed up for at least 6 months postoperatively for determining their morbidity and mortality. RESULT: The patients' characteristics were similar between the groups, except for the presence of atrial fibrillation and congestive heart failure which was more frequent in the MVR group. Also, the preoperative left ventricular ejection fraction was lower in the MVR group than in the MVr group (64+/-9% versus 69+/-5%, respectively, p=0.043). There were no significant differences of the hemodynamics between the groups. The use of inotropic drugs and pacemakers during the 12hrs postoperatively was more common in the MVR group than in the MVr group (48% versus 24%, p=0.025 and 52% versus 24%, p=0.035, respectively). The other postoperative outcomes were similar in both groups for at least the 6 months follow-up period. CONCLUSION: MVR with chordal preservation was comparable with regard to the hemodynamics and clinical outcomes, supporting the beneficial effect of preserving the subvalvular apparatus after MVR.
Atrial Fibrillation ; Follow-Up Studies ; Heart Failure ; Hemodynamics* ; Humans ; Length of Stay ; Mitral Valve ; Mitral Valve Insufficiency* ; Mortality ; Prospective Studies ; Stroke Volume ; Ventricular Function

BACKGROUND: This study was designed to compare the effect of low-molecular 6% hydroxyethyl starch (HES) 130/0.4 on hemostasis and hemodynamic efficacy with that of medium-molecular 6% HES 200/0.5 in patients undergoing off-pump coronary artery bypass surgery. METHODS: Forty-eight patients were randomized to receive up to 33 ml/kg of either 6% HES 130/0.4 or 6% HES 200/0.5. Hemodynamic variables and blood tests including thromboelastography were measured 10 min after induction (baseline value, T0), 5 min after acute loading of HES 10 ml/kg (T1) in hypovolemic patients, after sternum closure (T2), and 16 hr after intensive care unit (ICU) arrival (T3). Chest tube drainage was recorded until 16 hours after ICU arrival. RESULTS: Hemodynamic variables were similar in both groups. Chest tube drainage at 16 hr after surgery was higher in HES 200/0.5 group than that in HES 130/0.4 group. Maximum clot firmness was decreased in HES 200/0.5 group at sternal closure but not in HES 130/0.4 group. CONCLUSIONS: Both HES 200/0.5 and HES 130/0.4 were equally efficient in maintaining stable hemodynamics during off-pump coronary artery bypass surgery. However, HES 130/0.4 may reduce postoperative blood loss compared to that of HES 200/0.5 at the same dose of 33 ml/kg.
Blood Coagulation ; Chest Tubes ; Coronary Artery Bypass, Off-Pump* ; Drainage ; Fluid Therapy ; Hematologic Tests ; Hemodynamics* ; Hemostasis* ; Humans ; Hypovolemia ; Intensive Care Units ; Postoperative Hemorrhage ; Starch* ; Sternum ; Thrombelastography

BACKGROUND: Ischemia-reperfusion injury related to unsuccessful myocardial protection affects postoperative ventricular function and mortality during open-heart surgery. We prospectively compared the effects of administration of histidine-tryptophan-ketoglutarate (HTK) solution and cold blood cardioplegia (CBC) on myocardial protection and clinical outcome in patients undergoing mitral valve surgery. MATERIAL AND METHOD: Seventy patients with mitral regurgitation (MR) undergoing mitral valve surgery were randomly divided into the HTK group (n=31) and the CBC group (n=31); eight patients were excluded. Perioperative hemodynamics, cardiac medications, pacing, postoperative outcomes and complications were recorded during the hospital stay. All patients received follow-up for at least 6 months postoperatively for morbidity and mortality. RESULT: There were no significant differences in the hemodynamics between the groups during the study period, except for the mean pulmonary artery pressure (MPAP), PCWP and CVP that were lower in the HTK group at 15 min after weaning of CBP. There were no differences for inotropic support and pacing during the 12 hrs postoperatively between the groups. CK-MB values on day 1 and day 2 were 77+/-54 and 41+/-23 for the HTK group and 70+/-69 and 44+/-34 for the CBC group, respectively (p=NS). Postoperative clinical outcomes were similar in both groups for at least 6 months during the follow-up period. CONCLUSION: These results suggest that the use of HTK solution is as safe as cold blood cardioplegia in terms of myocardial protection.
Cardioplegic Solutions* ; Follow-Up Studies ; Heart Arrest, Induced ; Hemodynamics ; Humans ; Length of Stay ; Mitral Valve Insufficiency ; Mitral Valve* ; Mortality ; Prospective Studies ; Pulmonary Artery ; Reperfusion Injury ; Ventricular Function ; Weaning

Intraoperative transesophageal echocardiography (TEE) during cardiac surgery is an invaluable procedure, which aids hemodynamic management as well as surgical directions. TEE adds valuable information to the assessment of cardiac structures and in contrast to transthoracic echocardiography (TTE), due to its proximity to left atrium (LA), it is especially useful in detection of mass lesions in the LA. The following case describes a patient undergoing aortic valve replacement under cardiopulmonary bypass with low risk of thrombi formation and undetected thrombi in the LA appendage by preoperative TTE. These thrombi could be detected by intraoperative TEE and removed at the same operation, thus avoiding thromboembolic complication and second operation.
Aortic Valve* ; Cardiopulmonary Bypass* ; Echocardiography ; Echocardiography, Transesophageal* ; Heart Atria ; Hemodynamics ; Humans ; Thoracic Surgery ; Thrombosis ; Weaning*

BACKGROUND: It is important to assess cardiac preload for management of patients undergoing off pump coronary artery bypass surgery (OPCAB). Recently, several studies have documented the good correlation between right ventricular end-diastolic volume index (RVEDVI) and stroke volume index (SVI), compared with cardiac filling pressures. However, none of these studies have evaluated relationship between predictors of preload and SVI measured with volumetric pulmonary artery catheter during OPCAB. The correlation of continuous RVEDVI and SVI measured with volumetric pulmonary artery catheter during OPCAB was evaluated in this study. METHODS: Fifty three patients undergoing OPCAB were included. Hemodynamic parameters were measured 10 min after induction (T1), 10 min after Y-graft formation started (T2) and 10 min after sternum closure (T3). The correlation of parameters were assessed by simple linear regression. RESULTS: Central venous pressure (CVP) and pulmonary artery occlusion pressure (PAOP) did not correlate with SVI during OPCAB. On the other hand, a statistically significant result was found between RVEDVI and SVI at T2 (r(2)=0.133, P=0.007) and T3 (r(2)=0.380, P < 0.000). But RVEDVI and SVI were weakly correlated. And at T1, RVEDVI and SVI did not correlate. CONCLUSIONS: RVEDVI is a more reliable predictor of preload compared to CVP and PAOP during OPCAB. But in post-induction period (T2), RVEDVI did not correlate with SVI.
Catheters* ; Central Venous Pressure ; Coronary Artery Bypass, Off-Pump* ; Hand ; Hemodynamics ; Humans ; Linear Models ; Pulmonary Artery* ; Sternum ; Stroke Volume* ; Stroke*

BACKGROUND: Femoral to radial arterial pressure gradient (deltaP) often develops after cardiopulmonary bypass (CPB) where radial artery pressure (RAP) does not reflect the actual perfusion pressure. Renin-angiotensin system antagonists (RAS-A) are increasingly prescribed preoperatively which causes vasodilation and vascular remodeling. We evaluated the effect of RAS-A medication on ?P after CPB in patients undergoing valvular heart surgery. METHODS: Eighty-five patients scheduled for elective valvular heart surgery for regurgitant lesions were divided into two groups: the RAS-A group, in which patients were on RAS-A preoperatively (n = 52) and the control group (n = 33). Hemodynamic variables including RAP, femoral arterial pressure (FAP), body temperature, and hematocrit were recorded at after induction of anesthesia, pre-and post-CPB and sternum closure. RESULTS: After CPB, systolic deltaP was significantly greater in the RAS-A group than in the control group. Nine (27%) and 36 (69%) patients after CPB, and 6 (18%) and 23 (44%) patients after sternum closure developed systolic deltaP more than 10 mmHg, in the control and RAS-A group, respectively, which were statistically significant. Body temperature, hematocrit and systemic vascular resistance index were not different between groups. CONCLUSIONS: Preoperative treatment with RAS-A resulted in clinically significant deltaP after cardiopulmonary bypass in about 70% of patients undergoing valvular heart surgery. Concomitant monitoring of FAP with RAP might be helpful to prevent inadequate vasopressor therapy guided by inaccurate RAP after CPB in this subset of patients.
Anesthesia ; Arterial Pressure* ; Body Temperature ; Cardiopulmonary Bypass* ; Heart* ; Hematocrit ; Hemodynamics ; Humans ; Perfusion ; Radial Artery ; Renin-Angiotensin System* ; Sternum ; Thoracic Surgery* ; Vascular Resistance ; Vasodilation