Transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI) has become an established therapy-option for patients with symptomatic severe aortic stenosis. Conscious sedation (CS) has proven to be an alternative to general anesthesia . So far, the outcome of patients undergoing unplanned periprocedural conversion from CS to general anesthesia has not been investigated. All patients undergoing transfemoral transcatheter aortic valve implantation in CS between 2014 and 2019 were included. The primary end point was early safety at 30 days according to Valve Academic Research Consortium-2 criteria. The reasons for conversion and length of ICU-/ hospital stay were further analyzed. Of 1,058 included patients 35 (3.3%) required a conversion. The end point was documented in 13 (37%) of the converted and 110 (11%) of nonconverted patients (p < 0.001). The causes were: unrest in 11/35 patients, procedural complications in 10/35 patients, respiratory distress in 8/35, and cardiovascular decompensation in 6 patients (17.1%). Compared with the group without conversion (Median (interquartile range ), 4 [4-5] days), length of hospital stay was longest in the group with procedural complications (6 [1-11] days) followed by cardiovascular decompensation (5 [4-7] days). In conclusion, the conversion rate to general anesthesia was low in a large cohort of unselected transcatheter aortic valve implantation patients. Additionally, hospital stay was longer dependent on the reason for conversion.

Conscious Sedation (CS) has become increasingly popular for patients undergoing transfemoral Transcatheter Aortic Valve Replacement (TAVR). The incidence of periprocedural unplanned conversion from CS to general anesthesia (GA) was at 6% in recent publications. The mortality of patients with

Objectives: The aim of this investigation was to identify patient's characteristics and periprocedural variables related to periprocedural transfusion in transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI). Background: Transfusion of allogenic red-blood cells (RBC) in tf-TAVI and the number of transfused units has been linked to an increased 30-day mortality. In line with the trend of minimization and cost-effectiveness, transfusion should be avoided, wherever possible. Methods: Between 2007 and 2015, 1,734 procedures were analyzed from our prospective registry for RBC-transfusion. Multiple logistic regression analysis was used to identify the dependent variables. Results: Transfusion was considered necessary in 14% (n = 243) of the patients. Female gender (OR [95% CI]) (1.680 [1.014-2.783]) and preprocedural moderate (7.594 [4.404-13.095]) and severe anemia (8.202 [0.900-74.752]) according to WHO were the most important preprocedural variables. Periprocedural, pericardial effusion (12.109 [3.753-39.063]), emergency extracorporeal circulation (54.5288 [6.178-481.259]) and major vascular injury (2.647 [1.412-4.962]) were related to transfusion. The same applies to moderate (4.255 [1.859-9.740]) and severe anemia (31.567 [8.560-116.416]) as well as periprocedural experience (0.072 [0.035-0.149] - 0.141[0.079-0.251], P < 0.001) Conclusion: Procedural experience, serious adverse events, low pre- and periprocedural Hb levels and female gender were the main variables relating to transfusion. Even in experienced high-volume centers, transfusion is still necessary in a considerable number of patients.

Different sedation regimens have been described for use during transfemoral transcatheter aortic valve implantation (tf-TAVI) for treatment in patients with severe aortic stenosis. The purpose of this study was to compare dexmedetomidine (DEX) with a combination of propofol-opioid (PO) with respect to periprocedural gas exchange and hemodynamic support.

Transfemoral Transcatheter Aortic Valve Implantation (tf-TAVI) has become an established therapy for elderly patients with aortic stenosis and can be performed under procedural sedation. Propofol (often combined with opioids) is usually the first choice for procedural sedation. Nevertheless, adverse events like hypotension, hypoxemia and hypercapnia have been described. In this context, the pharmacologic properties of dexmedetomidine (DEX) as a central Alpha-2 receptor agonist may be favourable. Data was obtained from our prospectively maintained AVIATOR TAVI registry. Moderate sedation – as defined by the ASA – was the targeted depth of sedation. Premedication consisted of 3.75mg midazolam p.o. Patients were either sedated with a combination of propofol and opioid (P/O) or DEX. To minimise a potential selection bias in the choice of the sedation technique, a 1-to-1 nearest neighbour matching was used. Sex, body mass index, left-ventricular ejection fraction, EUROScore II and a combined endpoint for pulmonary condition (COPD, pulmonary function, smoking) were included in the matching algorithm. Periprocedural gas-exchange and need for haemodynamic support were the endpoints. Furthermore, the need for additional sedatives/opioids in the DEX group was investigated. Out of 1088 tf-TAVI patients (09/2013 – 02/2016) 312 eligible (n= 152 P/O / n= 160 DEX) were identified in our database. After matching 272 patients (n= 136 P/O, n= 136 DEX) were analysed. Baseline characteristics were comparable. Periprocedural data are shown in Table 1. In terms of efficacy, additional analgo-sedative therapy was required in 20 DEX patients (15%). Twelve patients received only propofol, five a combination of propofol and opioids and further three only opioids.

Editor—We read with interest the paper by Mayr and colleagues1Mayr NP Hapfelmeier A Martin K et al.Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome.Br J Anaesth. 2016; 116: 90-99Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar comparing the cerebral oxygen saturation and neurocognitive outcome in patients having transcatheter aortic valve implantation under either sedation or general anaesthesia. It is interesting to note that despite using a low baseline reading of cerebral oxygenation with the patients breathing room air ( rSO2 RA baseline), and that during the procedure the patients were either ventilated with a fractional inspired O2 of 1.0 or breathing 8 litre min−1, 39% of their patients experienced a perioperative decrease in rSO2 below the desaturation threshold ( rSO2 20% below baseline of an absolute value below 50%). We undertook similar measurements in 50 patients undergoing transcatheter aortic valve implantation under general anaesthesia, in which we used a baseline under general anaesthesia (fractional inspired O2<0.5) before the procedure. With this higher threshold, we noted a desaturation below the same cut-offs used by Mayr and colleagues1Mayr NP Hapfelmeier A Martin K et al.Comparison of sedation and general anaesthesia for transcatheter aortic valve implantation on cerebral oxygen saturation and neurocognitive outcome.Br J Anaesth. 2016; 116: 90-99Abstract Full Text Full Text PDF PubMed Scopus (43) Google Scholar in 44% of patients. Two factors relating to the degree of cerebral desaturation and later recovery are worthy of note. Firstly, the magnitude of cerebral desaturation <50% was inversely related to the intraoperative haemoglobin concentration (P=0.013, r=−0.35), and secondly, the magnitude of the increase in cerebral saturation during the recovery phase was related to preoperative left ventricular ejection fraction (P=0.04, r=0.29). None declared. Patient factors that influence cerebral desaturation during transcatheter aortic valve implantation: ReplyBritish Journal of AnaesthesiaVol. 117Issue 3PreviewEditor—We thank Dr Bennett and colleagues for their comments on our trial.1 Their finding of 44% of patients desaturating during the procedure (despite a higher threshold) is in line with our measurements. In our patient group, the correlation between the intraoperative haemoglobin concentration (measured after balloon valvuloplasty) revealed a high negative two-sided correlation (Spearman) to the area under the curve for desaturation (R=−0.812, P<0.001). Taking a closer look at the two described anaesthesia techniques [general anaesthesia (TAVI-GA) or sedation (TAVI-S)] revealed the following negative correlations: TAVI-GA; R=−0.902, P<0.001; and TAVI-S, R=−0.638, P=0.035. Full-Text PDF Open Archive

BACKGROUND Transcatheter aortic valve implantation (TAVI) is a treatment strategy for patients with severe aortic stenosis. Although general anaesthesia (TAVI-GA) and sedation (TAVI-S) have previously been described for TAVI, the difference in safety and efficacy of both methods has not been studied in a randomized trial. METHODS The INSERT trial was a single centre, controlled parallel-group trial with balanced randomization. Sixty-six patients (68-94 yr) with acquired aortic stenosis undergoing transfemoral CoreValve™ were assigned to TAVI-GA or TAVI-S. Comparable operative risk was determined from risk-scores (EUROscore, STS-Score). Monitoring and anaesthetic drugs were standardized. Near-Infrared-Spectroscopy was used to monitor cerebral-oxymetry blinded. Primary outcome was the perioperative cumulative cerebral desaturation. As secondary outcomes, changes in neurocognitive function and respiratory and haemodynamic adverse events were evaluated. RESULTS Of 66 included patients, 62 (TAVI-GA: n=31, TAVI-S: n=31) were finally analysed. Baseline characteristics were comparable. In 24 patients (39%) cerebral desaturation was observed. Cumulative cerebral desaturation was comparable (TAVI-GA:(median [IQR]) (0[0/1308] s%) vs. TAVI-S:(0[0/276] s%); P=0.505) between the groups. Neurocognitive function did not change within and between groups. Adverse events were more frequently observed in TAVI-S patients (P<0.001). Bradypnoea (n=16, 52%) and the need for airway manoeuvres (n=11, 36%) or bag-mask-ventilation (n=6, 19%) were the most common respiratory adverse events. CONCLUSIONS Cerebral desaturation occurred in both patient groups, but there was no significant difference between the two groups. Based on primary outcome, both methods were shown to be comparable. Neurocognitive outcome was similar. The higher incidence of adverse events in the sedation group suggests a potential advantage of general anaesthesia. CLINICAL TRIAL REGISTRATION NCT 01251328.

Successful glycemic control reduces morbidity and mortality in cardiac surgery patients. Protocols that include insulin infusions are commonly followed to achieve target blood glucose levels. Insulin resistance has been reported and linked to low serum phosphate levels in animal models and studies in diabetic outpatients, but not in postoperative patients. The following case series is a retrospective observational review of 8 cardiac surgery patients who developed insulin resistance early after surgery; this resistance was reversed by correcting serum hypophosphatemia. We discuss the multiple underlying mechanisms causing hypophosphatemia.

Vena cava superior syndrome is a serious complication after heart transplantation, leading to low cardiac output, cerebral edema, and multi-organ dysfunction. We report three adult patients who underwent heart and heart–lung transplantation and required immediate postoperative balloon angioplasty and stent placement by interventional radiology. The observed obstructions were located at sites of intraoperatively removed pacemaker or defibrillator wires. Percutaneous stent placement immediately improved the hemodynamic condition of the patients. Early recognition of the complication and availability of immediate intervention are essential to prevent further deterioration. doi: 10.1111/jocs.12387 (J CardSurg2014;29:733–736)

OBJECTIVE:Postcardiopulmonary bypass hemorrhage remains a serious complication of cardiac surgery. Given concerns regarding adverse effects of blood product transfusion and limited efficacy of current antifibrinolytics, procoagulant medications, including recombinant factor VIIa (rFVIIa) and factor eight inhibitor bypass activity (FEIBA), increasingly have been used in managing refractory bleeding. While effective, these medications are associated with thromboembolic complications. This study compared the efficacy and risk of adverse events of rFVIIa and FEIBA in cardiac surgical patients with refractory bleeding.DESIGN:This retrospective study evaluated 168 patients who underwent cardiac surgery and received either FEIBA or rFVIIa to manage postbypass hemorrhage. Demographic, clinical, and outcomes data were collected and statistical analysis performed to compare thromboembolic event rates, relative efficacy, and 30-day mortality following administration of these medications.SETTING:Single university hospital.PARTICIPANTS:Patients undergoing cardiac surgery.INTERVENTIONS:None.MEASUREMENTS AND MAIN RESULT:Sixty-one patients received rFVIIa, and 107 received FEIBA. Demographics, surgical procedures, and preoperative anticoagulation were similar between the cohorts; however, the rFVIIa cohort had longer durations of cardiopulmonary bypass (305.1 v 243.8 min, p<0.01). There were no significant differences in the number of thromboembolic events, 30-day mortality, or rates of revision surgery. Neither group demonstrated a clear relationship between dosage and occurrence of thromboembolic events. The rFVIIa cohort received more platelets than the FEIBA cohort (3.13 v 1.67 units, p = 0.01), but transfusion rates of other blood products were similar.CONCLUSIONS:This study suggests that rFVIIa and FEIBA have similar efficacy and adverse event profiles in managing intractable postbypass hemorrhage in cardiac surgical patients. Further prospective studies are required.

Introduction: Postoperative muscle weakness is a serious complication in surgical intensive care patients. It is mostly described as critical illness polyneuromyopathy. Risk factors include intensive care length of stay, sepsis, poor glycemic control, and combined use of corticosteroids and neuromuscular blocking agents, malnutrition, and electrolyte imbalance. Methods: We report a case of late‐progressive, profound weakness after heart transplantation for noncompaction cardiomyopathy which required prolonged mechanical ventilation. The patient's muscle strength recovered completely after prolonged rehabilitation. Results: Electromyographic assessment showed myopathy. Muscle biopsy revealed Danon disease, a genetic disorder affecting the lysosomal‐associated membrane protein 2 gene ( LAMP2 ). Conclusions: The finding of this genetic disorder was unexpected, because the preoperative echocardiographic diagnosis of noncompaction cardiomyopathy has not been reported in Danon disease. This report underlines the need for early availability of pathology results from the explanted heart, which showed the same disorder. Muscle Nerve, 2013

Transesophageal echocardiography (TEE) is routinely used in our Institution for monitoring correct positioning of thoracic aortic stent grafts. We present a case of successful endovascular repair of three discrete thoracic aortic aneurysms with Zenith TX2 endovascular stent grafts in an 82-year-old female patient. Our focus is on the increased value of TEE guidance because of the ability of partial stent deployment and manipulation during insertion.

Introduction. Profuse post-CPB bleeding occurs in up to 29% of cardiac surgical patients. Studies have shown rFVIIa to be a useful rescue procoagulant in bleeding refractory to conventional hemostatic measures. Recently, FEIBA, available for <30% the cost of rFVIIa, has also been utilized in this setting. While efficacious, both compounds have been associated with thromboembolic events. This retrospective cohort study compares FEIBA and rFVIIa in treating refractory post-CPB bleeding. Methods. We reviewed records of all adult cardiac surgical patients who received FEIBA or rFVIIa from January 1, 2005 to September 30, 2010. Primary outcomes included total numbers of thromboembolic events in the first 30 post-operative days. Secondary outcomes included 30-day mortality, transfusion requirements prior to and after FEIBA or rFVIIa administration, and number of reoperations for excessive bleeding. Results. Of 2619 cases performed during the study period, 107 patients received FEIBA, and 61 received rFVIIa. There were no significant demographic differences between the cohorts, but patients in the rFVIIa group had significantly longer CPB times (305 v. 244 min) and were more frequently undergoing reoperations (56% v. 35%). There were no differences in the number of thrombembolic events, 30-day mortality, re-operations for bleeding, or overall transfusion requirements with the exception of platelets (FEIBA 1.7 v. rFVIIa 3.1). The most common thrombotic events in the FEIBA and rFVIIa cohorts were pulmonary embolism (5.6%) and stroke (6.6%), respectively. Discussion. This study contains the largest case series of FEIBA utilization in cardiac surgical patients to date, and suggests that FEIBA and rFVIIa may have similar efficacy and safety profiles when used for refractory post-CPB bleeding. FEIBA may represent an economically viable alternative to rFVIIa in this setting. Further studies are required to define the roles of these procoagulants in cardiac surgery.

IntroductionProfuse bleeding following cardiac surgery due to coagulopathy is a major problem, requiring multiple blood products. Recently recombinant activated Factor VII (rFVIIa) has been introduced to acutely promote haemostasis [1Levy J.H. Tanaka K.A. Prohemostatic agents to prevent perioperative blood loss.Semin Thromb Hemost. 2008; 34: 439-444Crossref PubMed Scopus (8) Google Scholar]. Serious embolic complications have been reported. Factor VIII inhibitor bypass activity (FEIBA) is used as an alternative, with the same reported risk factors [2Turecek P.L. Váradi K. Gritsch H. et al.FEIBA: mode of action.Haemophilia. 2004; 10: 3-9Crossref PubMed Google Scholar]. This retrospective study presents a comparison between rFVIIA and FEIBA in two cohorts of bleeding patients.MethodThe data collection included the period January 1, 2005 until March 1, 2009. Out of 2,580 patients, two groups could be identified: 78 received rFVIIa and 59 FEIBA. The primary endpoints were the total number of embolic events of stroke, myocardial infarction (MI), deep vein thrombosis (DVT) and pulmonary embolism (PE). Secondary outcomes focused on 30 day mortality, amount of blood products used postoperatively and number of reoperations due to bleeding together with costs.ResultsThe two groups did not differ in demographics, types of surgery and bypass times. Mean dose: rVIIa 91.0 mcg/kg, FEIBA 19 units/kg. The outcomes for rVIIA vs. FEIBA were: stroke 7 vs. 1%, MI 1.4 vs. 1%, DVT 0 vs. 3%, PE 2.8 vs. 4%. Mortality was 15 vs. 10%, reoperations 25 vs. 15%. The amount of blood products used was similar. The costs of FEIBA were 25% of the rFVIIa costs.DiscussionBoth rFVIIa and FEIBA were introduced to treat patients with haemophilia. They are frequently used as procoagulants to treat intractable bleeding in surgical patients. The findings in this study confirm the reported serious embolic complications with both compounds, in spite of the relatively low dose. Since our findings suggest that FEIBA is as effective as rVIIA, but significantly cheaper, it may be preferred to rVIIa. IntroductionProfuse bleeding following cardiac surgery due to coagulopathy is a major problem, requiring multiple blood products. Recently recombinant activated Factor VII (rFVIIa) has been introduced to acutely promote haemostasis [1Levy J.H. Tanaka K.A. Prohemostatic agents to prevent perioperative blood loss.Semin Thromb Hemost. 2008; 34: 439-444Crossref PubMed Scopus (8) Google Scholar]. Serious embolic complications have been reported. Factor VIII inhibitor bypass activity (FEIBA) is used as an alternative, with the same reported risk factors [2Turecek P.L. Váradi K. Gritsch H. et al.FEIBA: mode of action.Haemophilia. 2004; 10: 3-9Crossref PubMed Google Scholar]. This retrospective study presents a comparison between rFVIIA and FEIBA in two cohorts of bleeding patients.

Editor—Coagulopathy after cardiopulmonary bypass (CPB) remains a complex issue in terms of monitoring and treatment. Point-of-care testing with thromboelastography (TEG) has shown to have a positive predictive value of 87–89% and a negative predictive value of 92% for postoperative haemorrhage.1Essell JH Martin TJ Salinas J Thompson JM Smith VC Comparison of thromboelastography to bleeding time and standard coagulation tests in patients after cardiopulmonary bypass.J Cardiothorac Vasc Anesth. 1993; 7: 410-414Abstract Full Text PDF PubMed Scopus (142) Google Scholar Since it takes 15–20 min to obtain complete conventional TEG results, a more rapid modification, RapidTEG®, was developed, which incorporates tissue factor to the kaolin-activated thromboelastogram.2Chavez JJ Foley DE Snider CC et al.A novel thrombelastograph tissue factor/kaolin assay of activated clotting times for monitoring heparin anticoagulation during cardiopulmonary bypass.Anesth Analg. 2004; 99: 1290-1294Crossref PubMed Scopus (30) Google Scholar This double activation accelerates both the intrinsic and extrinsic coagulation pathways. We designed a study to assess if the data obtained from RapidTEG® concerning clot strength correlate with similar data from conventional TEG. In 24 adult cardiac surgery patients, three samples were obtained from each patient, one before (baseline) and two after CPB (one immediately after protamine and one 10 min later). All samples underwent simultaneous analysis with RapidTEG® and conventional TEG. R- and K-times, α-angles, and MA amplitudes were compared. Pre- and post-CPB platelet counts were recorded as well. Data are reported as mean (sd) or median (inter-quartile range). The Wilcoxon rank-sum test was used for intergroup comparisons. The Spearman correlation (ρ) and locally weighted regression analysis were used to examine the association between different TEG measurement methods.3Cleveland WS Robust locally weighted regression and smoothing scatterplots.J Am Stat Assoc. 1979; 74: 829-836Crossref Scopus (7348) Google Scholar Bias and limits of agreement were investigated by the Bland–Altman analysis.4Bland JM Altman DG Statistical methods for assessing agreement between two methods of clinical measurement.Lancet. 1986; 327: 307-310Abstract Scopus (39376) Google Scholar A P-value of <0.05 was considered statistically significant. MA amplitudes decreased significantly with both TEG methods during CPB. With conventional TEG, from baseline median 70.0 (66.4–72.5) to 59.4 (57.4–66.5) mm (P=0.0002) in sample 1 and to 59.3 (56.9–65.1) mm (P<0.0001) in sample 2. With RapidTEG®, from 67.2 (62.4–69.6) to 60.8 (57.3–63.8) mm (P=0.0001) in sample 1 and to 62.0 (57.2–66.1) mm (P<0.01) in sample 2. Of all the TEG variables studied, only MA amplitudes demonstrated a significant correlation between conventional and RapidTEG®. The Bland–Altman analysis showed minimal bias for baseline values (4.5%) and Protamine-2 (−1.6%), with small 95% limits of agreements (within 20%). More variations in MA values were noted at the time point of Protamine-1 (Fig. 1) Median platelet count decreased significantly from 238 (190–277)×109 litre−1 pre-CPB to 142 (108–170)×109 litre−1 post-CPB (P<0.0001). The results show that there is a significant correlation for MA magnitude data obtained with RapidTEG® compared with conventional TEG, providing a reliable indication of maximal clot strength. The correlation was better 10 min after heparin reversal. MA values are reported to be mainly dependent on platelet numbers and on fibrinogen levels.5Moganasundram S Hunt BJ Sykes K et al.The relationship among thromboelastography, hemostatic values, and bleeding after cardiopulmonary bypass surgery in children.Anesth Analg. 2010; 110: 995-1002PubMed Google Scholar The relationship between platelet numbers and MA values was confirmed in our study. In contrast, there was no correlation for α-angles, representing the speed of clot formation, including platelet activity. Earlier studies have shown that these values are strongly depending on concentrations of fibrinogen and FXIII.6Bolliger D Szlam F Molinaro RJ Rahe-Meyer N Levy JH Tanaka KA Finding the optimal concentration range for fibrinogen replacement after severe haemodilution: an in vitro model.Br J Anaesth. 2009; 102: 793-799Abstract Full Text Full Text PDF PubMed Scopus (192) Google Scholar They are apparently significantly affected by RapidTEG®. These findings are important, since impaired haemostasis after CPB is considered to be partly due to platelet dysfunction,7Hartmann M Sucker C Boehm O Koch A Loer S Zacharowski K Effects of cardiac surgery on hemostasis.Transf Med Rev. 2006; 20: 230-241Abstract Full Text Full Text PDF PubMed Scopus (88) Google Scholar which has a multifactorial underlying mechanism including preoperative medication, fibrinolysis, receptor defect, contact activation, and hypothermia. RapidTEG® allows more rapid detection of impairment of clot strength due to low platelet numbers. Larger studies, preferably multicentre and prospective, have to be performed to assess if RapidTEG® may contribute to the reduction of transfusion requirements. None declared.

Rationale: Chronic rejection, manifested pathologically as airway fibrosis, is the major problem limiting long-term survival in lung transplant recipients. Airway hypoxia and ischemia, resulting from a failure to restore the bronchial artery (BA) circulation at the time of transplantation, may predispose patients to chronic rejection. To address this possibility, clinical information is needed describing the status of lung perfusion and airway oxygenation after transplantation.Objectives: To determine the relative pulmonary arterial blood flow, airway tissue oxygenation and BA anatomy in the transplanted lung was compared with the contralateral native lung in lung allograft recipients.Methods: Routine perfusion scans were evaluated at 3 and 12 months after transplantation in 15 single transplant recipients. Next, airway tissue oximetry was performed in 12 patients during surveillance bronchoscopies in the first year after transplant and in 4 control subjects. Finally, computed tomography (CT)-angiography studies on 11 recipients were reconstructed to evaluate the post-transplant anatomy of the BAs.Measurements and Main Results: By 3 months after transplantation, deoxygenated pulmonary arterial blood is shunted away from the native lung to the transplanted lung. In the first year, healthy lung transplant recipients exhibit significant airway hypoxia distal to the graft anastomosis. CT-angiography studies demonstrate that BAs are abbreviated, generally stopping at or before the anastomosis, in transplant airways.Conclusions: Despite pulmonary artery blood being shunted to transplanted lungs after transplantation, grafts are hypoxic compared with both native (diseased) and control airways. Airway hypoxia may be due to the lack of radiologically demonstrable BAs after lung transplantation.

OBJECTIVE:This study was undertaken to compare the effect of deep hypothermic circulatory arrest, compared with moderate hypothermia, on the plasma concentrations and pharmacokinetic profile of vancomycin, administered as prophylaxis, in patients undergoing cardiac surgery with cardiopulmonary bypass.METHODS:Two groups of adult cardiac surgery patients were prospectively studied. One group consisted of 12 patients undergoing valvular surgery with moderate hypothermia, and another group was of 12 patients undergoing surgery with the use of profound hypothermic circulatory arrest. Vancomycin was administered before skin incision, and plasma levels were measured at regular intervals for 24h.RESULTS:The plasma concentrations of vancomycin showed a similar pattern in both groups. The pharmacokinetic profile showed a three-compartment model in both groups.CONCLUSION:The dosing of vancomycin, if used as antibiotic prophylaxis, does not need to be adjusted in cardiac surgery patients when undergoing profound hypothermic circulatory arrest, since the plasma concentrations and pharmacokinetic profile are similar to patients with moderate hypothermia. The pharmacokinetic profile, consisting of three compartments, was not changed by the differences in temperature.

BACKGROUND:Delirium is a neurobehavioral syndrome caused by the transient disruption of normal neuronal activity secondary to systemic disturbances.OBJECTIVE:The authors investigated the effects of postoperative sedation on the development of delirium in patients undergoing cardiac-valve procedures.METHODS:Patients underwent elective cardiac surgery with a standardized intraoperative anesthesia protocol, followed by random assignment to one of three postoperative sedation protocols: dexmedetomidine, propofol, or midazolam.RESULTS:The incidence of delirium for patients receiving dexmedetomidine was 3%, for those receiving propofol was 50%, and for patients receiving midazolam, 50%. Patients who developed postoperative delirium experienced significantly longer intensive-care stays and longer total hospitalization.CONCLUSION:The findings of this open-label, randomized clinical investigation suggest that postoperative sedation with dexmedetomidine was associated with significantly lower rates of postoperative delirium and lower care costs.

Background—Endoleaks after stent-graft repair of aortic dissections are poorly understood but seem substantially different from those seen after aneurysm repair. We studied anatomic and clinical factors associated with endoleaks in patients who underwent stent-graft repair of complicated type B aortic dissections. Methods and Results—From 2000 to 2007, 37 patients underwent stent-graft repair of acute (≤14 days; n=23), subacute (15 to 90 days; n=10) or chronic (>90 days; n=4) complicated type B aortic dissections using the Gore Thoracic Excluder (n=17) or TAG stent-grafts (n=20) under an investigator-sponsored protocol. Endoleaks were classified as imperfect proximal seal, flow through fenestrations or branches, or complex (both). Variables studied included coverage of the left subclavian artery, aortic curvature, completeness of proximal apposition, dissection chronicity, and device used. Endoleaks were found during follow-up (mean, 22 months) in 59% of patients, and they were associated with coverage of the left subclavian artery (complex, P<0.001), small radius of curvature (type 1 and complex, P=0.05), and greatest length of unapposed proximal stent graft (complex, P<0.0001). During follow-up, 10 endoleaks resolved spontaneously, 6 required reintervention for false lumen dilatation, and 2 were stable without clinical consequences. Conclusions—Endoleaks are common after stent-graft repair of aortic dissection and may lead to false lumen enlargement necessitating reintervention. Anatomic complexities such as acute aortic curvature and covered side branches were associated with endoleaks, illustrating the need for dissection-specific device development.