Perfusion
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Cardiac power output has been shown to quantify cardiac reserve. Cardiac reserve is defined as the difference between basal and maximal cardiac performance. We compared cardiac power index to other commonly used hemodynamic parameters to validate its usefulness to stage heart failure patients and determine the optimal time for implantation of mechanical circulatory support. A retrospective study of twenty-eight heart failure patients implanted with mechanical circulatory support was analyzed at three levels of drug therapy. Subjects were further separated into two categories: survived versus deceased. Cardiac power index was the only statistically significant hemodynamic parameter that identified cardiac reserve (p<0.05) in this patient population. These results showed that a cardiac power index at or below 0.34 Watts/m(2) resulted in increased mortality rate, ninety days post-implantation. ⋯ Cardiac reserve was a determinant of post-device survival; therefore, these data suggest that device implantation should occur prior to the 0.34 Watts/m(2) threshold.
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Veno-venous extracorporeal membrane oxygenation (VV-ECMO) has been indicated in patients with severe refractory respiratory failure from various causes for more than 30 years, even for the small infant.(1) Improved outcome from using ECMO for respiratory failure has been reported worldwide, ranging from 15% to over 50% in recent reviews.(1,2) The rationale of this therapy is to allow time for the lungs to heal, minimizing further lung injury from positive pressure ventilation.(3,4) We describe a case of severe acute respiratory distress syndrome (ARDS) with extensive barotrauma supported by VV-ECMO for 96 days in a resource-limited center. This is likely the longest ECMO support ever reported in a child.
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Surgical repair of transverse aortic arch aneurysms frequently employ hypothermia and antegrade cerebral perfusion as protective strategies during circulatory arrest. However, prolonged mesenteric and lower limb ischemia can lead to significant lactic acidosis and end organ dysfunction, which remains a significant cause of post-operative morbidity and mortality. We report our experience with additive warm mesenteric and lower body perfusion (1-3 L/min, 30°C) in addition to continuous cerebral and myocardial perfusion in 5 patients who underwent total aortic arch replacement with trifurcated head vessel re-implantation and distal elephant trunk reconstruction. ⋯ Median intensive care unit and total hospital lengths of stay were 5 and 16 days, respectively. Our results suggest early serum lactate clearance, normalization of acidosis, and metabolic recovery when utilizing a simultaneous cerebral perfusion and warm body protection strategy for complex aortic arch surgery. This additive perfusion strategy may attenuate visceral and lower body ischemia that normally develops during periods of deep hypothermic circulatory arrest.
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Review Meta Analysis
Is there any difference between blood and crystalloid cardioplegia for myocardial protection during cardiac surgery? A meta-analysis of 5576 patients from 36 randomized trials.
To compare the efficacy of blood versus crystalloid cardioplegia for myocardial protection in patients undergoing cardiac surgery. ⋯ We found evidence that argues against any superiority in terms of hard outcomes between blood or crystalloid cardioplegia for myocardial protection during cardiac surgery.
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This extension study investigated the association between preoperative cerebral blood flow (CBF) velocity and postoperative cognitive decline (POCD) at a three-month follow-up in patients who underwent cardiac surgery. Continuous transcranial Doppler ultrasound on both middle cerebral arteries (MCAs) was used preoperatively in 31 right-handed cardiac surgery patients at rest. ⋯ Moreover, the group with POCD had a significantly lower CBF velocity in the left than in the right MCA, whereas no difference between the left and right CBF velocity was found in the group without POCD. These preliminary findings suggest that reduced preoperative CBF velocity in the left MCA may represent an independent risk factor for cognitive decline in patients three months after surgery.