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Obiettivo. Lo scopo del presente lavoro è decrivere la gestione anestesiologica e l’outcome della rivascolarizzazione coronarica a cuore battente.Metodi. È stato svolto uno studio prospettico, presso un ospedale universitario, su 100 pazienti adulti consecutive sottoposti a rivascolarizzazione coronarica a cuore battente. I punti salienti della gestione anestesiologica sono il mantenimento della stabilità emodinamica e del contributo diastolico atriale.Risultati. L’introduzione degli stabilizzatori meccanici ha migliorato le gestione di questi pazienti. L’incidenza di complicazioni è stata: mortalità ospedaliera 1%; infarto miocardico acuto 3%; sindrome da bassa gittata 2%; fibrillazione atriale 16%. L’incidenza di insufficienza renale acuta postoperatoria è stata limitata al 2% e in nessun caso si è reso necessario un trattamento sostitutivo renale. Non è stato registrato nessun evento neurologico. Solo il 19% dei pazienti ha ricevuto emotrasfusioni. Il 97% dei pazienti è stato estubato entro 12 h dalla fine dell’ intervento.Conclusioni. La strategia anestesiologica applicata, combinata a una buona tecnica chirurgica e all’uso di dispositivi innovativi, rende questo tipo di chirurgia sicura anche in pazienti ad alto rischio. AIM: The aim of this paper is to describe the anesthesiological management and the outcome of beating heart revascularization.METHODS: A prospective study has been performed in a tertiary teaching hospital on 100 consecutive patients undergoing off-pump coronary artery revascularization. The main features of anesthetic technique are the maintenance hemodynamic stability and atrial kick.RESULTS: Mechanical stabilisers shunts have improved the management of these patients. In hospital mortality was 1%, acute myocardial infarction 3%, low output syndrome 2%, atrial fibrillation 16%. Only 2% of patients had acute renal failure, but no patient needed renal replacement treatment. No neurologic event was noted. Only 19% of patients received blood transfusion. Ninety-seven % of patients were extubated within 12 h.CONCLUSIONS: The application of this anesthetic strategy combined with surgical skillful and new devices makes off-pump surgery safe also in high risk patients.

Aim. A high postoperative peak of cardiac Troponin I is associated to an increased risk of morbidity and mortality after cardiac operations. The aim of this study was to investigate the release of cardiac Troponin I in different cardiac surgical procedures. Methods. This was a prospective, single-centre study performed at the IRCCS San Raffaele Hospital in Milan, Italy. The study group consisted of 194 consecutive patients undergoing cardiac surgery. For each of them creatinkinase MB and cardiac Troponin I were assayed preoperatively, at ICU arrival, 4 h and 18 h postoperatively. Results. Different cardiac surgical procedures were characterized by different release of cardiac biomarkers (P < 0.001, ANOVA test). Off-pump coronary artery bypass grafting (CABG) was associated to the smallest amount of myocardial injury while mitral valve replacement produced the largest amount of biomarkers release. Patients who suffered a postoperative cardiac event released more myocardial necrosis biomarkers; than those with an uneventful course (P=0.01). Conclusion. We showed that each type of cardiac operation has a peculiar amount of myocardial necrosis biomarkers: mitral valve replacement in particular is associated to the highest release of cardiac biomarkers.

Background Previous studies showed that desmopressin decreases post-operative blood loss in patients undergoing cardiac surgery. These studies were small and never studied the effect of desmopressin in patients with active bleeding. Objective of the study was to determine whether desmopressin reduces red blood cells transfusion requirements in patients with active bleeding after cardiac surgery who had been pre-treated with tranexamic acid. Methods This multicenter, randomized, double-blind, placebo-controlled, parallel-group study randomized elective patients with bleeding after cardiac surgery despite pre-treatment with tranexamic acid, to receive placebo (saline solution) or a single administration of desmopressin (0.3 μg/kg in saline solution). The primary endpoint was the number of patients requiring red blood cells transfusion after randomization and during hospital stay. Secondary end points were: blood loss from chest tubes during the first 24 h after study drug administration, hours of mechanical ventilation, intensive care unit stay, and in-hospital mortality. Results The study was interrupted after inclusion of 67% of the planned patients for futility. The number of patients requiring red blood cells transfusion after randomization was 37/68 (54%) in desmopressin group and 33/67 (49%) in placebo group (P = 0.34) with no difference in blood loss: 575 (interquartile 422–770) ml in desmopressin group and 590 (476–1013) ml in placebo group (P = 0.42), mechanical ventilation, intensive care unit stay or mortality. Conclusions This multicenter randomized trial demonstrated that, in patients pre-treated with tranexamic acid, desmopressin should not be expected to improve treatment of patients who experience bleeding after cardiac surgery.

Objective There is initial evidence that the use of volatile anesthetics can reduce the postoperative release of cardiac troponin I, the need for inotropic support, and the number of patients requiring prolonged hospitalization following coronary artery bypass graft (CABG) surgery. Nevertheless, small randomized controlled trials have failed to demonstrate a survival advantage. Thus, whether volatile anesthetics improve the postoperative outcome of cardiac surgical patients remains uncertain. An adequately powered randomized controlled trial appears desirable. Design Single blinded, international, multicenter randomized controlled trial with 1:1 allocation ratio. Setting Tertiary and University hospitals. Interventions Patients (n = 10,600) undergoing coronary artery bypass graft will be randomized to receive either volatile anesthetic as part of the anesthetic plan, or total intravenous anesthesia. Measurements and main results The primary end point of the study will be one-year mortality (any cause). Secondary endpoints will be 30-day mortality; 30-day death or non-fatal myocardial infarction (composite endpoint); cardiac mortality at 30 day and at one year; incidence of hospital re-admission during the one year follow-up period and duration of intensive care unit, and hospital stay. The sample size is based on the hypothesis that volatile anesthetics will reduce 1-year unadjusted mortality from 3% to 2%, using a two-sided alpha error of 0.05, and a power of 0.9. Conclusions The trial will determine whether the simple intervention of adding a volatile anesthetic, an intervention that can be implemented by all anesthesiologists, can improve one-year survival in patients undergoing coronary artery bypass graft surgery.

Objectives: The purpose of this study was to evaluate the effects of thoracic epidural anesthesia on postoperative Nterminal pro B-natriuretic peptide (NT-proBNP) release in elderly patients undergoing elective coronary artery bypass graft (CABG) surgery. Design: A case-matched, nonrandomized study. Setting: A university hospital, single institution. Participants: 46 consecutive and 46 control patients. Interventions: Ninety-two elderly patients (>65 years old) undergoing elective CABG surgery were recruited. Forty-six patients receiving general and epidural anesthesia were case matched (preoperative medications, ejection fraction, and cornorbidities) with 46 control subjects receiving general anesthesia. The primary outcome measure was postoperative NT-proBNP release. The preoperative or intraoperative variables significantly associated with an intensive care unit stay longer than 4 days were determined by logistic regression. Measurements and Main Results: The median (interquartile range) plasma concentrations of NT-proBNP before surgery were 402 (115-887 pg/mL) in the epidural group versus 508 (228-1,285 pg/mL) in the general anesthesia group (p = 0.9), whereas 24 hours after surgery it increased to 1846 (1,135-3,687 pg/mL) versus 5,005 (2,220-11,377 pg/mL) (p = 0.001), respectively. There were more patients (p = 0.043) in the control group (9/46 = 19.5%) than in the thoracic epidural anesthesia group (4/46 = 8.8%) with an intensive care unit stay longer than 4 days. The absence of preoperative beta-blocker therapy (odds ratio = 3.94; 95% confidence interval, 1.123-13.833; p = 0.03) and of an epidural catheter (odds ratio = 3.91; 95% confidence interval, 1.068-14.619; p = 0.04) were the only preoperative and intraoperative variables independently associated with a prolonged intensive care unit stay. Conclusions: Epidural anesthesia added to general anesthesia for CABG surgery significantly attenuates NT-proBNP release in elderly patients and reduces the incidence of prolonged intensive care unit stay. (C) 2009 Elsevier Inc. All rights reserved.

Objective: Systolic anterior motion can complicate mitral valve repair. It can have no clinical consequence or cause low cardiac output syndrome and hypotension. The management of systolic anterior motion in the operating room remains controversial: some groups advocate nonsurgical management, and others propose immediate surgical correction. Conventional hemodynamic measures require time and can be unsuccessful. While describing our experience, we propose a simple and innovative management and classification of this complication. Methods: Presenting the data of 608 consecutive patients who underwent mitral valve repair for degenerative mitral valve disease, we describe a novel 2-step conservative management consisting of intravascular volume expansion and discontinuation of inotropic drug (step 1) and increasing afterload by means of ascending aortic manual compression while administering beta-blockers (step 2). We also describe a novel classification of systolic anterior motion: easy to revert (responding to step 1), difficult to revert (responding to step 2), or persistent. Results: The overall incidence of systolic anterior motion was 9.8% (60/608): 40 patients had easy-to-revert systolic anterior motion, and 15 had difficult-to-revert systolic anterior motion. Five patients had a persistent condition and underwent surgical intervention within 48 hours. Conclusions: Systolic anterior motion after repair of a degenerative mitral valve is common. Surgical revision in the minority of patients unresponsive to standard conservative management is suggested.

Objective: Myocardial ischemic damage is reduced by volatile anesthetics in patients undergoing coronary artery bypass graft surgery, but it is unknown whether this benefit exists in patients undergoing valvular surgery with ischemia-reperfusion injury related to cardioplegic arrest and cardiopulmonary bypass. This study compared cardiac troponin release in patients receiving either volatile anesthetics or total intravenous anesthesia for mitral valve surgery. Design: Randomized controlled study. Setting: University hospital. Participants: One hundred twenty patients undergoing mitral valve surgery. Interventions: Fifty-nine patients received the volatile anesthetic desflurane for 30 minutes before cardiopulmonary bypass, whereas 61 patients received a total intravenous anesthetic with propofol. All patients had an opioid-based anesthetic for the mitral valve surgery. Measurements and Main Results: Peak postoperative troponin I release was measured as a marker of myocardial necrosis after mitral valve surgery. Patient mean age was 60 years, and 54% were men. There was no significant (p = 0.7) reduction in median (25th-75th percentiles) postoperative peak troponin, 11.0 (7.5-17.4) ng/dL in the desflurane group versus 11.5 (6.9-18.0) ng/dL in the propofol group. A subgroup of patients with concomitant coronary artery disease had the expected reduction (p = 0.02) of peak troponin I in those receiving desflurane, 14.0 (9.7-17.3) ng/dL, when compared with patients receiving total intravenous anesthesia, 31.6 (15.7-52.0) ng/dL. Conclusions: Myocardial damage measured by cardiac troponin release was not reduced by volatile anesthetics in patients undergoing mitral valve surgery, whereas it was reduced in patients with concomitant coronary artery disease. (C) 2007 Elsevier Inc. All rights reserved.

Background. Given that there is an association between the degree of hemodilution during cardiopulmonary bypass (CPB) and postoperative complications, patients-outcome might be improved if the nadir hematocrit concentration is kept within an optimal range. Smaller patients are more likely to have a low hematocrit during CPB: this phenomenon may be related, at least partially, to the extreme hemodilution induced by a large fixed CPB priming volume. Methods. Forty patients with a body surface area (BSA) < 1.7 m2 undergoing open heart operations were randomized to either standard CPB with full prime volume (control group) or reduced prime extracorporeal circuit and vacuum-assisted venous drainage (VAVD) (study group). Results. There were no significant differences between the groups with respect to baseline characteristics, body surface area, hematologic profile and operative data. Clinical outcomes were similar. Nadir hematocrit and hemoglobin on bypass were significantly lower in the control group (22 ± 2.3 vs 24 ± 2.5%, p < 0.02 and 7.4 ± 0.7 vs 8 ± 0.9g/dl, p < 0.04, respectively). Postoperative chest tube drainage was significantly higher in the control group (272 ± 253vs 139 ± 84ml, p < 0.04). There was no difference in blood transfusion in the two groups (0.5 ± 1.14 v 1.0 ± 1.77 units of packed red blood cells (PRBC), p = 0.29). Conclusions. Lowering CPB priming volume by means of using a small oxygenator and vacuum-assisted venous drainage (VAVD) resulted in a significant decrease of intraoperative hemodilution. This technique should be strongly considered for patients with a small BSA (2) undergoing open heart surgery. Perfusion (2007) 22, 317—322.

Objective: The aim of this study was to evaluate the performance of a new temperature management system specifically designed for cardiac surgery (Allon Thermo-Wrapping Thermoregulation System; MTRE Advanced Technologies Ltd, Or Akiva, Israel) using a circulating-water garment and to compare it with a conventional forced-air cover system in order to determine whether it could reduce the incidence of perioperative hypothermia during off-pump coronary artery bypass graft (OPCAB) surgery. Design: Prospective, randomized. Setting: University, tertiary care hospital. Participants: Thirty-one patients undergoing primary OPCAB surgery. Interventions: Patients undergoing OPCAB surgery were randomized into the new thermoregulation system, Allon (study group, n = 15), and the standard forced-air system, Bair Hugger (Sterile Cardiac Access blanket Model 645; Augustine Sa, Berne, Switzerland) (control group, n = 16). Measurements and Main Results: Rectal temperature was recorded each 30 minutes during surgery and at intensive care unit arrival. Patients in the study group had higher temperatures than the control group at all time points, and the difference reached statistical significance after 2 hours of surgery. Moreover, fewer patients in the study group suffered perioperative hypothermia (defined as rectal temperature

Objective To report our experience with minimally invasive mitral valve repair. Methods From 1999 to 2003, 104 patients underwent mitral valve repair through a right anterolateral minithoracotomy. Most of them were in New York Heart Association functional class I-II, had normal ejection fraction and were in sinus rhythm. Eighty-five patients suffered from severe mitral regurgitation due to degenerative disease (n = 82) or healed endocarditis (n = 3) and 19 patients had severe mitral stenosis. Sixty-two patients underwent edge-to-edge repair due to anterior/bileaflet prolapse, 23 had a quadrangular resection of the posterior leaflet and 19 a commissurotomy. Results No conversions to sternotomy were necessary. Mean cardiopulmonary bypass and aortic cross-clamp times were 75 +/- 14 and 54 +/- 8 min, respectively. Median mechanical ventilation and intensive care unit stay times were 6 and 13 h, respectively. No in-hospital deaths and no major postoperative complications occurred. At a mean follow-up of 27.4 +/- 10.6 months, all patients but two were in New York Heart Association functional class I. The survival rate was 100% and freedom from reoperation was 95.2 +/- 3.3% at 4 years. No or mild residual mitral regurgitation was detected at echocardiography in 100 patients (96%) and moderate insufficiency was found in two (1.9%). The degree of satisfaction in terms of cosmetic result and postoperative discomfort was very high. Conclusions Mitral valve repair can be effectively performed through a minimally invasive approach achieving excellent mid-term results and a high degree of patient satisfaction in terms of comfort, cosmetic result and prompt recovery. At our institution, this approach has now become the standard procedure for mitral valve disease in young and active patients. J Cardiovasc Med 7:57-60 (C) 2006 Italian Federation of Cardiology.

"Low cardiac output syndrome and hypotension are dreadful consequences of systolic anterior motion (SAM) after a mitral valve (MV) repair. The management of SAM in the operating room remains controversial. We validate a recently suggested two-step management method and classification of this complication. This was a teaching hospital-based observational study. We validated a novel two-step conservative management method, consisting in intravascular volume expansion and discontinuation of inotropic drugs (step 1), and increasing the afterload by ascending aorta manual compression while administering esmolol e.v. (step 2). We also validate a novel classification of SAM: easy-to-revert (responding to step 1), difficult-to-revert (responding to step 2), or persistent. Fifty patients had an easy-to-revert while 26 had a difficult-to-revert SAM; 4 patients had a persistent condition (promptly diagnosed through our decisional algorithm) and underwent an immediate second pump run to repeat the mitral repair surgery. We confirmed that SAM after a repair of a degenerative MV is common and validated a simple two-step conservative management method that allows to clearly identify those few patients who require immediate surgical revision."

Perioperative and postoperative morbidity and mortality associated with cardiac surgery affect both the outcome and quality of life. Markers such as troponin effectively predict short-term outcome. In a prospective cohort study in a University Hospital we assessed the role of cardiac biomarkers, also as predictors of long-term outcome and life quality after cardiac surgery with a three-year follow-up after conventional heart surgery. Patients were interviewed via phone calls with a structured questionnaire examining general health, functional status, activities of daily living, perception of life quality and need for hospital readmission. Descriptive statistics and multivariate analysis were performed. Out of 252 consecutive patients, 8 (3.2%) died at the three years follow up: 7 for cardiac complications and 1 for cancer. Thirty-six patients (13.5%) had hospital readmission for cardiac causes (mostly for atrial fibrillation or other arrhythmias (9.3%), but none needed cardiac surgical reintervention; 21 patients (7.9%) were hospitalised for non-cardiac causes. No limitation in function activities of daily living was reported by most patients (94%), 92% perceived their general health as excellent, very good or good and none considered it insufficient; 80% were NYHA I, 17% NYHA II, 3% NYHA III and none NYHA IV. Multivariate analysis indicated preoperative treatment with digitalis or nitrates, and postoperative cardiac biomarkers release was independently associated to death. Elevated cardiac biomarker release and length of hospital stay were the only postoperative independent predictors of death in this study.

Objective: To investigate N-terminal amino-acid sequence of the B-natriuretic peptide (NT-proBNP) release and its prognostic characteristics after coronary artery bypass graft surgery with and without cardiopulmonary bypass. Design: Observational study. Setting: Teaching hospital. Participants: One hundred eighty-four patients. Interventions: The authors determined plasma concentrations of NT-proBNP just before anesthesia induction and 24 hours after the end of the surgery. Measurements and Main Results: NT-proBNP concentrations (median [interquartile range]) increased from 270 (75716) pg/mL preoperatively to 1,664 (978-3,193) pg/mL on postoperative day 1 (p < 0.001), and all postoperative values were higher than the preoperative ones. NT-proBNP concentrations at clay 1 were correlated to those at day 0 (r(2) = 0.34, p < 0.001). Patients showing elevated concentration of cTnl at day 1 (>14 ng/mL) had significantly (p = 0.04) higher plasma NT-proBNP levels than patients with a low cardiac troponin I concentration. Patients with prolonged intensive care unit (ICU) stay (>4 days) showed at day 1 significantly higher (p = 0.003) plasma NT-proBNP levels than patients with ICU stay

The diffusion of minimally invasive cardiac surgery (MICS) during open-heart surgery has increased the use of assisted venous drainage support for cardiopulmonary bypass (CPB). Peripheral cannulation with small cannulae and vacuum-assisted venous drainage (VAVD) during MICS has been adopted in our institution since 1998. After the Heartport technique (HP) experience, the trans-thoracic clamp technique is now currently used. The aim of this study is to report our experience with extrathoracic CPB with VAVD application (on CPB) during open-heart MICS. From October 1999 to June 2006, 193 patients underwent MICS. Thirty-seven (19.2%) patients were treated with the HP - 13 (35%) with robotic technology and 156 (80.8%) with trans-thoracic aortic clamping (TTAC). Mean age was 39 years (range: 12-77), and 114 patients (59.1%) were female. A total of 128 patients (66.3%) underwent mitral valve surgery, 57 (29.6%) atrial septal defect closure, five (2.6%) cardiac mass removal, and three (1.5%) tricuspid valve repair. Four patients (2.0%) had a previous cardiac procedure. Peripheral CPB was established with a standard coated circuit. A 14 Fr arterial cannula was inserted into the right jugular vein and positioned at the atrial/superior vena cava junction. A 21 or 28 percutaneous femoral cannula, depending on body surface area, was inserted in the femoral vein and an arterial cannula in the right femoral artery. Gravitational drainage was combined with VAVD. To improve the safety and effectiveness of this technique, we monitored the pressure on each venous cannula and in the reservoir. The mean CPB time was 74.8∓30 min (TTAC) and 119∓48 min (HP); mean aortic clamping time was 51∓19 min (TTAC) and 73∓29 min (HP). We did not record any neurological complication. Two patients (1.0%), one from each group, were converted to sternotomy. Three patients (1.5%) underwent re-exploration for bleeding. In-hospital mortality was 0.5% (N = 1) (HP). Mechanical ventilation time and intensive care unit stay were comparable to those recorded with conventional sternotomy. In conclusion, we found that extrathoracic CPB and VAVD during trans-thoracic clamping is a safe, simple, and effective technique for MICS. However, there is a potential risk of haemolysis and air embolism, which can be prevented with vacuum monitoring, and with the addition of gravitational drainage to reduce vacuum pressure.

Objective: To investigate the changes in perioperative anticoagulation management using a heparin-concentration-based system (HMS), and its effect on postoperative outcome. Methods: A total of 39 patients undergoing elective primary open heart surgery were randomly assigned to a heparin-concentration-based system approach (study group: 17 patients) or a standard ACT-based anticoagulation system (control group: 22 patients). Measurements and main results: Patients in the study group received a statistically significant higher dose of heparin (median 29 000 IU with IQR 22 500 33 500 IU versus median 19 000 IU with IQR 17 775 21 500 IU; p 9/L versus 125±27 × 109/L, p=0.002). None of the study patients, but six patients in the control group required transfusion of blood products (p=0.02). No differences were recorded in postoperative antithrombin activity, bleeding, and other clinical outcomes. Conclusion: he HMS system, by facilitating maintenance of a stable heparin concentration, and by determining an appropriate dose of protamine, is associated with reduced platelet consumption and does not increase AT-III consumption and postoperative bleeding.

36-YEAR-OLD woman, scheduled to undergo surgical correction of severe mitral and moderate tricuspidal regurgitation, whose surgical plan switched from a minithoracotomy to midsternotomy after an unexpected transesophageal echocardiography (TEE) finding, is presented. After induction of general anesthesia, the patient was intubated with a doublelumen endotracheal tube, and a TEE probe was inserted to perform a baseline examination (the preoperative diagnosis was made only by transthoracic echocardiography because the patient refused TEE examination) and to supervise the insertion of the venous cannula (in the minithoracotomic approach a large 14F cannula is placed percutaneously through the right jugular vein into the superior vena cava). 1

Background and objective Patients undergoing off-pump coronary artery bypass grafting (CABG) may need emergent institution of cardiopulmonary bypass (CPB) for circulatory collapse during the operation. Our aim was to evaluate outcome in such patients and identify preoperative and intraoperative risk factors. Methods This is an observational study in a University Hospital setting. In the period June 2001-July 2003, data from 988 consecutive patients undergoing CABG in our institution were prospectively collected. No interventions were made. Prolonged hospital stay (>7 days), hospital mortality, temporal trends and risk factors for conversion from off-pump to on-pump surgery were studied. Results Fifty-four patients with emergency operations and six with associated carotid artery surgery were excluded. Of the remaining 928 patients, 450 (48.5%) were planned for off-pump surgery. Thirty-seven (8.2%) of them required conversion to CPB on an emergency basis. These patients had higher mortality (5.4%) than the off-pump group (1.5%) and the CPB group (0.4%), P = 0.02. The incidence of prolonged hospital stay was also higher (conversion group = 27%, off-pump group = 12.3%, CPB group = 17.6%; P = 0.02). We did not identify any perioperative characteristics significantly associated with the risk of requiring conversion. The conversion rate was uniformly distributed over the study period. Conclusions Patients who are emergently converted to CPB during attempted off-pump procedures are at higher risk of death and prolonged hospital stay; this population should be included in comparative studies as "intention to treat" in the off-pump group.

Objective: The purpose of this study was to evaluate the effects of volatile anesthesia versus total intravenous anesthesia on cardiac troponin release in off-pump coronary artery bypass grafting (OPCAB). Design: The authors performed a multicenter randomized controlled study to compare cardiac troponin release in patients receiving either volatile anesthetics or total intravenous anesthesia for cardiac surgery on the beating heart, which is an excellent model of human myocardial ischemia. Setting: Three university hospitals. Participants: The authors randomly assigned 57 patients to desflurane (volatile anesthetic) and 55 patients to propofol (intravenous anesthetic) in addition to an opiate-based anesthesia for OPCAB. Interventions: The 2 groups of patients received either desflurane (volatile anesthetic) or propofol in addition to an opiate-based anesthesia for OPCAB. Peak postoperative troponin I release was measured as a marker of myocardial necrosis. Prolonged hospitalization was considered as a secondary outcome. Measurements and Main Results: Patient mean age was 69 years, and 82% were men. There was a significant (p < 0.001) reduction in postoperative median (25th-75th percentiles) peak of troponin I in patients receiving volatile anesthetics, 1.2 (0.9-1.9) ng/dL, compared with patients receiving total intravenous anesthesia, 2.7 (2.1-4.0) ng/dL. This myocardial protection resulted in a reduced (p = 0.04) number (percentage) of patients requiring postoperative inotropes, 20 (35%) versus 31 (56%), and a reduced number (percentage) of patients submitted to prolonged hospitalization ( 7 days), 7 (12%) versus 20 (36%) in the 2 groups (p = 0.005). One patient receiving total intravenous anesthesia died within 30 days of surgery. Conclusions: Myocardial damage measured by cardiac troponin release could be reduced by volatile anesthetics during OPCAB. Because patients underwent cardiac surgery on the beating heart, these results could have implications for cardiac patients undergoing noncardiac surgery. (C) 2006 Elsevier Inc. All rights reserved.

BACKGROUND: During cardiopulmonary bypass, blood contact with the large nonendothelial surfaces of the extracorporeal circuit induces activation and consumption of platelets and plasma coagulation factors. Phosphorylcholine (Pc) coating of oxygenators has been designed to improve surface biocompatibility. We evaluated the effects of a Pc-coated oxygenator on blood coagulation in patients undergoing high-risk open heart surgery and receiving tranexamic acid.METHODS: Thirty-nine patients undergoing reoperative valvular or combined procedures were randomized to the use of an oxygenator treated with Pc coating (Pc group) or of a standard oxygenator (control group). Platelet count, soluble CD40 ligand, fibrinogen, antithrombin, D-Dimer, prothrombin fragment 1.2 (F1.2), and free plasma hemoglobin levels were measured at baseline, at aortic unclamping, and at arrival in the intensive care unit.RESULTS: Postoperative bleeding, need for blood products, and clinical outcomes were similar in the two groups. At unclamping, F1.2, a marker of in vivo thrombin formation, increased to a greater extent in control patients than in Pc patients (p = 0.02), and in the latter group of patients was positively correlated with aortic cross-clamp times (r = 0.70). Relative to baseline values, the percent decrease in platelet count, fibrinogen, and antithrombin levels was not significantly different in Pc patients and in control patients after adjustment for multiple comparisons, but the percent decrease in platelet counts was negatively correlated with F1.2 levels in the entire series of patients (r = -0.62, p < 0.0001). All the evaluated parameters were similar in the two groups of patients at arrival in the intensive care unit.CONCLUSIONS: For patients undergoing high-risk open heart surgery and receiving tranexamic acid, a phosphorylcholine-coated oxygenator may reduce intraoperative thrombin formation and the associated consumption of platelets, fibrinogen, and antithrombin.

All patients undergoing heart surgery experience a certain amount of nonspecific myocardial injury documented by the release of cardiac biomarkers and associated with poor outcome. We investigated the role of unipolar radiofrequency ablation of atrial fibrillation on the release of cardiac biomarkers in 71 patients undergoing mitral valve surgery and concomitant left atrial ablation case-matched with 71 patients undergoing isolated mitral surgery. The study was powered to detect a 3 ng/mL difference. There was no difference between the 2 groups in terms of cardiac troponin 1 (10 +/- 5.3 versus 12 + 10.4 ng/mL; P = 0.7) or creatine kinase-MB (50 +/- 21.8 versus 57 +/- 62.0 ng/mL; P = 0.5) release. Postoperative peak cardiac troponin I levels had univariate associations with the duration of cardiopulmonary bypass (P = 0.002) and aortic cross-clamping (P = 0.001) and with the surgical technique (15 +/- 12 ng/mL for mitral valve replacement versus 9 +/- 14.8 for mitral valve repair; P = 0.0007) at univariate analysis. Mitral valve replacement was the only independent predictor of postoperative peak release of cardiac troponin I identified with multivariate analysis (P = 0.005). Radicifrequency ablation of atrial fibrillation does not significantly increase cardiac biomarker release compared with isolated mitral surgery; mitral valve repair is associated with less release of cardiac biomarkers compared with mitral valve replacement.

Objective : Atrial fibrillation is the most common complication after coronary artery bypass graft surgery. This arrhythmia may lead to hemodynamic compromise, prolonged hospitalization, and increased risk for cerebral thromboembolism. Older age is the only variable consistently associated with the development of postoperative atrial fibrillation; however, no strong predictive model exists. The purpose of this study was to identify perioperative characteristics associated with new-onset atrial fibrillation in patients undergoing off-pump coronary artery bypass grafting. Design : Prospective, observational. Setting : University tertiary care hospital. Participants : One hundred sixty consecutive patients undergoing off-pump coronary artery bypass grafting. Interventions : None. Measurements and Main Results : Incidence of postoperative atrial fibrillation was the major outcome. Atrial fibrillation occurred in 33 patients (20.6%). Multivariate analysis identified reintervention (odds ratio 26.8), revascularization of the ramus medianus (odds ratio 3.9), and age (odds ratio 1.069 per year) as the only independent predictors of postoperative atrial fibrillation. All patients were in sinus rhythm at hospital discharge. One hospital death was noted. Conclusions : Despite the less invasive approach, the incidence of postoperative atrial fibrillation is high after off-pump coronary artery bypass grafting. Older age, grafting of the ramus medianus, and a redo operation were predictors of new-onset postoperative atrial fibrillation. It is possible that left atrial stretching with heart dislocation during revascularization of the lateral wall could lead to postoperative atrial fibrillation.

Objective: Atrial fibrillation is a common complication after cardiac surgery. Magnesium is an effective and safe antiarrhythmic agent for arrhythmias that develop after cardiac surgery. The authors performed a study to evaluate the role of perioperative magnesium for prophylaxis of atrial fibrillation after off-pump coronary artery surgery. Design: Randomized controlled study. Setting: University teaching hospital. Participants: One hundred sixty consecutive patients undergoing elective, isolated, off-pump coronary artery bypass grafting were prospectively randomized into 2 groups. Interventions: Patients in the magnesium group (n=80) received a 2.5-g (20 mEq) magnesium sulphate infusion intraoperatively over 30 minutes, and the placebo group (n=80) received normal saline solution. Measurements and main results: Postoperative atrial fibrillation occurred in 16 of 80 patients (20%) in the magnesium group and in 18 of 80 (22.5%) in the placebo group (p=0.9). Conclusion: The use of 2.5 g of intraoperative magnesium showed no effect in preventing atrial fibrillation after off-pump coronary artery bypass. (C) 2005 Elsevier Inc. All rights reserved. OBJECTIVE: Atrial fibrillation is a common complication after cardiac surgery. Magnesium is an effective and safe antiarrhythmic agent for arrhythmias that develop after cardiac surgery. The authors performed a study to evaluate the role of perioperative magnesium for prophylaxis of atrial fibrillation after off-pump coronary artery surgery.DESIGN: Randomized controlled study.SETTING: University teaching hospital.PARTICIPANTS: One hundred sixty consecutive patients undergoing elective, isolated, off-pump coronary artery bypass grafting were prospectively randomized into 2 groups.INTERVENTIONS: Patients in the magnesium group (n = 80) received a 2.5-g (20 mEq) magnesium sulphate infusion intraoperatively over 30 minutes, and the placebo group (n = 80) received normal saline solution.MEASUREMENTS AND MAIN RESULTS: Postoperative atrial fibrillation occurred in 16 of 80 patients (20%) in the magnesium group and in 18 of 80 (22.5%) in the placebo group (p = 0.9).CONCLUSION: The use of 2.5 g of intraoperative magnesium showed no effect in preventing atrial fibrillation after off-pump coronary artery bypass.

Background— Acute renal failure is a serious complication of cardiac surgery causing high morbidity and mortality. The aim of this study was to evaluate the usefulness of fenoldopam, a specific agonist of the dopamine-1 receptor, in patients at high risk of perioperative renal dysfunction. Methods and Results— A prospective single-center, randomized, double-blind trial was performed after local ethical committee approval and after written consent was obtained from 80 patients undergoing cardiac surgery. Patients received either fenoldopam at 0.05 μg/kg per minute or dopamine at 2.5 μg/kg per minute after the induction of anesthesia for a 24-hour period. All these patients were at high risk of perioperative renal dysfunction as indicated by Continuous Improvement in Cardiac Surgery Program score >10. Primary end point was defined as 25% creatinine increase from baseline levels after cardiac surgery. The 2 groups (fenoldopam versus dopamine) were homogeneous cohorts, and no difference in outcome was observed. Acute renal failure was similar: 17 of 40 (42.5%) in the fenoldopam group and 16 of 40 (40%) in the dopamine group ( P =0.9). Peak postoperative serum creatinine level, intensive care unit and hospital stay, and mortality were also similar in the 2 groups. Conclusions— Despite an increasing number of reports of renal protective properties from fenoldopam, we observed no difference in the clinical outcome compared with dopamine in a high-risk population undergoing cardiac surgery.

Objective: Complications occurring after coronary artery bypass graft (CABG) surgery, particularly neurologic damage, have been mainly correlated with the use of cardiopulmonary bypass (CPB). The aim of this work was to compare postoperative outcomes of patients undergoing CABG surgery, with or without the use of CPB, focusing on neurologic events. Design: Observational study. Setting: University tertiary care hospital. Participants: Two thousand seven hundred and forty consecutive patients who underwent CABG surgery in the period January 1998 to January 2003. Interventions: None. Measurements and Main Results: For 738 patients, the operation was performed off-pump (OP group), and for 2002 patients CPB was used (CPB group). OP and CPB groups were compared with regard to preoperative status, anesthetic management, and postoperative outcomes, by means of univariate and multivariate analyses. Surgeons' propensity to operate off-pump was based on patients' age, renal conditions, and hemodynamics. Univariate and multivariate analyses showed that CPB was associated with a higher incidence of type I neurologic events compared with OP technique (2.1% versus 0.9%, odds ratio [OR]: 2.6, 95% confidence interval [CI], 1.2-5.9). A history of previous stroke (OR: 2.7, 95% CI, 1.2-5.9) and advanced age (OR: 1.06 per year, 95% CI, 1.02-1.09) were additional independent predictors of postoperative type I neurologic events. Conclusions: In the authors' experience, off-pump CABG surgery offers some benefits compared with CPB in respect to major neurologic complications. (c) 2005 Elsevier Inc. All rights reserved.

Background. The aim of this study is to report our overall experience with minimally invasive mitral valve repair for correction of severe mitral regurgitation in the setting of Barlow's disease. Methods. Between 1999 and 2003, 48 patients with bileaflet prolapse in the context of Barlow's disease underwent minimally invasive mitral valve repair using the "edge-to-edge" technique. Mean age was 37.9 &PLUSMN; 9.1 and 58% were female. Most of the patients were in New York Heart Association (NYHA) class I or II and all of them had normal left ventricular ejection fraction. Results. There were no conversions to sternotomy. Mean cardiopulmonary bypass and aortic cross-clamp times were 77 &PLUSMN; 16 minutes and 56 &PLUSMN; 8 minutes. No in-hospital deaths and no major postoperative complications occurred. At a mean follow-up of 22.7 &PLUSMN; 10.6 months, survival rate and freedom from reoperation were 100%. All patients were in NYHA class I and in sinus rhythm. No residual mitral regurgitation was detected at echocardiography in 33 (68.7%) patients and mild insufficiency was found in 15 (31.2%). The degree of satisfaction in terms of cosmesis and postoperative pain was very high and 73% of the patients were back to work and to normal activity in 4 weeks. Conclusions. Mitral insufficiency due to Barlow's disease can be effectively corrected through a minimally invasive approach by using the "edge-to-edge" technique. In our opinion, the excellent midterm results and the high degree of patients satisfaction certainly justify the adoption of this strategy in a selected group of young and active people. © 2005 by The Society of Thoracic Surgeons.

Objective: To investigate the release of cardiac biomarkers (troponin 1 and CK-MB) in patients undergoing coronary artery bypass graft (CABG) with or without cardiopulmonary bypass (CPB). Design: Prospective study. Setting: University tertiary hospital. Participants: Sixty-five consecutive patients undergoing coronary artery bypass grafting (greater than or equal to2 vessel disease, ejection fraction greater than or equal to0.35%, elective procedure). Interventions: Cardiac biomarkers were measured before surgery, at intensive care unit arrival, 4 and 18 hours after the end of the procedure. Measurements and Main Results: Cardiac biomarker release was higher in on-pump than in off-pump patients at every time point. On multivariate analysis, CPB (p < 0.0001), number of distal grafts (p = 0.005), and hypertension treatment (p = 0.03) were the only independent predictors of peak cardiac troponin release. Conclusions: Cardiac troponin 1 release after multivessel CABG is associated with the technique. Different values for the normal range should be considered. OPCABG is minimally invasive for the heart as far as myocardial marker release is concerned. (C) 2004 Elsevier Inc. All rights reserved.

Objective: The purpose of this study was to determine whether coronary artery bypass grafting (CABG) surgery on the beating heart (BH) is associated with reduction of R-wave potentials on the precordial leads on the surface electrocardiogram (ECG) as previously shown for CABG with cardiopulmonary bypass. Methods: Fifty-four patients undergoing CABG surgery at a single tertiary care university hospital were analyzed. Patients suffering a postoperative cardiac event (myocardial infarction) or nonspecific ECG changes were excluded. ECG results were recorded at arrival in the intensive care unit, after 4 and 18 hours postoperatively; simultaneously, myocardial cell damage biomarkers (CK-MB and cTnl) were assayed. A control group of 31 patients undergoing mitral valve repair was also evaluated. Results: Patients operated with the BH (OPCABG) technique did not show any decrease of R-wave amplitude at 0, 4, and 18 hours postoperatively; whereas those operated with CPB, both for coronary artery surgery and for mitral repair, had a similar extent and pattern of R-wave reduction. The release of myocardial necrosis markers was significantly lower in coronary artery patients operated with BH than in those operated with CPB; however, no statistically significant correlation between the ECG changes and release of myocardial cell damage markers was observed in any of the groups. Conclusions: The findings indicate, for the first time, that CABG surgery on the BH is not followed by any reduction of R-wave amplitude on precordial leads and confirms that the BH technique is associated with a lower release of myocardial cell damage markers. (C) 2004 Elsevier Inc. All rights reserved.

Objective: The appearance of new Q waves on the electrocardiogram (ECG) after cardiac surgery has been traditionally considered a sign of major myocardial tissue damage. The aim of this study was to investigate the clinical significance of new Q waves appearing following cardiac surgery and to correlate them with the release of myocardial cell damage biomarkers. Methods: 206 consecutive patients undergoing cardiac surgery were prospectively evaluated. A 12 lead ECG was recorded and cardiac troponin I and creatinekinase subtraction MB assayed the day before surgery, on arrival at the intensive care Unit. 4 and 18 h postoperatively and every morning until the fifth postoperative day. Results: The incidence of new Q waves was 7.3%. Patients with isolated ECG findings had an uneventful postoperative course; on the contrary, when ECG changes were coupled with the release of myocardial necrosis biomarkers, patients had a complicated postoperative course. Conclusions: The association of a new Q wave and high levels of myocardial necrosis biomarkers is strongly associated with postoperative cardiac events. On the contrary, the isolated appearance of a new Q wave has no impact on the postoperative cardiac outcome. (C) 2004 Elsevier B.V. All rights reserved.

Aim. The aim of the study was to investigate if the off-pump technique could reduce the hospital mortality after coronary artery bypass grafting when compared to the standard cardiopulmonary bypass (CPB) technique. Methods. An observational study with propensity score matching analysis was performed in a university teaching hospital in 2 899 consecutive patients undergoing elective coronary artery bypass grafting. No intervention was performed. Major perioperative complications and hospital mortality were noted. Results. The overall hospital mortality was 1.3% (39/2 899) with no difference between the off-pump (16/802, 2.0%) and the CPB group (23/2 097, 1.1%) P=0.09. Since the off-pump group included patients at high risk, a propensity score analysis was then performed and off-pump patients matched 1: 1 to CPB patients in order to have the same pre-operative variables identified by a multivariate analysis as associated to surgeon propensity to operate off-pump: (age, chronic renal failure and low ejection fraction) and the same number of graft performed. The results of the propensity matching still showed no difference in hospital mortality between off-pump and CPB group (1.6% vs 1.1% P=0.6). The off-pump technique showed advantages in terms of transfusion of blood products (P < 0.001) and reduction of surgical re-exploration (P=0.04). Conclusion. No difference in hospital mortality in coronary artery bypass grafting patients could be observed between patients operated off-pump or with the standard CPB technique.