IntroductionCardioplegia (CP) is integral to myocardial protection during cardiac surgery. Two standard cardioplegic solutions viz. Del Nido solution (DNS) and St Thomas solution (STS) are widely used in cardiac surgeries. The DNS is a single-dose CP that offers superior myocardial protection in adults, and studies have claimed myocardial injury in STS patients. The elevated circulatory level of citric acid cycle intermediate, succinate is a metabolic hallmark of ischemia. Its rapid oxidation after reperfusion causes ischemia-reperfusion (IR) injury through mitochondrial reactive oxygen species production. Succinate has been identified as an early marker of IR injury through blood plasma/serum-based clinical metabolomics studies. The primary objective of the study was metabolomic profiling of succinate from the coronary sinus and venous blood.MethodsTwo blood samples each were obtained from coronary sinus (CS) & venous reservoir from patients before the application of aortic cross-clamp and after the release of aortic cross-clamp from 22 patients divided into two groups. The blood-serum metabolic profiles were measured by 800 MHz NMR spectrometer and compared using univariate statistical analysis methods. The study also compared the two groups' cardiopulmonary bypass variables and left ventricle functions.ResultDNS leads to increased serum levels of succinate in the coronary sinus blood after the reperfusion compared to STS. The results of our study are consistent with a previous study that found DNS administration (90minutes) increases the inflammatory response in the myocardium.ConclusionNMR-based serum metabolomics revealed significantly increased circulatory succinate in coronary sinus blood of patients administered with DNS cardioplegia in comparison to STS cardioplegia. URL- https://ctri.nic.in/Clinicaltrials/login.php.

IntroductionExtracorporeal membrane oxygenation (ECMO) provides critical support to patients in severe cardiac and respiratory failure, but it requires anticoagulation to prevent complications like bleeding and thrombosis. Heparin, the primary anticoagulant utilized, is monitored by activated partial thromboplastin time (aPTT) and anti-Factor Xa (AntiXa) levels. Discordance between the two assays complicates its titration and the impact on patient outcomes is not well-established. This study examines the prevalence of discordance, its impact on heparin dosing, and the association of bleeding, thrombosis, ICU-free days, and mortality in pediatric ECMO patients.MethodsThis secondary analysis of the Bleeding and Thrombosis on Extracorporeal Membrane Oxygenation study consisted of 511 patients under 19 years. Demographics, laboratory results, ECMO indications, daily heparin doses, and clinical outcomes were collected. Discordance was categorized as major or minor, and adjustments to heparin dosing were analyzed for appropriateness based on normal ranges of aPTT and AntiXa. Logistic regression models assessed the impact of heparin titration strategies on bleeding, clotting, ICU-free days, and mortality.ResultsMajor discordance occurred on 17.5% of days with high aPTT and low AntiXa being most common. Titrating heparin based on AntiXa in scenarios of discordance was associated with an 11% lower incidence of bleeding compared to aPTT (p = .02). Higher proportion of concordance was independently associated with increased bleeding and/or clotting, but not significantly affect ICU-free days or mortality.ConclusionDiscordance is common in pediatric ECMO patients. AntiXa-guided heparin titration, notably during discordant periods, is associated with fewer bleeding and clotting events. This emphasizes the need for improved anticoagulation protocols since discordance does not demonstrate worse ICU-free days or mortality.

BackgroundThis meta-analysis aimed to compare survival outcomes among patients experiencing improvement in untreated significant mitral regurgitation (MR) following surgical aortic valve replacement (SAVR) or transcatheter aortic valve replacement (TAVR) for severe aortic stenosis, in contrast to those without improvement.MethodsWe conducted a comprehensive search through February 2024. Pooled hazard ratios (HR) with 95% confidence intervals (CI) were computed. Kaplan-Meier curves depicting all-cause mortality were reconstructed using individual patient data derived from the included studies.ResultsA systematic review identified twelve non-randomized studies encompassing 4040 patients. The pooled all-cause mortality of the meta-analysis demonstrated a significant reduction in patients whose MR improved compared to those with persistent MR after aortic valve replacement (AVR) (HR [95% CI] = 0.55 [0.47-0.64], p < .01). The hazard ratio, derived from reconstructed time-to-event data, indicated lower all-cause mortality in patients with improved MR after AVR relative to the other cohort (HR [95% CI] = 0.50 [0.40-0.62], p < .01 in all patients, 0.48 [0.34-0.68], p < .01 in patients undergoing SAVR, and 0.58 [0.42-0.80], p < .01 in those receiving TAVR).ConclusionIn conclusion, this meta-analysis revealed that improved MR after AVR, whether surgically or by transcatheter approach, correlates with superior survival. The benefits of simultaneous or staged intervention on the mitral valve in individuals undergoing AVR warrant validation in future investigations.

Transcatheter aortic valve implantation (TAVI) has revolutionized the treatment of severe aortic stenosis in high-risk patients, offering a minimally invasive alternative to open-heart surgery. However, complications such as hemodynamic instability may require mechanical circulatory support. In some cases, emergent cardiac surgery may be required, necessitating a swift transition to cardiopulmonary bypass (CPB). We modified the CPB circuit allowing for circulatory support and easy transition to CPB. No bleeding or vascular complications were observed. The modified CPB circuit minimizes hemodynamic disruptions and allows for postoperative ECMO support.

BackgroundThe inflammatory response to cardiopulmonary bypass (CPB) in pediatric patients remains an unresolved challenge. Sanguineous CPB prime, composed of allogenic blood products, is one potentially important stimulus. This study aims to identify specific inflammatory mediators active in sanguineous CPB prime and their impact on the inflammatory response at CPB initiation.MethodsIn a post-hoc analysis of a prospective observational cohort study (NCT05154864), where pediatric patients undergoing cardiac surgery with CPB were enrolled after informed consent, patients were grouped by CPB prime type (sanguineous vs crystalloid). Arterial samples were collected post-sternotomy as a baseline and again at CPB initiation from all patients. In the sanguineous group, CPB prime samples were also collected after buffered ultrafiltration but before CPB initiation. Luminex® measured concentrations of 24 inflammatory mediators for comparison between groups. Statistical analyses were by Mann-Whitney test and Wilcoxon signed-rank test. Data are presented as median [IQR].ResultsForty consecutive pediatric patients participated. The sanguineous group (n = 26) was younger (4.0 [0.2 – 6.0] vs 48.5 [39.0 – 69.5] months; p = 2.6 × 10−7) and smaller (4.9 [34 – 6.6] vs 17.2 [14.9 – 19.6] kg; p = 2.6 × 10−7) than the crystalloid group (n = 14). Despite this, baseline concentrations of 20 complement and cytokine concentrations were comparable between groups (p > 0.05) while four showed differences between groups (p < 0.05). The sanguineous prime contained supraphysiologic concentrations of complement mediators: C2, C3, C3a, C3b, and C5a. Correspondingly, upon CPB initiation, patients receiving sanguineous prime exhibited a significantly larger burden of C2, C3, C3b, C5, and C5a (p < 0.001) relative to the crystalloid group. Cytokine and chemokine mediators were present at trace levels in the sanguineous prime.ConclusionsSanguineous prime contains activated complement that accelerates the inflammatory response at CPB initiation in neonates and infants. Immunomodulatory interventions targeting complement during CPB prime preparation could offer substantial benefits for these vulnerable patients.

Managing intracranial hemorrhage in patients supported by extracorporeal oxygenation (ECMO) presents significant clinical challenges. We report a case of a postpartum patient with severe acute respiratory distress syndrome (ARDS) necessitating venovenous ECMO support, complicated by multicompartmental intracranial hemorrhage resulting in brain herniation and necessitating emergent medical and surgical management of refractory intracranial hypertension. Care was guided by multimodal neuromonitoring, including intracranial pressure monitoring and electroencephalography. Despite these challenges, the patient achieved excellent neurological recovery. This case underscores the intricacies of managing neurological complications during ECMO and highlights the potential benefits of comprehensive neuromonitoring strategies.

Sternal reentry for repair of aortic pseudoaneurysms poses a unique technical challenge to prevent exsanguination. Initiation of peripheral cardiopulmonary bypass and deep hypothermic circulatory arrest prior to reentry are the cornerstones of a successful surgical approach. Adjunctive bilateral antegrade cerebral perfusion increases safe arrest time and reduces neurologic morbidity. Herein, we describe our safe reentry technique for aortic pseudoaneurysm repair in two patients.

IntroductionSurgical repair of aortic arch hypoplasia in children requires a "dry" surgical field with reliable end-organ protection. Perfusion strategies commonly involve deep hypothermic circulatory arrest (DHCA) and variations of the continuous perfusion techniques, such as selective antegrade cerebral perfusion (SACP) and full-flow perfusion with double aortic cannulation (DAC). We aimed to evaluate the end-organ protection in the surgery of aortic arch hypoplasia in newborns and infants using DHCA and DAC.Materials and methods66 newborns and infants with aortic arch hypoplasia and biventricular anatomy were enrolled in this prospective study. Patients were randomly assigned into two groups according to the perfusion strategy - DHCA (n = 33); and DAC (n = 33). Primary endpoint: acute kidney injury (AKI), graded according to the KDIGO score. Secondary endpoints: neurological sequelae (pre- and postoperative MRI), in-hospital mortality.ResultsThe lowest temperature was 32 (28; 34)°С in the DAC group and 23 (20; 25)°С in the DHCA group. The patients with DAC had lower incidence of AKI (6 patients (18.2%) versus 19 patients (57.6%); p = .017). In the multivariate analysis, the inotropic index at 48h was identified as a risk factor, increasing the risk of AKI by 4%. The DHCA group was associated with a 3.8-fold increase in the risk of AKI. There was no difference in hospital mortality between the DAC and DHCA groups (1 patient (3%) versus 3 patients (9.1%); p = .61). Neurological sequelae by MRI scan were observed in 18 patients (54.5%) in the DHCA group compared to 5 patients (15.15%) in the DAC group (p = .026). The only risk factor identified in the multivariate analysis for neurological lesions on MRI scan was the DHCA group, which increased the risk by 8.8 times.ConclusionsSurgical reconstruction of the aortic arch hypoplasia using the method of full-body perfusion reduces the incidence of neurological lesions and renal complications requiring renal replacement therapy compared with the deep hypothermic circulatory arrest in neonates and infants.

ObjectivesVeno-arterial extracorporeal life support (V-A ECLS) is increasingly being utilized for postcardiotomy shock (PCS), though data describing the relationship between type of indexed operation and outcomes are limited. This study compared V-A ECLS outcomes across four major cardiovascular surgical procedures.MethodsThis was a single-center retrospective study of patients who required V-A ECLS for PCS between 2015 and 2022. Patients were stratified by the type of indexed operation, which included aortic surgery (AoS), coronary artery bypass grafting (CABG), valve surgery (Valve), and combined CABG and valve surgery (CABG + Valve). Factors associated with postoperative outcomes were assessed using logistic regression.ResultsAmong 149 PCS patients who received V-A ECLS, there were 35 AoS patients (23.5%), 29 (19.5%) CABG patients, 59 (39.6%) Valve patients, and 26 (17.4%) CABG + Valve patients. Cardiopulmonary bypass times were longest in the AoS group (p < 0.01). Regarding causes of PCS, AoS patients had a greater incidence of ventricular failure, while the CABG group had a higher incidence of ventricular arrhythmia (p = 0.04). Left ventricular venting was most frequently utilized in the Valve group (p = 0.07). In-hospital mortality was worst among CABG + Valve patients (p < 0.01), and the incidence of acute kidney injury was highest in the AoS group (p = 0.03). In multivariable logistic regression, CABG + Valve surgery (odds ratio (OR) 4.20, 95% confidence interval 1.30-13.6, p = 0.02) and lactate level at ECLS initiation (OR, 1.17; 95% CI, 1.06-1.29; p < 0.01) were independently associated with mortality.ConclusionsWe demonstrate that indications, management, and outcomes of V-A ECLS for PCS vary by type of indexed cardiovascular surgery.