Objective To evaluate the effectiveness and safety of dexmedetomidine for postoperative sedation in cardiac patients. Methods Such databases as PubMed, EBSCO, Springer, Ovid, The Cochrane Library, CBM, CNKI, VIP and WanFang Data were searched electronically from the date of their establishment to May 2012, and other relevant journals and references of the included literature were also searched manually. Two reviewers independently screened the studies in accordance with the inclusion and exclusion criteria, extracted data and assessed methodology quality. Then the meta-analysis was performed using RevMan 5.1software. Results A total of 8 randomized controlled trials (RCTs) involving 1 157 patients were included. The Jadad scores of 7 RCTs were more than 3, and only 1 RCT scored 2. The results of meta-analysis showed that compared with the control group, dexmedetomidine significantly raised peripheral oxygen saturation (RR=0.90, 95%CI 0.31 to 0.49, P=0.003), decreased the incidence of average heart rate (RR=–5.86, 95%CI –7.31 to −4.40, Plt;0.000 01), ventricular tachycardia (RR=0.27, 95%CI 0.08 to 0.88, P=0.03), delirium (RR=0.28, 95%CI 0.16 to 0.48, Plt;0.000 01) and postoperative hyperglycemia (RR=0.57, 95%CI 0.38 to 0.85, P=0.006), and reduced the number of patients who needed vasoactive agents such as epinephrine (RR=0.53, 95%CI 0.29 to 0.96, P=0.04) and β-blocker (RR=0.60, 95%CI 0.38 to 0.94, P=0.03). However, it failed to shorten the time of both ICU stay (RR=−1.24, 95%CI −4.35 to 1.87, P=0.43) and mechanical ventilation (RR=−2.28, 95%CI −5.13 to 0.57, P=0.12), increase mean artery pressure (RR=−2.78, 95%CI −6.89 to 1.34, P=0.19), and well control postoperative nausea, vomiting and atrial-fibrillation. There were no significant differences between the two groups in myocardial infarction, acute cardiac failure, acute kidney failure, and mortality rate. Conclusion For postoperative sedation in cardiac patients, dexmedetomidine can effectively stabilize hemodynamic indexes, and reduce tachycardia, delirium, postoperative hyperglycemia and vasoactive agents. However, it has no marked influence on the prognosis. For the quantity and quality limitation of included studies, this conclusion needs to be proved by performing more high quality and large sample RCTs.
Objective To systematically review the effectiveness and safety of thoracic epidural analesis (TEA) for postoperative complications after cardiac surgery. Methods Such databases as PubMed, Science Citation Index, EMbase, The Cochrane Library, CNKI and CBM were electronically searched from inception to October 2012 for collecting the randomized controlled trials on the effectiveness and safety of thoracic epidural analgesisa for postoperative complications after cardiac surgery. Two reviewers independently screened literature according to inclusion and exclusion criteria, extracted data, and assessed the methodological quality of the included studies. Then, meta-analysis was performed using RevMan 5.1 software. Results Totally 14 studies were eligible, involving 1 942 patients. The results of meta-analysis showed that, TEA combined with general anesthesia (GA) was superior to GA alone in reducing the incidences of myocardial ischemia/infarction (RR=0.63, 95%CI 0.41 to 0.96, P=0.03), respiratory complications (RR=0.55, 95%CI 0.40 to 0.75, P=0.000 1), supraventricular arrhythmias (RR=0.64, 95%CI 0.47 to 0.88, P=0.005), and duration of mechanical ventilation (MD= –2.15, 95%CI –3.72 to –0.58, P=0.007), with significant differences. Conclusions Current evidence shows that, TEA after surgery is effective in reducing the incidences of myocardial ischemia/infarction, respiratory complications, supraventricular arrhythmias, and duration of mechanical ventilation. There is the lack of data on the adverse events of TEA (mainly referring to epidural hematoma). Due to limited quality and quantity of the included studies, patients’ conditions should be fully considered before applying TEA in clinical practice.
Objective To analyze the risk factors for ventilator-associated pneumonia( VAP) in adult patients undergoing cardiac surgery with cardiopulmonary bypass ( CPB) . Methods A total of 127 consecutive adult patients who received postoperative ventilation for more than 48 hours between January 2002 and June 2008 in the cardiac surgical intensive care unit( CSICU) were included in this study. The patients were assigned into a VAPgroup( n =64) and a control group( n = 63) . Pre-, intra-, and postoperative factors were collected and analyzed between two groups, and the multivariate analysis( logistic regression)were used to identify the risk factors of VAP. Results The overall incidence of VAP was 5.1%. The mortality of VAP was 28. 1% . Compared to the control group, the patients in the VAP group had longer duration of cardiopulmonary bypass time, ventilation time, more blood products usage and the duration of stay in CSICU( P lt; 0. 001) , higher morbidity of low cardiac output syndrome and tracheotomy( P lt; 0. 01) and higher rate of aortic surgery and mortality( P lt; 0. 05) . The preoperative left ventricular ejection fraction ( LVEF) and postoperative oxygenation index( PaO2 /FiO2 ) were lower in the VAP group than those of the control group( P lt; 0. 001) . Five variables were found to be significantly related to the development of VAP by multivariate analysis: CPB time gt; 120 min( OR = 6. 352, P = 0. 000) ; PaO2 /FiO2 lt; 300 mm Hg( OR =3. 642, P = 0. 017) , transfusion of blood products ≥1500 mL( OR = 5. 083, P = 0. 039) , ventilation time≥5 days( OR = 9. 074, P = 0. 047) and tracheotomy( OR = 19. 899, P = 0. 021) . A total of 102 pathogens were obtained by sputum culture in 64 VAP patients. There were 62( 60. 8% ) cases of gram negative bacilli, 19 cases( 18. 6% ) of gram positive cocci and 21( 20. 6% ) cases of eumycetes. Conclusion This study shows that the cardiopulmonary bypass time, ventilation time, hypoxemia, blood products transfusion and tracheotomy are risk factors most likely associated with VAP development.
Objective To assess the value of pulmonary ventilation test in evaluating the prognosis of cardiac surgery patients. Methods Data were collected retrospectively from consecutive patients with coronary heart disease or valvular disease, who were prepared for cardiac surgery in Zhongshan Hospital from January 2007 to December 2008. The main outcome indices were mortality of surgery, the prolonging time of using artificial airway ( ≥3 days) , and the prolonging time in intensive care units ( ICU) ( ≥5 days) . Then the relationship between the poor outcome and ventilation disorder was analyzed. Results In the 422 cases,the incidence of ventilation disorder was 55% , included 27. 5% restrictive ventilation disorder, 15. 6% obstructive ventilation disorder, and 11. 8% mixed ventilation disorder. And the severity of pulmonaryventilation disorder was mild of 34. 6% , moderate of 15. 2% , and severe of 5. 2% . Among the 42 patients who gave up surgery,50% were due to ventilation dysfunction, and the patients were prone to give up surgery with the deterioration of pulmonary function( P lt; 0. 001) . But comparing with the patients with normal pulmonary function, the risk of poor outcome after surgery did not significantly increase in the patients with ventilation disorder ( P gt; 0. 05 ) . The logistic regression analysis indicated that cardiopulmonary bypass ( CPB) was an absolute risk factor ( P lt; 0. 05) . Conclusions The incidence of ventilation disorder in patients with cardiac disease is quite high. Severe pulmonary ventilation disorder is the significant cause of giving up surgery, but may be not the absolute contraindication of cardiac surgery.
Objective To investigate the prognosis and risk factors of cardiac surgical patients with preoperative renal dysfunction，and evaluate the accuracy of estimated glomerular filtration rate （eGFR） as a predictor of adverse outcomes. Methods A total of 2 151 adult patients undergoing cardiac surgery in Renji Hospital，School of Medicine of Shanghai Jiaotong University from January 2005 to December 2009 were included in this study. There were 1 267 male patientsand 884 female patients with their average age of 58.7 （18-99）years. Clinical characteristics of patients with preoperative renal dysfunction，severity of postoperative acute kidney injury （AKI）and patients’ outcomes were analyzed. Multivariate logistic regression was performed to analyze perioperative risk factors of postoperative AKI. Receiver operating characteristic（ROC） curve was used to evaluate the accuracy of eGFR to predict patients undergoing postoperative renal replacement therapy （RRT） and in-hospital death. Results A total of 221 patients （10.27%） had preoperative renal dysfunction，among whom 124 patients （56.11%） developed postoperative AKI. Patients with preoperative renal dysfunction were older，had more comorbidities including hypertension and diabetes mellitus，were more likely to receive postoperative RRT，and had worse outcomes. Patients with decreased preoperative eGFR had significantly higher in-hospital mortality. Patients with preoperative renal dysfunction who developed postoperative AKI had the worst prognosis. Multivariate logistic regression showed that hypertension （OR=4.497，P=0.003），postoperative central venous pressure （CVP） ＜6 cm H2O （OR=16.410，P=0.000） and postoperative CVP＞14 cm H2O （OR= 5.178，P=0.013） were independent predictors of postoperative AKI for patients with preoperative renal dysfunction. The areas under the ROC curves of eGFR to predict in-hospital mortality and postoperative RRT were 0.691 and 0.704 respectively （95% CI 0.630-0.752，P=0.000；95% CI 0.614-0.795，P=0.001）. Conclusion Patients with preoperative renal dysfunction are older，have more comorbidities，higher likelihood to develop postoperative AKI and worse prognosis. Hypertension，postoperative CVP＜6 cm H2O and postoperative CVP＞14 cm H2O are independent predictors of postoperative AKI for patients with preoperative renal dysfunction. We believe eGFR can accurately predict the risk of adverse kidney outcomes and in-hospital death of patients undergoing cardiac surgery.
Objective To analyze risk factors of acute kidney injury （AKI） after cardiac surgery in adults and develop a clinical score system to predict postoperative AKI. Methods Clinical data of 3 500 consecutive patients undergoing cardiac surgery from June 2010 to April 2011 in Beijing Anzhen Hospital of Capital Medical University were retrospectively analyzed. According to whether they had postoperative AKI，all these patients were divided into AKI group and non-AKI group. AKI group was consisted of 1 407 patients （40.2%） with a mean age of 58±12 years，including 1 004 male patients （71.4%）. The non-AKI group was consisted of 2 093 patients （59.8%） with a mean age of 55±13 years，including 1 259 male patients （60.2%）. Predictive score system of postoperative AKI was established by univariate analysis between the AKI and non-AKI group and multivariate logistic regression and then verified. Results The predictive score system was as followed：male gender （2 points），every 5 years older than 60 years （1 point），diabetes mellitus （2 points），preoperative use of angiotensin converting enzyme inhibitor or angiotensin AT1 receptor blocker （1 point），every 10 ml / （min·1.73 m2） of preoperative estimated glomerular filtration rate （eGFR） under 90 ml / （min·1.73m2） （1 point），preoperative NYHA class Ⅳ （3 points），cardiopulmonary bypass time＞120 minutes （2 points），intraoperative hypotension duration＞60 minutes （2 points），postoperative hypotension duration＞60 minutes （3 points），postoperative peak dosage of intravenous furosemide＞100 mg/day （3 points），postoperative peak dosage of intravenous furosemide 60-100 mg/day （2 points），and postoperative mechanical ventilation time＞24 hours （2 points）. The predictive score system presented a good discrimination ability with the area under the receiver operating characteristic（ROC）curve of 0.738 with 95% CI 0.707 to 0.768，while it also presented a good calibration with Hosmer-Lemeshow statistic （P=0.305）. Conclusion A clinical predictive score system for AKI after cardiac surgery in adults is established，which may help clinicians implement early preventive interventions.
Abstract： Objective To summarize surgical results of secondary subaortic stenosis （SSS） after congenital heart disease （CHD） operations，and analyze the pathogenesis of SSS. Methods We retrospectively analyzed clinical data of 19 patients who underwent surgical repair for SSS in Guangdong General Hospital from 1st June 2008 to 31st December 2012. There were 10 males and 9 females. CHD types included double outlet right ventricle，ventricular septal defect and partial atrioventricular septal defect，et al. The median age of the patients when they received their first CHD operations was 4 months （15 days to 5 year and 11 months）. The median age of the patients when they received SSS repair was 5 years and 3 months （1 year to 15 years and 3 months）. The median time interval from CHD operation to SSS repair was 4 years and 10 months （8 months to 13 years and 11 months）. Results All the patients successfully received their SSS repair. There was no surgical death in this study. Median cardiopulmonary bypass time was 79 （39 to 172） minutes，and median aortic cross-clamp time was 42 （22 to 124） minutes. Median postoperative hospital stay was 7 （5 to 9） days. Postoperatively， 1 patient required permanent pacemaker implantation. All the patients were followed up after discharge for a median durationof 1 year and 10 months （5 months to 4 years and 4 months） . During follow-up， none of the patients had any clinical symptom，their heart function was normal，and there was no late death. One patient received another subaortic stenosis repair for gradually aggravating left ventricular outflow tract stenosis. Conclusions SSS is very rare after CHD operations. The pathogenesis of SSS is perhaps related to abnormal blood flows in the left ventricular outflow tract after CHD operations. The pathogenesis time of SSS and types of CHD leading to SSS cannot be predicted. Subaortic stenosis repair is a simple and safe procedure for SSS，but postoperatively left ventricular outflow tract stenosis may appear and aggravate again.
Bloodless surgery is a comprehensive and systematic perioperative treatment approach in order to avoid allogeneic transfusion for surgery，improve patient prognosis，and relieve blood shortage. Bloodless heart surgery indicates some perioperative strategies to avoid allogeneic transfusion and improve clinical outcomes，which involves participation of cardiac surgeons and other professionals during cardiac surgery. For years，many cardiac surgeons have utilized several blood management and conservation techniques during open heart surgery to avoid allogeneic transfusion. Research results from major medical centers indicate that bloodless heart surgery can shorten postoperative recovery period and improve patientprognosis. In this review，we describe basic theory and systematic methods of bloodless surgery，and summarize applicationprogress of bloodless heart surgery and current status in China.
Abstract： Objective To validate the value of Cleveland Clinical Score to predict acute renal failure（ARF） requiring renal replacement therapy （RRT） and in-hospital death in Chinese adult patients after cardiac surgery. Methods A retrospective analysis was conducted for all the patients who underwent cardiac surgery from January 2005 to December 2009 in Renji Hospital of School of Medicine, Shanghai Jiaotong University. A total of 2 153 adult patients, 1 267 males and 886 females，were included. Their age ranged from 18 to 99 years with an average age of 58.70 years. Cleveland Clinical Score was used to predict ARF after cardiac surgery. ARF was defined as the need for RRT. Based on Cleveland Clinical Score, the patients were divided into four risk categories of increasing severity：0 to 2 point（n=979）, 3 to 5 point （n=1 116）, 6 to 8 point（n=54）, 9 to 13 point（n=4）. The rates of ARF, multiple organ system failure （MOSF）, and mortality were compared among the 4 categories. The predictive accuracy of postoperative ARF and hospital mortality was assessed by area under the receiver operating characteristic curve （AUC-ROC）. Results In the four categories, the rate of postoperative ARF was 0.92%, 1.88%, 12.96%, and 25.00%, respectively； MOSF rate was 1.23%, 1.88%, 3.70%, and 25.00%, respectively; mortality was 0.92%, 4.21%, 25.93%, and 50.00%, respectively. There was significant dif ference among the four categories in ARF rate （χ2=55.635, P=0.000），MOSF rate（χ2=16.080, P=0.001）, and mortality （χ2=71.470, P=0.000）. The AUC-ROC for Cleveland Clinical Score predicting ARF rate and hospital mortality was 0.775 （95%CI 0.713 to 0.837, P=0.000）and 0.764（95%CI, 0.711 to 0.817, P=0.000）, respectively. Conclusion Cleveland Clinical Score can accurately predict postoperative ARF and hospital mortality in a large, unselected Chinese cohort of adult patients after cardiac surgery. It can be used to provide evidence for effective preventive measures for patients at high risk of postoperative ARF.
Abstract： Objective To analyze the early outcomes of open heart surgery for congenital heart diseases in sixty low birth weight infants and premature infants. Methods Sixty low birth weight infants （body weight＜2 500 g） and premature infants with congenital heart diseases undergoing surgical repair from May 2003 to October 2011 were studied retrospectively in Guangdong Cardiovascular Institute. There were 43 male patients and 17 female patients with their mean gestational age of 33.5±4.1 weeks （ranging from 26 to 42 weeks） and mean age at operation of 24.9±12.5 d（ranging from 4 to 55 d）. Among them there were 47 premature infants with their mean birth weight of 1 729.3±522.5 g（ranging from 640 to 2 500 g）and mean weight at operation of 1 953.2±463.6 g （ranging from 650 to 2 712 g）. All the patients received preoperative treatment in newborn intensive care unit（NICU） and underwent surgical repair under general anesthesia, including 29 patients without cardiopulmonary bypass （CPB）and 31 patients with CPB . All surviving patients received postoperative monitoring and treatment in NICU, and their postoperative complications and in-hospital death were reported. Results A total of 13 patients died during hospitalization with a total in-hospital mortality of 21.7%（13/60）, including 4 intra-operative deaths, 6 early deaths （within 72 h postoperatively） and 3 patients giving up postoperative treatment. CPB time was 121.0±74.7 min, aortic clamp time was 74.8±44.7 min, and postoperative mechanicalventilation time was （136.9±138.1）h. Thirteen patients underwent delayed sternal closure. Eight patients underwentreexploation for postoperative bleeding. Ten patients had severe pneumonia, 2 patients had pulmonary hypertensive crisis, and 8 patients had low cardiac output syndrome. All the postoperative complications were resolved or improved after proper treatment. Follow-up was complete in 47 patients from 2 to 12 monthes, and all the patients were alive during follow-up. Conclusion Early surgical repair for low birth weight infants and premature infants with congenital heart diseases is safe and effective.