Abstract Current guidelines on postcardiotomy veno‐arterial extracorporeal oxygenation ECMO (vaECMO) do not mention the assessment of pulmonary function, especially prior to the weaning procedure in the operation room (OR). Mucociliary dysfunction, a nearly ubiquitous finding among mechanically ventilated patients, might put these patients at risk for potential airway problems and associated weaning failure at the time of vaECMO weaning in the OR. In conformity to veno‐venous ECMO management, we suggest routine bronchoscopy with bronchial hygiene in the ICU prior to vaECMO weaning in the OR. Likewise, an assessment of patient pleura for effusions should be routinely performed. Although cardiac and respiratory failure often co‐exist and there are multiple causes of respiratory failure in patients who require vaECMO, we anticipate that vaECMO patients would significantly benefit from an expanded focus on the pulmonary function and possible respiratory mucous congestion. A routine preweaning bronchoscopy would reduce the frequency of weaning failures in this particular setting, especially in those patients with successfully restored cardiac function.
This 3100 g neonate (born at 40th weeks/+1 day of gestation) with hypoplastic right heart syndrome (tricuspid/pulmonary atresia, atrioventricular septum defect, persistent ductus arteriosus) underwent ultrasound-guided parasternal pectointercostal chest wall block on day five postpartum with 1.8 mL of ropivacaine 0.375% and 4 mcg of dexmedetomidine distributed over four injection sites prior to palliation with an aortopulmonary shunt. Figure 1 shows the neonate on the first postoperative day. An allergic reaction to local anaesthetics was initially suspected by the ward physicians, but the partially tricolour appearance with pale skin in the center of the hyperaemic rings around the injection sites (additional livid center in the right upper lesion) did not fit this diagnosis. An allergic reaction would likely result in a local hyperaemic area around the injection sites or a systemic reaction. The pallor and discrete central cyanotic zone in some of the efflorescences fit more with the concept of a local vasoconstrictive drug effect. A literature search suggested that the clinical picture may be a direct vasoconstrictor effect of ropivacaine, consistent with the report by Kopacz and colleagues in an animal study. In this study ropivacaine decreased blood flow by approximately 50%, whereas bupivacaine increased blood flow by approximately 90%.1 Similarly, a study by Cederholm and colleagues found a reduction in skin blood flow in healthy participants after intradermal injection of ropivacaine.2 The addition of dexmedetomidine to a local anaesthetic is known to enhance the analgesic effect; however, dexmedetomidine has vasoconstrictive properties as well, which aids to prolong the action of the local anaesthetic.3, 4 Thus, the action of dexmedetomidine may have contributed to the vasoconstrictive effect of ropivacaine. In our routine practice with the application of parasternal blocks in adults, consisting of ropivacaine + dexmedetomidine, such skin lesions have never been observed, nor have they been seen with the use of bupivacaine instead of ropivacaine. Based on these findings, we advocate the use of bupivacaine (0.25%, max. 1 mL/kg) instead of ropivacaine for chest wall blocks, especially in neonates. Support was provided solely from institutional and/or departmental sources. Open access funding provided by Inselspital Universitatsspital Bern. The authors declare no competing interests. We received consent from the parents of the child to publish this information and the image. The data that support the findings of this study are available on request from the corresponding author. The data are not publicly available due to privacy or ethical restrictions.
I would like to thank Drs. Peltola and Lane for their letter about our recent paper 1. The trial by Patel et al. was a double-blind study in patients with non-valvular atrial fibrillation at increased risk for stroke, which compared non-inferiority of rivaroxaban with warfarin, measuring stroke prevalence as the primary end-point. In 4692 out of 14,264 (32.9%) enrolled patients, rivaroxaban was temporarily interrupted; 2997 (63.9%) of this population required surgery/procedural intervention, including cardiac surgery. In most patients, rivaroxaban was stopped at least 3 days before the procedure, and heparin bridging anticoagulation was used. The rates of stroke/systemic embolism (0.30% vs. 0.41% per 30 days; heart rate (HR) (95%CI) 0.74 (0.36–1.50)) and major bleeding (0.99% vs. 0.79%, HR (95%CI) 1.26 (0.80–2.00)) were low and did not differ between the rivaroxaban-treated and warfarin-treated groups, respectively (p = 0.40 and 0.32). ‘Tc’ denotes thrombocytes, by which we mean platelets. For severe bleeding, we recommend consideration of platelets, cryoprecipitate and prothrombin complex concentrate administration, as non-specific measures to reduce bleeding (Table 1, Figs. 1 and 2).
To investigate the periprocedural inflammatory response in patients with isolated aortic valve stenosis undergoing surgical aortic valve replacement (SAVR) or transcatheter aortic valve implantation (TAVI) with different technical approaches.Patients were prospectively allocated to one of the following treatments: SAVR using conventional extracorporeal circulation (CECC, n = 47) or minimized extracorporeal circulation (MECC, n = 15), or TAVI using either transapical (TA, n = 15) or transfemoral (TF, n = 24) access. Exclusion criteria included infection, pre-procedural immunosuppressive or antibiotic drug therapy and emergency indications. We investigated interleukin (IL)-6, IL-8, IL-10, human leukocyte antigen (HLA-DR), white blood cell count, high-sensitivity C-reactive protein (hs-CRP) and soluble L-selectin (sCD62L) levels before the procedure and at 4, 24, and 48 h after aortic valve replacement. Data are presented for group interaction (p-values for inter-group comparison) as determined by the Greenhouse-Geisser correction.SAVR on CECC was associated with the highest levels of IL-8 and hs-CRP (p<0.017, and 0.007, respectively). SAVR on MECC showed the highest descent in levels of HLA-DR and sCD62L (both p<0.001) in the perioperative period. TA-TAVI showed increased intraprocedural concentration and the highest peak of IL-6 (p = 0.017). Significantly smaller changes in the inflammatory markers were observed in TF-TAVI.Surgical and interventional approaches to aortic valve replacement result in inflammatory modulation which differs according to the invasiveness of the procedure. As expected, extracorporeal circulation is associated with the most marked pro-inflammatory activation, whereas TF-TAVI emerges as the approach with the most attenuated inflammatory response. Factors such as the pre-treatment patient condition and the extent of myocardial injury also significantly affect inflammatory biomarker patterns. Accordingly, TA-TAVI is to be classified not as an interventional but a true surgical procedure, with inflammatory biomarker profiles comparable to those found after SAVR. Our study could not establish an obvious link between the extent of the periprocedural inflammatory response and clinical outcome parameters.
Abstract We describe the case of a 23-year-old patient presenting for redo aortic arch surgery because of recoarctation and poststenotic aneurysm formation after patch aortoplasty in infancy. Using the hemi-clamshell approach, the entire aortic arch was replaced and the supraaortic branches were reimplanted. The applied surgical technique using hypothermic extracorporeal circulation without cardiac arrest allowed an uninterrupted cerebral and spinal cord perfusion due to stepwise clamping of the aortic arch during reconstruction and resulted in an excellent neurologic outcome at six-month follow-up. (J Card Surg 2010;25:560-562)
