Abstract: Anxiety is a feeling of discomfort produced in face of an unknown event, as an impending cardiac surgery, that can lead to inconveniences in the intervention and subsequent recovery. Being the purpose of this research to analyze pre-surgical anxiety, a descriptive cross-sectional study among patients undergoing cardiac surgery was carried out. Data about sociodemographic variables were collected and the level of anxiety prior to surgery was assessed using the STAI-S scale. Subsequently, descriptive data analyses were performed, relationships among variables were analyzed, and a binary logistic regression model was developed in order to analyze the role of the variables involved in the development of preoperative anxiety. Sixty subjects were finally included; more than 80% had a moderate to high level of anxiety. 26.7% underwent valve surgery and 47% underwent coronary artery bypass graft (CABG) surgery, in the latter case presenting higher levels of anxiety. Statistically significant relationships were found among the level of anxiety and (a) level of studies, (b) first surgical intervention, and (c) the rating given to their previous surgical experience. We concluded that preoperative anxiety in people undergoing cardiac surgery is high and yet it is an underestimated phenomenon. The relationship between the received information and their anxiety level is inversely proportional, so that people programmed for cardiac surgery should be provided with all the information they required, through an individualized intervention.
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In the last decade, many publications have evaluated the accuracy and reliability of novel urinary and serum bio- markers like neutrophil gelatinase-associated lipocalin (NGAL) for the early detection and/or predict the progno- sis of AKI . However, there remains the space between the damage in biological processes and the clinical presen- tation during AKI, so such markers have not yet found a place in routine clinical practice [29,30]. Although, none novel biomarkers has the consensus to approach in clinical decision making in diagnosis patients with AKI, but NGAL detected patients with subclinical AKI in spite of un- changed SCr . In addition, delayed diagnosis of AKI based on SCr changing could explain some negative results of the interventions in many clinical trials . NGAL is a 25 kDa protein covalently bound to gelatinase in neutro- phils and is usually expresses at very low levels in several human tissues, including kidney, lung, stomach, and colon [33,34]. During AKI, NGAL expression is markedly in- creased in the injured distal nephron epithelia, and is not reabsorbed by the damaged proximal tubules resulting in an elevation of urinary NGAL . NGAL protein was eas- ily detected in the blood and urine soon after AKI in animal and human diseases [36,37] and used in the detection of CSA-AKI in patients undergoing cardiac surgery [38,39].
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Abstract: Objective: This paper aimed to investigate the effects of dexmedetomidine on activin A (ActA) and neuron specific enolase (NSE) in the serum of patients undergoing cardiac surgery with cardiopulmonary bypass (CPB). Methods: Altogether 56 patients undergoing cardiac surgery with CPB were enrolled and evenly included into a control group and a study group. The patients in the study group were administrated dexmedetomidine, while those in the control group were administrated the same volume of normal saline. The Mini-Mental State Examination (MMSE) was used to assess the patients’ cognitive function before each operation (Ta), and at 10 days (Tb), 20 days (Tc), and 30 days after each operation (Td). The incidence of postoperative cognitive dysfunction (POCD) in the patients was measured at 3, 7, 21, and 30 days after each operation. An enzyme-linked immunosorbent assay (ELISA) was used to measure the levels of serum ActA and NSE in the patients before each operation (T1), and at 6 h (T2), 12 h (T3), and 24 h after each operation (T4). The Pearson method was used to analyze the correlations between the ActA and NSE levels and the MMSE scores, as well as between the serum ActA levels and the NSE levels. Results: At T2, T3, and T4, the MMSE scores in the study group were significantly higher than they were in the control group (P<0.05). At 3, 7, and 21 days after each operation, the incidence of POCD in the study group was significantly lower than it was in the control group (P<0.05). At T2, T3, and T4, the ActA and NSE levels in the study group were significantly lower than they were in the control group (P<0.05). The serum ActA and NSE levels were significantly negatively correlated with the MMSE scores (r=-0.572, P<0.05, r=-0.549, P<0.05); the serum ActA levels were significantly positively correlated with the NSE levels (r=0.552, P<0.05). Conclusion: Dexmedetomidine can reduce the incidence of POCD in patients undergoing cardiac surgery with CPB, which may be related to the reduction of the serum ActA and NSE levels.
No significant impairments in respiratory muscle strength were found two months after cardiac surgery, as compared to preoperative values. This is the first study to describe respiratory muscle strength after dis- charge in patients undergoing cardiac surgery. Riedi et al.  has reported an 11 % reduction in MIP five days after surgery, and Morsch et al.  a 36 % reduc- tion in MIP six days after surgery. Reduced respiratory muscle strength in the early postoperative period after cardiac surgery might be due to sternal pain that affects the possibility of performing the respiratory muscle tests properly. It is still unclear whether muscle strength is as- suredly affected by surgery, or whether it is masked by pain or patients ’ motivation and skills to perform the test postoperatively, which might be challenging after surgery. After median sternotomy, distortion of the chest wall configuration reduces chest wall compliance and the ability to breath. Altered respiratory movements, dis- tortion of the chest wall configuration and the reduction of the chest wall compliance might be one explanation for the decreased lung function found two months after surgery.
Postoperative AKI is a common complication in patients undergoing cardiac surgery . Some studies have reported that levosimendan therapy in patients undergoing cardiac surgery is associated with lower renal replacement therapy and a shorter duration of mechanical ventilation [5, 28, 29]. However, controversial or negative results on the effect of levosimendan have been reported . Our ana- lysis showed a significant reduction in the risk of renal re- placement therapy with levosimendan therapy in patients undergoing cardiac surgery. In addition, we also found that levosimendan therapy reduced mechanical ventilation dur- ation in patients undergoing cardiac surgery. Subgroup ana- lysis indicated that these benefits were confined to low-EF studies. Levosimendan might improve renal function in car- diac surgery due to its ability to improve cardiac systolic function and systemic hemodynamics . In acute decom- pensated heart failure, levosimendan has an immediate renoprotective effect, which is mediated by an increase in renal blood flow resulting from selective renal arterial and venous vasodilating action . One study also indicated that levosimendan therapy induced vasodilation, preferen- tially of preglomerular resistance vessels, thereby increasing both renal blood flow and glomerular filtration rate without jeopardizing renal oxygenation after cardiac surgery with cardiopulmonary bypass .
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This is to certify that the dissertation entitled "USEFULLNESS OF TRANEXAMIC ACID IN REDUCING POST OPERATIVE BLEEDING IN PATIENTS UNDERGOING CARDIAC SURGERY" presented here is the original work done by Dr.PREM ANAND.J, in department of Cardio Thoracic Surgery, Rajiv Gandhi Government General Hospital. Madras Medical College, Chennai – 600 003, in partial fulfillment of the University rules and regulations for the award of Branch-I M.Ch Cardio Vascular and Thoracic Surgery Degree under our guidance and supervision during the academic period from January 2013 to December 2013.
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In this study, the baseline platelet count was normal in all patients. In contrast to some previous studies reporting that platelet count and function are associated; our results did not show any significant association between platelet count and aggregation in all- time points (23, 24). We found that both platelet count and aggregation reduced significantly during CPB. Although platelet aggregation increased 24 hours after surgery, we did not observe any significant increase in platelet count. In fact, platelet count reduced by about 40 % after CPB compared with before CPB and remained at this level 24 hours after surgery. These results confirm those of the previous studies report- ing a 50% reduction in platelet count during CPB (24-26). Furthermore, similar to other studies, our results showed that platelet function recovered rapidly one day post oper- ation, but it did not reach baseline level (24, 25, 27, 28). However, a slow recovery of platelet aggregation was observed in children (12, 28).
Transthoracic echocardiograms were performed with patients in the left lateral position using a VIVID 7 echo- cardiograph (GE Medical, Milwaukee, Wisconsin, USA). Routine M-mode, two-dimensional and Doppler images were acquired, and all images were stored in digital raw data format for subsequent of ﬂ ine analysis using com- mercially available software (EchoPAC PC, GE, Horten, Norway). All patients were in sinus rhythm and three cardiac cycles were captured for each measurement. Two-dimensional images of the left ventricle were acquired at suf ﬁ cient frame rate to allow measurement of myocardial strain by speckle tracking from the four- chamber view. Chamber sizes and systolic function were measured according to the American Society of Echocardiography (ASE) guidelines. 19 Left ventricular ejection fraction was measured using a biplane Simpson ’ s method. Mitral in ﬂ ow and pulmonary venous ﬂ ow velocities were measured using pulsed wave Doppler with the transducer positioned at the apex according to the ASE guidelines. 20 Mitral annular veloci- ties were measured with the transducer at the apex and with placement of the sample volume over the septal and lateral mitral annulus. Peak systolic (S 0 ), early dia- stolic (E 0 ) and late diastolic (A 0 ) velocities were mea- sured at the septal and lateral annulus, and averaged to provide mean annular velocities. Strain and strain rate were measured in the six-wall segments seen in the apical four-chamber view using speckle tracking within the EchoPAC software. The peak global strain and strain rate are the peak values of the instantaneous mean of all six segments. The mean peak systolic strain and strain rate are the mean of the peak values in all segments and were, therefore, not acquired at the same time due to temporal variation between segments.
Vitamin C is the first-line antioxidant in the human body. It is widely used clinically because of its low price, wide range of uses, and high safety. Basic experi- ments have shown that vitamin C can reduce structural damage in the pulmonary blood vessels and alveoli of mice. 4 Based on previous experiments, researchers have also tried to clinically verify the protective effect of vita- min C on the lungs. At present, clinical trials have con- firmed that vitamin C can reduce ischemia-reperfusion injury (IRI) in isolated lung and stabilize the function of isolated lung. 5 When the body undergoes ischemia- reperfusion, xanthine oxidase formation increases, neutro- phil breathing bursts, mitochondrial function is impaired, and catecholamine auto-oxidation results in increased gen- eration of oxygen radicals. Oxygen free radicals cause damage to cell membrane phospholipids, proteins, nucleic acids, and extracellular matrix. Among them, oxygen free radicals produced by neutrophils and xanthine oxidase are the main mediators of pulmonary IRI. Vitamin C can remove oxygen free radicals in the human body and can remove the reactive oxygen species (ROS) in the body through rapid electron transfer to achieve antioxidant func- tions. Therefore, vitamin C is expected to reduce pulmon- ary complications in patients undergoing cardiac surgery. The relationship between vitamin C and PPCs after cardiac surgery has never been the focus of research.
hemodynamic stabilization/extubation mainly for potassium substitution to prevent arrhythmia, and the amount is gener- ally negligible. Further limitations arise from the imbalanced distribution of ascending aortic procedures between the groups, from the exclusion of patients undergoing only iso- lated CABG surgery, and due to the limited sample size. In addition, our study was designed as a pragmatic trial com- paring the two solutions in the context of both groups re- ceiving usual care. We cannot address the possible specific hemodynamic effects (e.g., vasodilatation) of either solution.
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As society ages, older patients are presenting for cardiac surgery with an increased prevalence of comor- bidities. In addition, the number of patients with ad- vanced heart failure has increased and the implantation of pulsatile-flow ventricular assist devices (VAD) has become an established therapeutic strategy to improve survival rates and quality of life . Malnutrition may be a significant comorbidity and driver for dysfunction of many organ systems. This can exacerbate an already impaired organ reserve, increasing susceptibility to opera- tive trauma, ischemia/reperfusion injury, anesthesia- related complications, and inflammation. Cardiac patients who are well-nourished prior to surgery experience less morbidity and mortality than those who are malnourished [11, 12]. Several observational studies have noted the importance of energy and protein metabolism in the early recovery period after cardiac surgery, documenting sig- nificant postoperative depletion of macronutrients and micronutrients [11–14]. Adequate nutritional therapy was suggested to improve patients’ outcomes through maintenance of energy metabolism, gut integrity, mi- crobial diversity and improved wound healing . In summary, preoperative nutritional status and postoper- ative nutritional management may represent important drivers for clinical outcomes in patients undergoing cardiac surgery, who are at high nutritional risk, which will be discussed in the following section.
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Despite the limited number of included cases, there is still some evidence from our study to suggest that PP has some positive effects on vital organ protection during CPB. Albeit, in the absence of intergroup differences, a relatively lower percentage of perioperative requirements of diuret- ics was observed in the low frequency pulsatile group. Our study did not show any differences of hepatic or renal serum markers (ALT, bilirubin, BUN and Cr) between groups. However, our study included only patients without existing organ dysfunction before surgery, undergoing straightfor- ward procedures with short aortic cross-clamping, and these markers might not be sufficiently raised to indicate organ impairments. If a case has higher risk, complex congenital malformation, presence of preoperative organ dysfunction, longer CPB duration, or more complicated surgical proce- dure, subsequent organ dysfunction might be detectable. The kidney is a sensitive organ in response to ischemic damage, and, in comparison with BUN and Cr, some available uri- nary markers are heralded as more powerful predictors of acute renal injury, such as N-acetyl- β - d -glucosaminidase
This single-center retrospective study was conducted to explore PCCs and mortality in elderly patients over 80 years old with CAD, who underwent elective noncardiac surgery in Peking Union Medical College Hospital (PUMCH) from January 1, 2004, to December 31, 2019. Ethical consent was approved by the Ethics Committee and Institutional Review Board of PUMCH (No. of ethical approval: S-K1212). We conducted this study in accordance with the Declaration of Helsinki. The data were anonymized before analysis. Informed consent was waived. The types of surgery were elective intermediate to high-risk noncardiac surgery based on the American College of Cardiology (ACC)/American Heart Association (AHA) guidelines of perioperative cardiovascular evaluation. 16 CAD was diag- nosed if any of the following conditions were met: CAD con ﬁ rmed by coronary angiography, history of myocardial infarction (MI), history of coronary revascularization, posi- tive myocardial perfusion scintigraphy, positive exercise stress test, or typical symptoms of angina pectoris with simultaneous signs of myocardial ischemia on the electro- cardiograph (ECG). 17
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between two major studies investigating tight glucose management in adults has led to unclear objectives, and in many ways has raised more questions than it has solved. A distinct lack of well designed, prospective RCTs means research has many unanswered questions. In children, where the effects of fluctuating blood glucose levels are not fully understood, it may well be the case that research has ground to a halt. There is simply not enough evidence to suggest that tight glycemic control would be of benefit in this patient population because the risks of hypoglycemia are felt to be too great. Until long-term data either confirm- ing or refuting intensive insulin therapy in this population of patients is found, current practice is unlikely to change. Further, the ethical implications of a randomized blinded trial which risks creating significant disability in children whose neurological systems are immature are unacceptable. On the other hand, being too cautious and exposing children to hyperglycemia of any intensity may come with its own risks. It is highly likely that glycemic targets will be of most benefit if they are age-related and take into account individual variability.
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The cardioprotective effects of potassium channel openers in vivo may be masked by the vascular haemodynamic actions. Nicorandil is the only drug of this class that has been used clinically; in a study by Saito et al (Saito et al., 1991), nicorandil was compared to nitroglycerin in patients undergoing angioplasty for proximal coronary stenoses. Intravenous nicorandil significantly reduced ST segment elevation with no systemic haemodynamic effects, but the duration of balloon inflation was only 30 seconds. This was in contrast to nitroglycerin which did not improve ST segments but did have haemodynamic effects. This suggests that this effect was related to potassium channel opening rather than due to the organic nitrate action. Nicorandil with its combined actions as an organic nitrate (which activates guanylate cyclase) and as a potassium channel opener could prevent cardiac damage during ischaemia by offloading the heart through its haemodynamic effects and redistribution of coronary blood flow and by direct myocardial protection via opening of the potassium channels.
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Guo et al. (2012) used an informative leaflet and verbal counseling by a multidisciplinary team and verified reduction of anxiety measured by the Hospital Anxiety and Depression Scale (HADS). Almeida et al. (2013), in a cohort study, compared the level of anxiety by the trait-state anxiety inventory (TSAI) in pre-operative coronary artery bypass graft and cardiac valve replacement patients before and after receiving guidelines in a group, by a multiprofessional team and reporteda significant reduction in anxiety levels. In this way, the literature has shown that non-pharmacological interventions can bring several benefits to patients undergoing cardiac surgery. The literature lacks more scientific studies using the Hamilton Anxiety scale to evaluate this outcome in cardiac surgical patients; the few scientific studies found address the type II diabetic population (Kian et al., 2018) and thalamic pain (Lin et al., 2018). However, in cardiac surgeries, other scales have been used for such assessments, including the Spielberger State Anxiety Inventory (Malek et al., 2018), State-Trait Operation Anxiety (STOA) (Heilmann et al., 2016), Hospital Scale of Anxiety and Depression (HSAD) (Guo et al., 2012) and Trait-State Anxiety Inventory (TSAI) (Almeida et al., 2013). The importance of this study comes from the fact that strategies involving educational actions reduce levels of stress and anxiety in patients undergoing cardiac surgery. As mentioned above, several strategies of this nature have been described in the literature shown beneficial effects for patients (Guo et al., 2012; Heilmann et al., 2016; Paiva et al., 2017; Rosenfeldt et al., 2018; Malek et al., 2018; Almeida et al., 2013). However their results are difficult to compare because they use different methods of intervention and evaluation. Different from other studies, the methodology used in this study emphasizes the importance of the multidisciplinary health team get involved in a group intervention strategy carried out in the week preceding the surgical procedure. Therefore, this methodology, besides effective, is also feasible and can be used in cardiac surgery services. It is still necessary to implement these services routinely, by multidisciplinary teams. On the other hand, this study had limitations in relation to inter-individual variability
According to the predefined criteria, high risk, emergency, and transplant cases were excluded. This allowed us to achieve a relatively homoge- nous study population. Analysis of peri-operative data suggests that there was no statistically sig- nificant difference in major co-morbidities, type or duration of surgery, or surgical complications. The incidence of diabetes and peripheral vascu- lar and coronary artery disease was significantly higher in the MdHO group, whereas the difference
Atrial fibrillation (AF) is an arrhythmia which also occurs after the cardiac surgery. Apart from clinical factors some genetic factors are also involved. To know whether a genetic variant has any role or not, this study has been designed in the North Indian patients. An ion-channel gene KCNE1G38S (rs1805127) was selected to investigate its association between genetic variant and postoperative AF. The study included age and sex matched 78 postoperated-AF rhythm patients as cases and 99 postoperated-patients as controls with sinus rhythm admitted in Cardiovascular and Thoracic Surgery Department of SGPGIMS, Lucknow. The SNP detection of KCNE1G38S was genotyped by using the polymerase chain reaction based restriction fragment length polymorphism method. The genotype frequencies of the AA, AG and GG were 19.20%, 56.40%, and 24.40%, respectively, in cases, whereas in controls had frequencies of 23.20%, 56.60% and 20.20% respectively. The observed frequencies were almost similar in cases and controls. The chi-square results were not statistically significant (c2=0.668, p=0.716) and the frequency of G allele between cases and controls did not vary (52.56% vs. 54.31%). In multivariate analyses, the KCNE1G38S variant was independently associated with a significant predisposing effect on AF after adjusting for related risk factors and the odds ratio for case was 1.272 (95 % CI: 0.594–2.726, p = 0.389). The study revealed that there is no association of AF with the genetic variant of ion channel gene KCNE1G38S in the North Indian population.
Abstract: Pancreas transplant rates, despite improving outcomes, have decreased over the past two decades. This is due, in part, to ageing, increasingly co-morbid pancreas transplant candidates. There is a paucity of published data regarding coronary artery disease (CAD) in this population. To inform peri-operative management strategies, we sought to understand the frequency of CAD among recipients of pancreas transplants at our center. Informed by these data, we sought to develop a standard protocol for evaluation. A retrospective review of pancreas transplants (solitary pancreas and simultaneous pancreas-kidney) was undertaken at the University of Maryland. Transplant outcomes and frequency of cardiac disease were analyzed. Current data were compared with historic controls. Over the study period, 59 patients underwent pancreas transplantation. Coronary architecture was assessed in 38 patients (64.4%). Discrete evidence of CAD was present in 28 of 39 patients (71.7%). All pancreas candidates (n = 21) who underwent left heart catheterization (LHC) demonstrated CAD (100%). No patients experienced myocardial infarction (MI) and no deaths resulted from cardiac disease in the early post-transplant period. Pancreas transplant candidates are at high risk for CAD. At a center in which pancreas transplant rates are increasing, a rigorous cardiac work up revealed that 71.7% of assessed recipients had CAD. Although asymptomatic, 6.8% required coronary artery bypass graft (CABG). Despite increasing age and co-morbid status, pancreas transplant recipients can enjoy excellent results if protocolized preoperative testing is used.
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The incidences of low cardiac output syndrome, pro- longed respiratory insufficiency, cardiac arrest, and death tended to be lower in the PACU group without reaching statistical significance. Because these complications were not primary end points, our study was underpowered for demonstrating significant differences between groups. The incidence of renal failure, stroke, resurgery, and mortality was similar for the PACU and the ICU group. Our study does not allow any conclusion about the safety of our fast-track concept. However, a significantly lower incidence of common postoperative complications for fast-track patients was demonstrated in a prospective study of 1,488 patients by Gooi et al. . Svircevic et al. could not find any evidence for increased risk of adverse outcomes in 7,989 patients undergoing fast-track cardiac surgery . In a recent review, Zhu et al. came to the con- clusion that fast-track interventions have similar risks of mortality and major postoperative complications to conven- tional (not fast-track) care, and therefore appear to be safe in patients considered to be at low to moderate risk .
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