bluuebunny/crossref_metadata_2025 huggingface dataset:
Extracorporeal Tubing in the Roller Pump Raceway: Physical Changes and Particulate Generation
Authors: Bednarski Spiwak Allison J. , Horbal Alexander , Leatherbury Robert , Hansford Derek J.
Published: July 2023

Plasticized polyvinyl chloride tubing is used as the blood conduit in the heart lung bypass circuit. The section in the roller pump undergoes rigorous compression. Fatigue leads to material changes in weight and length of the bulk material. Particles are released during normal pump operation. This study evaluates the time course of particle loss. Three segments of ½″ ID tubing run in the raceway for 30-minute, 1-hour, or 2-hour. The fluid path of each segment includes an oxygenator; a castor oil blend was used for the prime. The 5 mL sample was acquired at 10 minute intervals. Raceway tubing segments were measured for a change in weight and length. The same procedure repeated with ¼″ ID and ⅜″ ID tubing. All tubing increased at least 5 mm by the 2-hour trial. There were no remarkable changes in weight. Particles were measured for size and percent volume. Tubing with ½″ ID performed most consistently for particle release during all trials. Particles were observed as small as 1 nm. Particles as large as 3 micron could be confirmed. For all tubing there was particle release by 30 minutes. Perfusionists must consider tubing inner diameter and wall thickness in choosing the pPVC for the raceway in order to minimize particulate emboli. This research suggests that ⅜″ ID tubing produces spalls inconsistently compared to ½″ ID tubing. Thinner wall thickness tubing also has the potential to limit spall formation.
Autologous Platelet Gel Fails to Show Beneficial Effects on Wound Healing after Saphenectomy in CABG Patients
Authors: Buchwald Dirk , Kaltschmidt Christian , Haardt Helmut , Laczkovics Axel , Reber Delawer
Published: July 2023

Wound healing impairment in the leg after removal of the saphenous vein within the framework of a coronary artery bypass graft (CABG) operation represents a clinically significant problem. Patients suffer from this complication, and treatment of the wounds is costly in terms of both time and money. No method is known to date that reliably prevents postoperative wound healing disturbances. The effect of autologous platelet gel to stimulate wound healing is known from various medical disciplines. Within a prospective randomized study, we wanted to determine whether intraoperative use of autologous platelet gel on the leg during a CABG operation could reduce the incidence of postoperative wound healing disturbances. The application group (AG) included 35 patients and was compared to a control group (CG) that also had 35 patients. The platelet gel, as well as the thrombin required to activate the platelets, was prepared from autologous patient blood during the operation. Validation of the platelet gel comprised measurement of the growth factors platelet–derived growth factor AB (PDGF AB) and epidermal growth factor (EGF), as well as the thrombocyte and leukocyte counts. Wound healing was photographically documented after surgery, and the patients were contacted by telephone on day 50 after surgery to obtain information on wound healing status. After cell separation, the platelet count was 1616 ± 845/μL, which is higher than in whole blood by a factor of 7.1 ± 2.0, with a platelet yield of 47.0% ± 13.2%. The PDGF AB concentration after activation of the platelets was raised by a median factor of 158 and EGF by a median factor of 64 compared with whole blood. During the primary clinical stay, no statistically significant differences were recorded in the number of hematomas, postoperative leg swelling, or pain level. Large-area hematomas were less frequent in the application group (AG, 29.4% vs. CG, 60%,p= .007). In the follow-up 51 ± 9 days after surgery, 17.6% (6/34) of the patients from the AG and 31.4% (11/35) of the patients from the CG showed leg wound healing disturbances (p= .184). Using the cell separation system, a biological product that contains high concentrations of platelets, leukocytes, and growth factors can be prepared reproducibly. Despite optimum application of the autologous platelet gel to the wound, no clinically relevant differences were found between the groups, either during the primary clinic stay or in the follow-up period.
Excellent Outcomes in a Case of Complex Re-do Surgery Requiring Prolonged Cardioplegia Using a New Cardioprotective Approach: Adenocaine
Authors: O’Rullian James J. , Clayson Stephen E. , Peragallo Raul
Published: July 2023

A 71-year-old high-risk fourth-time redo male patient was diagnosed with prosthetic valve endocarditis of both aortic and mitral valves, and subsequently required a re-operative aortic and mitral valve replacement. He was placed on cardiopulmonary bypass (CPB) and arrested with normothermic hyperkalemic all-blood cardioplegia (microplegia) containing adjunctive adenosine-lidocaine-magnesium (adenocaine); aerobic arrest was maintained with near-continuous retrograde low potassium (∼2 mEq/L) adenocaine microplegia. After 4 hours of arrest on CPB, the aortic valve was found to be incompetent and was resected. A root replacement was required utilizing a Medtronic Freestyle Root prosthesis. Four separate periods of cross-clamp were required during the course of the entire operation. The patient was on CPB for 9.8 hours with a total cross-clamp time of 7 hours, during which he received 72 liters of all-blood adenocaine microplegia. After a terminal “hot shot” with adenocaine microplegia and no added potassium, CPB was discontinued with no systemic hyperkalemia (5.1 mmol/L), no hemodilution (hematocrit, 24%), no balloon pump, no antiarrhythmic agents, and modest inotropic support. The patient was hemodynamically stable, was extubated in 12 hours, and was transferred out of the cardiac ICU after 48 hours with a subsequent uneventful recovery.
Vacuum-assisted Venous Drainage and Gaseous Microemboli in Cardiopulmonary Bypass
Authors: Wang Shigang , Ündar Akif
Published: July 2023

When conventional gravity siphon venous drainage cannot achieve satisfactory venous drainage during minimally invasive cardiac and neonatal surgeries, assisted venous drainage techniques are needed to ensure adequate flow. One assisted venous drainage technique, vacuum-assisted venous drainage (VAVD), the aid of a vacuum in the venous reservoir, is now widely used to augment venous drainage during cardiopulmonary bypass (CPB) procedures. VAVD permits the use of smaller venous cannulae, shorter circuit tubing, and lower priming and blood transfusion volumes, but increases risk of arterial gaseous microemboli and blood trauma. The vacuum should be set as low as possible to facilitate full venous return, and realtime monitoring of gaseous microemboli in the arterial and venous line should be used to achieve the safest conditions. With current ultrasound technology, it is possible to simultaneously detect and classify gaseous microemboli in the CPB circuit. In this article, we summarize the components, setup, operation, advantages, and disadvantages of VAVD techniques and clinical applications and describe the basic principles of microemboli detectors, such as the Emboli Detection and Classification (EDAC) Quantifier (Luna Innovations, Roanoke, VA) and Bubble Counter Clinical 200 (GAMPT, Zappendorf, Germany). These novel gaseous microemboli detection devices could help perfusionists locate the sources of entrained air, eliminate hidden troubles, and minimize the postoperative neurologic impairments attributed to gaseous microemboli in clinical practice.
Use of a Multi-modality Life Support System
Authors: Brindisi Nicholas , Stammers Alfred , Trowbridge Cody , Klayman Myra , Pezzuto James , Marko Molly
Published: July 2023

The purpose of this study was to describe the design and utilization of a multi-modality life support system (MMLSS), which is used to provide extracorporeal support for cases such as left heart bypass (LHB), extracorporeal life support (ECLS), veno-venous bypass, and hypothermic resuscitation. The design of the MMLSS consisted of a mobile cart outfitted with a centrifugal pump, heater cooler, an in-line blood gas monitor, oxygen blender/flow meter, and assorted safety devices (pressure sensors and level and bubble detectors). A single disposable circuit was used for all procedures and designed to be easily modifiable to support a variety of clinical scenarios, with and without the use of an oxygenator. The system was designed for rapid deployment throughout the hospital. From January 1, 2006 to December 31, 2007, the MMLSS has been used in three LHB procedures (63 ± 72 minutes), four adult ECLS cases (57.2 ± 56.9 hours), four veno-venous bypasses (72 ± 35 minutes), and one hypothermic resuscitation (182 minutes). The MMLSS was designed to be used in patients >20 kg and could achieve flows in the range of 1-5.5 L. There were no complications associated with the device. The MMLSS is a versatile system that can be used throughout the hospital with a single disposable circuit, accommodating a diverse caseload in a safe and reproducible manner.
Effect of Foreign Surface Pacification with Albumin, Aprotinin, Propofol, and High-density Lipoprotein
Authors: Fontaine Eustace , Warwick Richard , Sastry Priya , Poullis Michael
Published: July 2023

Foreign surface pacification may significantly reduce the detrimental effects of the cardiopulmonary bypass (CPB) circuit. To date, albumin is the only intervention consistently shown to be beneficial. The cationic physical properties of aprotinin and the known negative charge on the plastic CPB circuit mean that aprotinin binds to the CPB circuit and membrane oxygenator. A previously validated model involving a parallel plate glass slide technique was used. The effects of albumin, aprotinin, propofol, and high-density lipoprotein (HDL) were assessed by the ability to inhibit platelet adhesion to the glass slide surface. The experiment was repeated with collagen-coated glass slides to reproduce the clinical effect of endothelial denudation. The interventions were repeated on membrane oxygenators that are used for CPB. Aprotinin resulted in a minimal reduction in platelet adhesion to uncoated or collagen-coated glass slides.

HDL significantly reduced platelet adhesiveness to uncoated or collagen-coated glass slides. Human albumin solution (HAS) and propofol produced an intermediary inhibitory effect on platelet adhesion on both collagen-coated and uncoated glass slides. The same effect was seen with membrane oxygenators that are used during CPB. HDL produced a significant reduction of neutrophil activation when used to coat a membrane oxygenator. Foreign surface pacification with HDL may have beneficial effects as assessed by platelet adhesiveness in a parallel plate assay. Aprotinin had minimal effect, and propofol had an intermediate effect. The same results were obtained using membrane oxygenators, confirming the validity of the parallel plate technique as clinically valid.
Use of a Thrombelastograph Platelet Mapping Assay for Diagnosis of Clopidogrel Resistance: A Case Report
Authors: Morton John , Nelluri Satyanarayana
Published: July 2023

A 62-year-old woman presented to the emergency department with sudden collapse, intractable ventricular fibrillation, and an inferior wall myocardial infarction (MI). An emergent cardiac catheterization showed a totally occluded right coronary artery (RCA). A bare-metal stent was placed in the stenosis, resulting in thrombolysis in myocardial infarction (TIMI)-III flow with 0% residual stenosis. Four days after stenting, the patient developed chest pain. A repeat cardiac catheterization showed a totally occluded stent. The patient was subsequently tested using a thrombelastograph (TEG) Platelet Mapping assay to exclude clopidogrel resistance. The assay confirmed the patient to be non-responsive to clopidogrel for the inhibition of platelet ADP receptors. In an attempt to increase ADP inhibition, the ADP antagonist was changed to ticlopidine. Further testing was confounded by the presence of abciximab; however, the patient has remained free of cardiac events.
Australian and New Zealand Perfusion Survey: Management and Procedure
Authors: Tuble Sigrid C. , Willcox Timothy W. , Baker Robert A.
Published: July 2023

In this report, we will discuss management and procedural aspects of perfusion practice. This report allows us to compare and contrast recent trends and changes in perfusion with historic practices. A survey comprised of 233 single-answer and 12 open-ended questions was sent by e-mail to senior perfusionists or individuals in charge of perfusion in 40 hospital groups. The survey encompasses a review of the perfusion practices for the calendar year of 2003, and respondents were required to answer the survey based on the predominant practice in their institutions. Standard management of routine adult cardiopulmonary bypass (CPB) in 2003 consisted of perfusion strategies that achieved a target temperature of 32.0°C (range, 28.0–35.0°C), a flow index of 2.4 L/min/m2(range, 1.6–3.0 L/min/m2) during normothermia and 1.8 L/min/m2(range, 1.2–3.0 L/min/m2) during hypothermia, and a pressure during CPB between 50 (range, 30–65 mmHg) and 70 mmHg (range, 60–95 mmHg). Myocardial protection with blood cardioplegia was used in 77% of the 20,688 CPB cases, whereas in 53% cases, cardiotomy blood was never processed. Pre-operatively, 76% of perfusion groups assessed their patients (21% directly with the patient), and 85% responded that perfusionists performed or participated in a formal pre-bypass checklist. The majority of the perfusion groups used a handwritten perfusion record (62%), 12% used an electronic perfusion record, and 26% used both, whereas more than one half of the groups were involved in quality assurance (79%), incident reporting (74%), audits (62%), research (53%), participating in interdisciplinary meetings (53%), and morbidity and mortality meetings (65%). Only 26% conducted formal perfusion team meetings. This report outlines the status of clinical management and procedural performance for perfusion practices in Australia and New Zealand in 2003. Awareness of these trends will allow perfusionists to assess both individual practices and unit performance.
Anti-Inflammatory Effect of Aprotinin: A Meta-Analysis
Authors: Brown Jeremiah R. , Toler Andrew W.J. , Kramer Robert S. , Landis R. Clive
Published: July 2023

It is important to define the extent, and any limitations, of potential anti-inflammatory regimens used in cardiac surgery to guide the rational combination of drugs to suppress the systemic inflammatory response. Aprotinin (Trasylol) is an anti-fibrinolytic agent with reported anti-inflammatory properties. In this study, we investigated the published data on aprotinin’s effect on acute phase protein and cytokine levels in cardiac surgery patients. Randomized placebo-controlled trials of aprotinin published between 1985 and 2007, in adult cardiac surgery using cardiopulmonary bypass, reporting tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), IL-8, and IL-10 levels were included for review. Two independent reviewers graded each paper and collected information on inflammatory markers. RevMan 4.3 statistical software was used to calculate and plot the weighted mean difference between placebo and aprotinin groups. Thirteen studies met the review criteria. None of the inflammatory markers were reduced by high-dose aprotinin treatment. Low-dose aprotinin significantly reduced IL-10 levels after protamine administration (−41.3 pg/mL; 95% CI: −59.5, −23.1), but this result was gone by the first post-operative day. These meta-analyses showed no significant effect of aprotinin on acute phase proteins or systemic cytokine markers of inflammation during clinical adult cardiac surgery using cardiopulmonary bypass. While recognizing that other host defense systems, such as coagulation and complement, contribute to the overall systemic inflammatory response, the evidence presented here does not support the clinical use of aprotinin as an anti-inflammatory agent on its own.
Influence of Cardiopulmonary Bypass on the Interaction of Recombinant Factor VIIa with Activated Platelets
Authors: Kjalke Marianne , Runge Marx , Rojkjaer Rasmus , Steinbruchel Daniel , Johansson Pär I.
Published: July 2023

Recombinant factor VIIa (rFVIIa) interacts preferentially with coated platelets characterized by a high exposure of phosphatidyl serine (PS), FV, FVIII, FIX, and FX binding, and fibrinogen. Cardiopulmonary bypass (CPB) is known to impair platelet function. In this study, the influence of CPB on formation of coated platelets and the interaction of rFVIIa with the platelets were studied. Blood was either exposed to a closed CPB circuit or obtained from patients undergoing CPB-assisted cardiac surgery, and platelets were analyzed by flow cytometry with and without dual agonist stimulation with thrombin and a GPVI collagen receptor agonist known to induce coated platelet formation. Platelets circulated within a closed CPB circuit did not spontaneously form coated platelets. Dual agonists stimulation caused formation of coated platelets at a reduced level compared to pre-CPB level (51 ± 21% vs. 80 ± 17% before CPB, p < .001). The rFVIIa interaction with the coated platelets was not impaired after CPB. Platelets isolated from patients undergoing CPB-assisted cardiac surgery also formed coated platelets only after dual agonist stimulation but to the same level as before surgery (76 ± 8% vs. 83 ± 14% before surgery, p = .17, n = 10). rFVIIa interaction with the coated platelets was not impaired after surgery. No spontaneous rFVIIa-binding platelets were found. The data indicate that CPB exposure in vivo does not compromise the platelet-dependent effects of rFVIIa either by spontaneous formation of coated platelets, thereby limiting the risk of systemic coagulation, or by impairing rFVIIa interaction with the agonist-induced coated platelets, thereby retaining the hemostatic potential of rFVIIa after CPB.
A Conversation with the Richmonds on Their 30 Years of Service with the American Board of Cardiovascular Perfusion
Authors: Palmer David A. , Mongero Linda B.
Published: July 2023

Beth A. Richmond, PhD, and Mark G. Richmond, EdD, Co-Executive Directors serving for the ABCP, have assumed this role for the past 30 years. Their experience working with a variety of perfusionists in the field influenced the profession and some of the professionals we view as perfusion leaders. Anyone with time working as a clinical perfusionist acknowledges the role they have had establishing the certification process and influencing perfusion education. The goal of this article is simply to highlight the Board’s history through the words of both Co-Directors. Our profession, young in years, has a unique history. The names have not been changed and many of the stories have yet to be told. During the winter of 2009, we sat down with Beth and Mark Richmond to talk about their experience working with different Boards over the past 30 years. The following article is their story in their words.
Soluble Fibrin Monomer Complex and Cardiopulmonary Bypass
Authors: Bonk Ryan , Trowbridge Cody , Stammers Alfred , Klayman Myra , Marko Molly , Brindisi Nicholas , Pezzuto James
Published: July 2023

Soluble fibrin monomer complexes (SFMCs) are precursors of fibrin polymer formation. Laboratory tests can be used to detect SFMCs in plasma. The purpose of this study was to determine whether a positive SFMC test is associated with pre-operative, intra-operative, and post-operative variables for patients that have undergone cardiopulmonary bypass (CPB). Pre-operative, operative, post-operative, and laboratory data from 120 consecutive adults patients (July 3, 2006 to June 29, 2007) that had undergone cardiac surgery with the use of CPB were obtained from a prospective quality control database. Two groups were created. Group 1 was all negative (NEG). This group had no SFMC test with a positive result (n = 60) and no positive SFMCs (POS, n = 60). Group 2 was any positive (POS). This group had at least one positive SFMC test (n = 60). The POS group had more patients with endocarditis (11.7% vs. 3.3%, p < .001), chronic obstructive pulmonary disease (COPD) (18% vs. 8.3%, p = .005), longer CPB time (172 ± 64 vs. 151 ± 53 minutes, p = .047), and fewer minimally invasive procedures (31.7% vs. 51.7%, p = .002). The POS group required intraoperative (70.0% vs. 53.3%, p = .010) and post-operative (75.5% vs. 45.0%, p < .001) transfusions more frequently than the NEG group, despite similar amounts of blood loss. SFMC tests in CPB may be associated with patient pre-operative status and an increase in transfusion requirements.
Gaseous Microemboli in a Pediatric Bypass Circuit with an Unprimed Venous Line: An In Vitro Study
Authors: Hudacko Andrea , Sievert Alicia , Sistino Joseph
Published: July 2023

Miniaturizing cardiopulmonary bypass (CPB) circuits to reduce hemodilution and allogenic blood product administration is common in cardiac surgery. One major concern associated with smaller CPB circuits is a possible increase in gaseous micro-emboli (GME) sent to the cerebral vasculature, which is exacerbated by vacuum-assisted venous drainage (VAVD). The use of VAVD has increased with smaller venous line diameter and venous cannulae. This study examines the effects of CPB initiation with an unprimed venous line and VAVD in a pediatric circuit. A CPB circuit was set up with reservoir, oxygenator, and arterial filter with a bag reservoir to simulate the patient. All trials were done in vitro, and GME were measured using the EDAC Quantifier by Luna Innovations. EDAC sensors were placed proximal and distal to the oxygenator and distal to the arterial filter. Group 1 was the control group with no VAVD and a primed venous line. Groups 2, 3, and 4 used an unprimed venous line and VAVD of −40, −20, and −10 mmHg, respectively. Total microemboli counts and total embolic load in micrometers were measured at each sensor. Groups 2 (12,379.00 ± 3180.37) and 3 (8296.67 ± 2818.76) had significantly more microemboli than group 1 (923.33 ± 796.08,p< .05) at the pre-oxygenator sensor. Group 2 (57.33 ± 25.01,p< .05) had significantly more microemboli than group 1 (5.33 ± 3.21) at the post-oxygenator sensor. No other findings were statistically significant. The results suggest that, if an oxygenator and arterial filter with sufficient air handling capabilities are used, this method to reduce prime volume may not increase GME in the arterial line distal to the arterial filter.
A 2007 Survey of Extracorporeal Life Support Members: Personnel and Equipment
Authors: Sutton Robin G. , Salatich Amy , Jegier Briana , Chabot David
Published: July 2023

Extracorporeal membrane oxygenation (ECMO) is used to support patients with cardiopulmonary failure in the intensive care unit. The purpose of this study is to determine what professional qualifications, equipment, and tests are used by established ECMO programs registered with the Extracorporeal Life Support Organization (ELSO). A survey link (Survey-Monkey) was e-mailed to the 110 registered ELSO program coordinators. Forty-nine responses were received. A test of binomial portions showed that nurses were more likely to be ECMO providers than respiratory therapists or perfusionists (p< .05). A χ2test identified a difference in the type of pump (roller or centrifugal) based on patient age (p< .005). The most common monitoring/safety devices were battery back-up (84%), pre- and post-oxygenator pressure (82%), mixed venous oxygen saturation (80%), venous line pressure (76%), blood flowmeter (63%), bubble detector (61%), point-of-care blood gases (59%), and in-line blood gas monitoring (47%). Laboratory tests available included d-dimer (65%), plasma-free hemoglobin (63%), anti-Xa plasma heparin concentration (43%), thromboelastograph (37%), and heparin concentration using protamine titration (35%). This survey of ELSO-registered centers represents an overview of current ECMO practices.
Percutaneous Assisted Venous Return Isolated Limb Perfusion
Authors: Justison George , Westfield Justin , Carr Leo , Bukovic MaryJo
Published: July 2023

Isolated limb perfusion (ILP) is a short term therapy used in conjunction with or without hyperthermia to deliver chemotherapeutic agents to localized areas, thus avoiding the severity of side effects caused by systemic administration. The most common treatment approach is hyperthermic isolated limb perfusion (HILP) with increased oxygenation of the chemotherapeutic perfusate for treatment of melanoma, soft tissue sarcoma, or synovial sarcoma. HILP traditionally involves open surgical dissection and direct cannulation. This approach involves significant morbidity including blood loss, infection, and nerve and blood vessel trauma. Isolated limb infusion (ILI) has been proposed as a less invasive procedure to reduce the morbidity and isolation complications of ILP. However, the warming and recirculation rates of ILI are inferior to traditional ILP. We describe a minimally invasive technique of angiographically placed percutaneous cannulae with vacuum assisted return for HILP. The extracorporeal circuit is comprised of a traditional hardshell oxygenator/ reservoir and accommodates all acid base management strategies. This technique allows superior circulation of chemotherapeutic agents with minimal morbidities and can be performed on an outpatient or limited stay basis.
Application of Autologous Derived-Platelet Rich Plasma Gel in the Treatment of Chronic Wound Ulcer: Diabetic Foot Ulcer
Authors: Akingboye Akinfemi Ayobami , Giddins Stephen , Gamston Philip , Tucker Arthur , Navsaria Harshad , Kyriakides Constantions
Published: July 2023

The treatment of chronic wounds remains problematic, despite new insight into the cellular and molecular basis of wound healing. Although the aetio-pathogenesis of chronic wounds is said to be multi-factorial, it is evident from literature that effective and adequate wound debridement has produced the most consistent effect in chronic wound treatment. There is a growing body of evidence that suggests that wound healing in chronic diabetic foot ulcers is growth factor dependent and that the therapeutic delivery of these growth factors to wounds topically, has the potential ability to accelerate wound healing in conjunction with conventional wound care. Autologous derived platelet concentrate is activated to release growth factors that are stored in the platelet granules. These secretory proteins include cytokines and growth factors such as transforming growth factor–beta, vascular endothelia growth factor, platelet derived growth factor, and so on. The enhancement of soft tissue healing by the application of autologous derived platelet rich plasma gel (APG) is supported by basic science and some clinical studies. This review article will attempt to provide a concise report of current concepts on the use of APG in treating chronic ulcers.
Microemboli from Cardiopulmonary Bypass are Associated with a Serum Marker of Brain Injury
Authors: Groom Robert C. , Quinn Reed D. , Lennon Paul , Welch Janine , Kramer Robert S. , Ross Cathy S. , Beaulieu Peter A. , Brown Jeremiah R. , Malenka David J. , O’Connor Gerald T. , Likosky Donald S. ,   for the Northern New England Cardiovascular Disease Study Group
Published: July 2023

An increasing number of reports surrounding neurologic injury in the setting of cardiac surgery has focused on utilizing biomarkers as intermediate outcomes. Previous research has associated cerebral microemboli and neurobehavioral deficits with biomarkers. A leading source of cerebral microemboli is the cardiopulmonary bypass (CPB) circuit. This present study seeks to identify a relationship between microemboli leaving the CPB circuit and a biomarker of neurologic injury. We enrolled 71 patients undergoing coronary artery bypass grafting at a single institution from October 14, 2004 through December 5, 2007. Microemboli were monitored using Power-M-Mode Doppler in the inflow and outflow of the CPB circuit. Blood was sampled before and within 48 hours after surgery. Neurologic injury was measured using S100β (microg/L). Significant differences in post-operative S100β relative to microemboli leaving the circuit were tested with analysis of variance and Kruskal-Wallis. Most patients had increased serum levels of S100β (mean .25 microg/L, median .15 microg/L) following surgery. Terciles of microemboli measured in the outflow (indexed to the duration of time spent on CPB) were associated with elevated levels of S100β (p = .03). Microemboli leaving the CPB circuit were associated with increases in postoperative S100β levels. Efforts aimed at reducing microembolic load leaving the CPB circuit should be adopted to reduce brain injury.
The Perfusionist’s Role in a Collaborative Multidisciplinary Approach to Blood Transfusion Reduction in Cardiac Surgery
Authors: Zelinka Edy S. , Brevig James , McDonald Julie , Jin Ruyun
Published: July 2023

Red blood cell transfusion is associated with adverse outcomes. Transfusion practices remain varied in cardiac surgery and are a subject of growing debate. We initiated a data-driven, multidisciplinary effort to decrease allogeneic red blood cell transfusion at our institution. Creative perfusion strategies are an essential component of our program and led to a low transfusion rate. Innovations in treatment protocols were implemented and evaluated to reduce hemodilution associated with the cardiopulmonary bypass machine. Frequent review of outcomes guided our evolving clinical practice. Standardization among the perfusionists was the first step to a successful blood conservation program. Techniques included vacuum assisted venous drainage with dry 3/8″ tubing, a short (10 foot) arterial-venous loop, retrograde autologous prime, and saline prime removal from the primary and cardioplegia circuit. We used a polymer-coated perfusion circuit. Hemoconcentrator and cell saver use was determined on a case-by-case basis. Normothermia was maintained except in cases of circulatory arrest or specific surgeon request. Two thousand nine hundred and seventy-nine consecutive cardiac surgical procedures (2.8% off pump coronary artery bypass) were performed from January 1, 2003 to December 31, 2008. Our overall utilization of red blood cell transfusion decreased from 43.2% to 13.6% for all patients and 38.5% to 8.7% for coronary artery bypass graft only patients. Patient outcomes were not significantly changed through 2007. Cardiopulmonary perfusion can be performed safely with low utilization of allogeneic red blood cell transfusions. Standardization and creative perfusion techniques, in the presence of a multi-faceted approach to blood management, play an important role in blood conservation.
Transport of Critically Ill Children on Cardiopulmonary Support Assistance
Authors: Eldadah Maher K. , Olsen Monica C. , Fakioglu Harun , DeCampli William M.
Published: July 2023

Objective: To report two patients helicopter transport on mechanical cardiopulmonary support to a transplant center. Setting: Cardiac intensive care unit (CICU) and transport helicopter. Patients: A 9 kg and 22 kg children who suffer cardiac deterioration needing air transport on mechanical cardiopulmonary support. Interventions and Results: CPS was initiated to support these patients failing cardiac function. Transport on CPS of these two patients to a transplant institution was accomplished after determining that heart transplantation would be their more likely chance for recovery. Conclusion: A cardiac deterioration event that will lead to the need for heart transplantation can be acute and sudden sparing no time for early referral to a transplant center. It is necessary for heart centers to have a plan of action to provide inter-hospital transport on cardiopulmonary support (CPS). This protocol can involve transport by the refer ral institution, the receiving institution or a third institution.
The Effect of the Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery Clinical Practice Guidelines of the Society of Thoracic Surgeons and the Society of Cardiovascular Anesthesiologists upon Clinical Practices
Authors: Likosky Donald S. , FitzGerald Daniel C. , Groom Robert C. , Jones Dwayne K. , Baker Robert A. , Shann Kenneth G. , Mazer C. David , Spiess Bruce D. , Body Simon C.
Published: July 2023

The 2007 Society of Thoracic Surgeons and the Soci ety of Cardiovascular Anesthesiologists Clinical Practice Guide line for Perioperative Blood Transfusion and Blood Conservation in Cardiac Surgery was recently promulgated and has received much attention. Using a survey of cardiac anesthesiologists and perfusionists’ clinical practice, we assessed the current practices of perfusion, anesthesia, and surgery, as recommended by the Guidelines and also determined the role the Guidelines had in changing these practices. Nontrainee members of the Society of Cardiovascular Anesthesiologists, the American Academy of Cardiovascular Perfusion, the Canadian Society of Clinical Perfusion, and the American Society of ExtraCorporeal Technology were surveyed using a standardized survey instrument that examined clinical practices and responses to the Guidelines. One thousand four hundred and two surveys from 1,061 institutions principally in the United States (677 institutions) and Canada (34 institutions) were returned, with a 32% response rate. There was wide distribution of the Guidelines with 78% of anesthesiologists and 67% of perfusionists reporting having read all, part, or a summary of the Guidelines. However, only 20% of respondents reported that an institutional discussion had taken place as a result of the Guidelines, and only 14% of respondents reported that an institutional monitoring group had been formed. There was wide variability in current preoperative testing, perfusion, surgical, and pharmacological practices reported by respondents. Twenty-six percent of respondents reported one or more practice changes in response to the Guidelines. The changes made were reported to be highly (9%) or somewhat effective (31%) in reducing overall transfusion rates. Only four of 38 Guideline recommendations were reported by more than 5% of respondents to have been changed in response to the Guidelines. Wide variation in clinical practices of cardiac surgery was reported. Little change in clinical practices was attributed to the Society of Thoracic Surgeons/Society of Cardiovascular Anesthesiologists Guidelines.
Perfusion Techniques Toward Bloodless Pediatric Open Heart Surgery
Authors: Olshove Vincent F. , Preston Thomas , Gomez Daniel , Phillips Alistair , Galantowicz Mark
Published: July 2023

There continues to be evidence regarding the negative impact of blood transfusion on morbidity and mortality in the adult literature, including infection risk, increased hospital and intensive care length of stay, and costs. More effort has been put into reducing the use of blood components in adult surgical centers but blood transfusions continue to be used frequently in pediatric centers. From 2002 through 2005, we embarked on a mission of reduced prime volume in an effort toward bloodless cardiac surgery to meet the needs of the Jehovah’s Witness patient. The same bloodless surgical and perfusion techniques were applied to all patients undergoing cardiopulmonary bypass beginning in 2006. Circuit size was minimized and acute normovolemic hemodilution (ANH) was considered and attempted more often, especially if a re-operation. Retrograde arterial prime (RAP) and venous antegrade prime (VAP), dilutional or balanced ultrafiltration during cardiopulmonary bypass, modified arteriovenous ultrafiltration post bypass, and cell salvage of remaining circuit contents after flushing with crystalloid were recorded. ANH, RAP, and VAP, separately or in combination, were used less than 1% of the time prior to 2006. From 2006–2008 ANH was performed on 42% of the patients and RAP/VAP was performed on 70% of the patients. From 2006–2008, 43% (287 of 662) of the open heart surgeries were performed bloodless in the operating room versus 30% (193 of 633) from 2003–2005. Bloodless surgery more than doubled for the 0–6, 6–15, and 15–20 kg groups from 3.5%, 23%, and 23% respectively in 2003–2005 to 9%, 44%, and 58%, respectively in 2006–2008. With the cooperation of the entire cardiac surgical team, bloodless open heart surgery is achievable in a pediatric cardiac surgical center, including neonates.
Minimizing Reperfusion Injuries: Successful Resuscitation Using eCPR After Cardiac Arrest on a Post-Operative Norwood Patient
Authors: Amberman Keith , Shen Irving
Published: July 2023

In patients with hypoplastic left heart syndrome (HLHS), the left ventricle is too small to circulate adequate oxygenated blood. If left untreated, HLHS is fatal. A 3-staged palliative procedure ultimately leading to a single ventricle physiology is the preferred management strategy for HLHS in most pediatric cardiac centers in the United States. In this report, a 1-month-old infant developed cardiac arrest 3 weeks after undergoing a Norwood procedure as an initial palliation for HLHS. After 151 minutes of cardio-pulmonary resuscitation (CPR) with intermittent, but non-sustainable return of spontaneous circulation, extracorporeal cardio-pulmonary resuscitation (eCPR) was used. Utilizing the carotid artery and internal jugular vein for cannulation, we connected our extracorporeal membrane oxygenation (ECMO) circuit to the patient. To minimize reperfusion injury, immediate cooling, arterial/venous shunting, minimal calcium, and hemodilution strategies were used. Once paCO2/pvCO2gradients were minimized, we instituted sweep gas and gradually increased fiO2as pH normalized. The patient was successfully weaned from ECMO and discharged. eCPR was used successfully in the resuscitation of this patient and reperfusion injuries were minimized despite prolonged CPR.
The investment and reinsurance game of insurers and reinsurers with default risk under CEV model
Authors: Hao Wenjing , Qiu Zhijian , Li Lu
Published: July 2023

On the premise of considering the interests of insurance companies and reinsurance companies at the same time, this paper studies the investment and reinsurance game between them. Suppose that the compensation process faced by an insurance company is described by Brownian motion with drift. Insurance companies can purchase proportional reinsurance from reinsurance companies, and both companies can invest in a risk-free asset, a risky asset whose price process follows the constant elasticity of variance (CEV) model, and a defaultable bond. With the goal of maximizing the expected utility of weighted terminal wealth, the corresponding Hamilton–Jacobi–Bellman (HJB) equations are established and solved by using the principle of dynamic programming, and the analytical expressions of the equilibrium investment-reinsurance strategies of insurers and reinsurers are derived respectively. Finally, the influence of each model parameter on the equilibrium strategy is analyzed by numerical examples.
Drucksenkender Effekt der interventionellen Fistelokklusion bei Sekundärglaukom infolge orbital drainierender intrazerebraler Fisteln
Authors: Kesper Christiane , Skalej Martin , Huth Andrea , Viestenz Arne , Heichel Jens
Published: July 2023

Hintergrund Carotis-Sinus-cavernosus-Fisteln (CSCF) stellen pathologische Verbindungen der A. carotis interna und/oder externa (und/oder deren Äste) zum Sinus cavernosus dar. Vor
allem bei Drainage über die V. ophthalmica superior kommt es zu ophthalmologischen Symptomen und Problemen.

Material und Methoden In die retrospektive monozentrische Studie wurden 7 Augen von 6 Patienten eingeschlossen, bei denen ein hochgradiger Verdacht für eine CSCF bestand. Bei den
eingeschlossenen Patienten wurde eine digitale Subtraktionsangiografie (DSA) durchgeführt, bei der bei gesichertem Vorliegen einer CSCF ein interventioneller Fistelverschluss erfolgte. Vier
der 6 Patienten erhielten eine prä- und postinterventionelle Tagesaugendruckprofilmessung (TDP). Ausgewertet wurden Anamnese, Symptome, Visus, spaltlampenmikroskopischer Befund, TDP sowie
der DSA-Befund.

Ergebnisse Die häufigsten von den Patienten angegebenen Symptome waren ein gerötetes Auge, Diplopie und Exophthalmus. Bei der Augeninnendruckmessung zeigte sich bei 83,33% der
Patienten ein erhöhter Augeninnendruck (IOD). Der mittlere IOD betrug in der Tagesaugendruckprofilmessung am betroffenen Auge präinterventionell 23,5 (± 2,7) mmHg im Vergleich zu 14,1
(± 2,3) mmHg am gesunden Auge. Damit konnte im Seitenvergleich ein signifikanter Unterschied nachgewiesen werden (p = 0,0047). Bei der postinterventionellen Messung zeigte sich ein mittlerer
IOD von 15,3 (± 1,0) mmHg am betroffenen Auge und somit ein signifikanter Unterschied zu der präinterventionellen Messung am betroffenen Auge (p = 0,0018). Präinterventionell wandten 4 der 6
Patienten mit CSCF drucksenkende Augentropfen an, postinterventionell waren es noch 2 Patienten. Auch die Anzahl der verwendeten Antiglaukomatosa konnte gesenkt werden.

Schlussfolgerung Der interventionelle Fistelverschluss stellt eine effektive Methode zur Behandlung der sekundären Augeninnendrucksteigerung bei CSCF dar. Es zeigte sich bei
erfolgreichem Verschluss der Fistel eine signifikante Erniedrigung des Augeninnendruckes, die durch alleinige Gabe von Antiglaukomatosa nicht möglich war. Als Differenzialdiagnose sollte das
Radius-Maumenee-Syndrom in Betracht gezogen werden.
Interdisziplinäre Empfehlungen zur Behandlung des fortgeschrittenen Nierenzellkarzinoms
Authors: Miller Kurt , Bergmann Lothar , Doehn Christian , Grünwald Viktor , Gschwend Jürgen E. , Ivanyi Philipp , Kuczyk Markus A.
Published: July 2023

In den letzten zwei Jahren sind Anti-VEGFR-Tyrosinkinase-Inhibitoren (TKI) in der Erstlinientherapie des fortgeschrittenen Nierenzellkarzinom nahezu komplett durch Immuntherapie-Kombinationen mit Checkpoint-Inhibitoren ersetzt worden. Die Prognose der Patienten konnte damit nochmals deutlich verbessert werden. In den entsprechenden Zulassungsstudien wurden mediane Überlebenszeiten von drei bis vier Jahren erreicht. Die TKI-Monotherapie hat bei günstigem Progressionsrisiko, bei Kontraindikationen gegen eine Immuntherapie und im Kontext der SARS-CoV-2-Pandemie aber weiterhin einen Stellenwert.

Die Frage, welche Therapie für welche Patient/-innen geeignet ist, stellt sich vor dem Hintergrund von zwei CPI-TKI-Kombinationen und einer reinen CPI-Kombination als neuem Erstlinien-Standard auf einer neuen Basis. Temsirolimus und die Kombination Bevacizumab + Interferon-alpha spielen nahezu keine Rolle mehr. In der Zweitlinientherapie wurde für Nivolumab und Cabozantinib nach TKI-Vortherapie ein signifikanter Überlebensvorteil gegenüber Everolimus gezeigt. Die Kombination Lenvatinib + Everolimus sowie Axitinib sind weitere zugelassene Substanzen. Auch für TKI liegen Daten vor, allerdings mit begrenzter Aussagekraft. Everolimus als Monotherapie ist durch die neuen Optionen in der Zweitlinie abgelöst worden. Insgesamt fehlt es an Biomarkern, die bei der Therapiewahl unterstützen könnten. Die kürzlich erfolgte Aktualisierung der S3-Leitlinie war daher ein wichtiger Schritt, um evidenzbasiert in der klinischen Praxis Orientierung zu geben.

Bei potenziell komplexeren Therapiealgorithmen und gleichzeitig nur wenig Evidenz muss auch die Frage nach der optimalen Sequenztherapie neu diskutiert werden. Die meisten Zweitlinien-Optionen wurden nach Versagen einer gegen VEGF-gerichteten TKI-Therapie geprüft, die nur noch für eine Minderheit der Patient/-innen infrage kommt.

Im Rahmen eines interdisziplinären Expertengesprächs wurden im November 2020 die aktuelle Datenlage einschließlich neuerer Studienergebnisse sowie relevante Kriterien für die individuelle Therapieentscheidung diskutiert. Auch die SARS-CoV-2-Pandemie fand dabei Berücksichtigung. Ziel war es, gemeinsame Empfehlungen auf Basis der aktuell publizierten Daten und der eigenen klinischen Erfahrung für den Praxisalltag abzuleiten. Die Ergebnisse werden in dieser Publikation vorgestellt.
A Review of Mental Health Issues in High-Performance and Elite-Level
Cycling
Authors: Smith Alexander , Buadze Ana , Colangelo Jill , Liebrenz Michael
Published: July 2023

Despite the public health benefits of cycling in the general population, mental
health issues may be evident in high-performance and elite-level competitive
domains. With prominent riders disclosing their experiences with psychiatric
symptoms, distinctive socioenvironmental factors could exacerbate
psychopathological vulnerabilities. This suggests a need for greater mental
health awareness amongst stakeholders, supplemented by actions from
international and national federations and regulators. To synthesise relevant
observations about psychiatric concerns in high-performance and elite-level
cycling, we conducted a keyword search of articles in APA PsycINFO, PubMed, and
Scopus based on specified exclusion criteria. Thirteen papers were identified
that examined mental health issues in high-performance and/or
elite-level cycling per classifications from the World Health
Organization’s International Classification of Diseases 11th Revision. A
large proportion of articles illustrated eating disorder symptomatology, but
others discussed attention deficit/hyperactivity disorder, anxiety
disorder, depression, sleep wake disorders, and substance use disorder. Existing
literature underlines important considerations for all stakeholders within the
cycling community around mental health initiatives and care provisions, which
are currently lacking across the sport. Such programmes could incorporate
consensus statements, psychiatric screening, psychoeducation, stigma-reducing
policies, and athlete advocacy. These can help mitigate socioenvironmental risk
factors and prioritise athlete wellbeing over performance-centred
motivations.
Excisão de tumor fibroso solitário na chanfradura ciática com compressão do nervo ciático – Um raro caso clínico
Authors: Fontainhas Tiago , Costa Ana Sofia , Sousa Rui , Resende Ana Flávia , Nelas João , Pereira David
Published: July 2023

É apresentado um caso clínico de uma paciente de 41 anos, sem antecedentes pessoais de relevo, que foi estudada por dor abdominal difusa autolimitada, tendo sido detectada incidentalmente uma massa tumoral extrabdominal, extraperitoneal ao nível da chanfradura ciática direita. Durante o estudo do caso, a doente resolveu as queixas abdominais, mas desenvolveu quadro de ciatalgia, irradiada para o pé direito e dor tipo choque elétrico. Biópsia guiada por TAC revelou tratar-se de uma neoplasia mesenquimatosa dos tecidos moles, de baixo grau, com características que a enquadram em um tumor fibroso solitário extrapleural. A paciente foi referenciada para a equipe de bacia do serviço de ortopedia para excisão cirúrgica da lesão, tendo sido operada sem intercorrências – excisão total da lesão, com margens livres, foi obtida e o exame anatomopatológico foi compatível com o realizado na biópsia. Após excisão da lesão, ocorreu resolução completa dos sintomas relacionados com compressão do nervo ciático.
Osteotomia de redução da cabeça femoral por sequelas de doença de Legg-Calvé-Perthes: Relato de caso
Authors: Fontainhas Tiago , Pereira David , Costa Ana Sofia , Sousa Rui , Resende Ana Flávia , Nelas Joaquim
Published: July 2023

A doença de Legg-Calvé-Perthes (DLCP) origina comumente sequelas na morfologia da articulação coxofemoral. Uma variante comum é a cabeça do fêmur não-esférica e sobredimensionada, associada a um colo femoral curto e grande trocânter elevado, que origina conflito femuroacetabular (CFA). A inovadora técnica de luxação cirúrgica do quadril de Ganz abriu novas possibilidades de tratamento para CFA, incluindo a originada por sequelas de DLCP, sem aumentar o risco de necrose avascular da cabeça femoral. Na coxa magna elipsoide resultante de DLCP, constatou-se que o desgaste articular era mais acentuado na porção central da cabeça do fêmur e que o terço lateral está íntegro, pois não articula com o acetábulo. Para estes casos, foi desenvolvida a técnica de osteotomia de redução da cabeça femoral, que resseca a porção danificada da cabeça femoral e restabelece a sua esfericidade. Os resultados a curto prazo são encorajadores. O presente relato de caso apresenta um paciente com sequelas de DLCP tratado com osteotomia de redução da cabeça femoral.