Outcomes of Del Nido and hyperkalemic blood cardioplegia in adult cardiac surgery with prolonged aortic cross-clamp times★.

Background: The utility and uptake of Del Nido cardioplegia in adult cardiac surgery is rapidly increasing. Cases with prolonged aortic cross-clamp times necessitate multi-dosing however an understanding of safe ischaemic times and definitive guidelines in this domain are lacking. Therefore, this study aimed to assess the safety and efficacy of our DNC strategy by comparing post-operative troponin profiles and clinical outcomes between Del Nido and hyperkalaemic cardioplegia for cases with aortic cross-clamp times of greater than 90 min.

Optimal Conduit Diameter Selection in Coronary Bypass Grafting Using Saphenous Vein.

Background: Predictors of long-term saphenous vein graft (SVG) patency following coronary artery bypass grafting (CABG) include harvesting technique, degree of proximal coronary stenosis, and target vessel diameter and runoff. The objective of this study was to evaluate the association between vein graft diameter and long-term survival.

Methods: Patients undergoing primary CABG (2000-2017) at Flinders Medical Centre, Adelaide, Australia, were categorised into three groups according to average SVG diameter (<3.

Cardiopulmonary bypass parameters improve the prediction of 30-day mortality following cardiac surgery.

Currently 30-day mortality is commonly used as a quality indicator for cardiac surgery; however, prediction models have not included the role of cardiopulmonary bypass (CPB). We hypothesized that reproducing currently utilised prediction model methods of 30-day mortality using the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) would identify relevant CPB predictors. Nine centers in Australia and New Zealand collected data using the ANZCPR between 2011-2020.

Quantification of the internal mammary artery size in Aboriginal and Torres Strait islanders.

Background: Variation in size of the internal mammary artery has been demonstrated in ethnic groups, but not reported in Aboriginal patients. We hypothesised that the left internal mammary artery is smaller in Aboriginal patients compared to non-Aboriginal patients and aimed to determine the impact on survival following coronary artery bypass graft (CABG) surgery.

Methods: Left internal mammary artery size was compared between Aboriginal (n = 345) and non-Aboriginal (n = 1819) in 2343 patients undergoing CABG at Flinders Medical Centre from January 2010 to June 2021.

Transcatheter mitral valve-in-valve: treatment of rheumatic heart disease in young patients.

Background: Rheumatic heart disease (RHD) in young people presents a complex management problem. In Australia a significant proportion of those affected are Aboriginal and Torres Strait Islanders. Transcatheter mitral valve-in-valve (TMViV) replacement has emerged as an alternative to redo surgery in high-risk patients with degenerated mitral bioprostheses.

Del Nido cardioplegia in adult cardiac surgery: analysis of myocardial protection and post-operative high-sensitivity Troponin T.

Background: del Nido cardioplegia has been adopted for use in adult cardiac surgery, despite a lack of robust randomised evidence supporting equivalence or superiority to conventional hyperkalaemic blood cardioplegia. We investigated the clinical surrogates of myocardial protection, and performed an extensive analysis of post-operative high-sensitivity Troponin T (hs-TnT) values in a general adult cardiac surgery population receiving del Nido, in comparison to a historical hyperkalaemic blood cohort.

Method: 171 consecutive patients of a single surgeon from between November 2018 and June 2020 received del Nido, and were compared to a historical cohort of 326 patients between January 2016 and November 2018 who received hyperkalaemic blood cardioplegia.

Acute kidney injury, stroke and death after cardiopulmonary bypass surgery: the role of perfusion flow and pressure.

Introduction: Acute kidney injury after cardiopulmonary bypass surgery is associated with morbidity and mortality. This study aims to evaluate the role of low perfusion flow and pressure in the development of cardiopulmonary bypass-associated acute kidney injury, stroke and death, using multicentre registry data.

Methods: We identified patients from the Australian and New Zealand Collaborative Perfusion Registry who underwent coronary artery bypass grafting and/or valvular surgery between 2008 and 2018.

Cardiopulmonary bypass management and acute kidney injury in 118 Jehovah's Witness patients: a retrospective propensity-matched multicentre cohort from 30,942 patients.

Introduction: Patients refusing blood products in cardiac surgery present challenges for cardiopulmonary bypass. Accurate detail of the modifiable factors of cardiopulmonary bypass relating to acute kidney injury is previously unreported in this patient population.

Methods: A total of 118 adult Jehovah's Witness patients refusing transfusion were propensity matched to 118 adult patients accepting transfusion from the 30,942 patients in the Australian and New Zealand Collaborative Perfusion Registry.

Predictive Capacity of Oxygen Delivery During Cardiopulmonary Bypass on Acute Kidney Injury.

Background: The randomized goal-directed perfusion trial confirmed retrospective findings that a goal-directed perfusion strategy to maintain oxygen delivery index (DOi) during cardiopulmonary bypass greater than 280 mL/min/m reduces the incidence of acute kidney injury (AKI). We developed a predictive model for AKI using data from the Australian and New Zealand Collaborative Perfusion Registry to determine whether these findings could be validated in a real-world clinical setting and to identify an optimal DOi threshold for predictive diagnostic accuracy.

Methods: Data in 19,410 cardiopulmonary bypass procedures were randomly divided into training (n = 9705) and validation (n = 9705) datasets.

Is Conventional Bypass for Coronary Artery Bypass Graft Surgery a Misnomer?

Although recent trials comparing on vs. off-pump revascularization techniques describe cardiopulmonary bypass (CPB) as "conventional," inadequate description and evaluation of how CPB is managed often exist in the peer-reviewed literature. We identify and subsequently describe regional and center-level differences in the techniques and equipment used for conducting CPB in the setting of coronary artery bypass grafting (CABG) surgery.

Outcomes of Redo Valve Surgery in Indigenous Australians.

Background: Rheumatic heart disease often leads to valve surgery at a young age in our Indigenous population. Anticoagulation can be problematic and therefore repeat surgery to replace degenerated bioprosthetic valves is common. We sought to examine outcomes following redo valve surgery in this population.

Integration of Electronic Perfusion Data for Perfusion Registries.

Although the potential for the utilization of electronic perfusion data (EPD) from proprietary software to facilitate the understanding and improvement of cardiopulmonary bypass (CPB) has been recognized, the generalizability of previous reports of EPD integration are limited by superceded software or lack of sufficient detail for reproducibility. To date, the Australian and New Zealand Collaborative Perfusion Registry (ANZCPR) is the only multicentre perfusion registry to have reported the integration of EPD. The inclusion of EPD in analyses of the impact of CPB on patient outcome is important in improving the understanding of CPB practice.

Goal-directed perfusion to reduce acute kidney injury: A randomized trial.

Objective: To determine whether a goal-directed perfusion (GDP) strategy aimed at maintaining oxygen delivery (DO) at ≥280 mL·min·m reduces the incidence of acute kidney injury (AKI).

Methods: This multicenter randomized trial enrolled a total of 350 patients undergoing cardiac surgery in 9 institutions. Patients were randomized to receive either GDP or conventional perfusion.

Low Oxygen Delivery as a Predictor of Acute Kidney Injury during Cardiopulmonary Bypass.

Low indexed oxygen delivery (DOi) during cardiopulmonary bypass (CPB) has been associated with an increase in the likelihood of acute kidney injury (AKI), with critical thresholds for oxygen delivery reported to be 260-270 mL/min/m. This study aims to explore whether a relationship exists for oxygen delivery during CPB, in which the integral of amount and time below a critical threshold, is associated with the incidence of postoperative AKI. The area under the curve (AUC) with DOi during CPB above or below 270 mL/min/m was calculated as a metric of oxygen delivery in 210 patients undergoing CPB.

Rewarming Temperature During Cardiopulmonary Bypass and Acute Kidney Injury: A Multicenter Analysis.

Background: Acute kidney injury (AKI) after cardiopulmonary bypass (CPB) is associated with a requirement for dialysis, a longer stay in the intensive care unit, a longer hospital length of stay, and mortality. An oxygenator arterial outlet temperature greater than 37°C has been reported to be associated with AKI; however, the influence of other rewarming temperatures is unclear. Using multicenter registry data, this study aimed to evaluate the role of CPB rewarming temperatures on AKI.

Should Air Bubble Detectors Be Used to Quantify Microbubble Activity during Cardiopulmonary Bypass?

Air bubble detectors (ABDs) are utilized during cardiopulmonary bypass (CPB) to protect against massive air embolism. Stockert (Munich, Germany) ABD quantify microbubbles >300 μm; however, their reliability has not been reported. The aim of this study was to assess the reliability of the microbubble data from the ABD with the SIII and S5 heart-lung machines.

Cardiovascular risk profile before coronary artery bypass graft surgery in relation to depression and anxiety disorders: An age and sex propensity matched study.

Objective: The cardiovascular risk profile and postoperative morbidity outcomes of anxiety disorder patients undergoing coronary artery bypass surgery is not known.

Methods: In a cross-sectional design, 114 consecutive coronary artery bypass graft surgery patients were evaluated to create four matched groups (30 with anxiety disorder, 27 with depression disorder and 57 age-sex matched coronary artery bypass surgery control patients with no depression or anxiety disorder).

Results: By comparison to non-depression disorder age-sex matched controls, depressed patients presented for coronary artery bypass surgery with significantly greater myocardial inflammatory markers (Troponin T>02, 33.

Oxygenator safety evaluation: a focus on connection grip strength and arterial temperature measurement accuracy.

This report describes the assessment of three specific safety-related specifications in the consideration of an alternate oxygenator; first the grip strength relationship between various oxygenator connectors and SMARxT tubing, second, the grip strength of various biopassive tubings and an isolated SMARxT connector, and finally, the accuracy of the arterial outlet temperature measurement. Grip strength experiments for the connections between the SMARxT tubing and the venous reservoir outlet and the oxygenator venous inlet and oxygenator arterial outlet of the Medtronic Affinity, Sorin Synthesis, Sorin Primox, and Terumo Capiox RX25 oxygenators were performed. In addition we compared the grip strength of polyvinyl chloride, Physio, Trillium, Carmeda, X-Coating, and SMARxT tubing.

Developing a benchmarking process in perfusion: a report of the Perfusion Downunder Collaboration.

Improving and understanding clinical practice is an appropriate goal for the perfusion community. The Perfusion Downunder Collaboration has established a multi-center perfusion focused database aimed at achieving these goals through the development of quantitative quality indicators for clinical improvement through benchmarking. Data were collected using the Perfusion Downunder Collaboration database from procedures performed in eight Australian and New Zealand cardiac centers between March 2007 and February 2011.

In vitro evaluation of gaseous microemboli handling of cardiopulmonary bypass circuits with and without integrated arterial line filters.

The delivery of gaseous microemboli (GME) by the cardiopulmonary bypass circuit should be minimized whenever possible. Innovations in components, such as the integration of arterial line filter (ALF) and ALFs with reduced priming volumes, have provided clinicians with circuit design options. However, before adopting these components clinically, their GME handling ability should be assessed.

Disconnection of Cobe SMARxT tubing from the venous outlet of the Terumo Capiox SX25RX oxygenator during cardiopulmonary bypass.

The use of surface modified, biocompatible tubing in cardiopulmonary bypass has been reported to decrease the inflammatory responses caused by blood contact with the non endothelial surface of poly vinyl chloride (PVC) tubing. The combination of advances in biocompatible tubing and increased affordability resulted in a change to our cardiopulmonary bypass circuit, with the Terumo Capiox SX25 oxygenator and Cobe PVC tubing being replaced with a Terumo Capiox SX25RX (with X coating) and Cobe SMARxT tubing. Prior to the introduction of the coated oxygenator, no connection problems had been evident.

Biofeedback: making the science real.

Neurological deficits such as stroke and subtle psychological, cognitive, and behavioral changes are known risks associated with cardiac surgery. These altered neurologic outcomes have a significant impact on patients and their quality of life postoperatively. Perioperative events, such as cerebral embolism and decrease in cerebral oxygenation and hypoperfusion have been identified as factors causal in producing adverse neurologic outcomes.

Implementing change in perfusion practice: quality improvement vs. experimentation?

The desire to optimize techniques and interventions that comprise clinical practice will inevitably involve the implementation of change in the process of care. To confirm the intended benefits of instituting clinical change, the process should be undertaken in a scientific manner. Although implementing changes in perfusion practice is limited by the availability of evidence based practice guidelines, we have the opportunity to audit our current practice according to institutional guidelines using quality improvement methods.

The Perfusion Downunder collaborative database project.

The Perfusion Downunder Collaboration provides research infrastructure and support to the Australian and New Zealand perfusion community, with the objective of determining best practices and producing relevant research publications. The Perfusion Downunder Collaborative Database (PDUCD) has been created for the purpose of collecting a dataset for cardiopulmonary bypass (CPB) procedures that includes integration with commercially available CPB data collection software. Initial testing of the PDUCD involved collection of data from four Australian and New Zealand hospitals from March to July 2007.