| 1. |
- Engström, Karin, et al.
(författare)
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Hazards with electrocautery-induced decomposition of fatty acids - in view of lipid embolization
- 2010
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Ingår i: Scandinavian Cardiovascular Journal. - : Informa UK Limited. - 1401-7431 .- 1651-2006. ; 44:5, s. 307-312
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Tidskriftsartikel (refereegranskat)abstract
- Objectives. Electrocautery is an appreciated surgical tool, which however, generates immense heat and fat-tissue melting. In cardiac surgery, liquefied fat collects on the surface of blood in the pericardial cavity and becomes aspirated by the heart-lung machine for aortic recycling. Deposits seen in the brain microcirculation after surgery are caused by lipid embolism. This study investigates lipid chemistry, whether heat from electrocautery generates fatty-acid fragmentation and decomposition. Design. Pericardial fat tissue was sampled from cardiac-surgery patients and from piglets. The human tissue was exposed to electrocautery, or to fixed temperatures in an in vitro model. Fatty-acid decomposition was explored by solid-phase microextraction gas chromatography and the distribution of fatty acids was measured. Results. Fatty-acid decomposition demonstrated a temperature-effect relationship (p=0.007). At 350 degrees C the proportion of polyunsaturated fatty acids became heavily reduced or were abolished (p=0.016). Electrocautery resulted in similar changes. Conclusions. Electrocautery induces a profound fatty-acid fragmentation to form short-chained compounds. The chemical and toxic nature of these compounds remains to be determined, including their clinical implications at blood recycling in cardiac surgery.
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| 2. |
- Johansson, Bengt, et al.
(författare)
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Evaluation of hyaluronan and calcifications in stenotic and regurgitant aortic valves.
- 2011
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Ingår i: European Journal of Cardio-Thoracic Surgery. - : Elsevier. - 1010-7940 .- 1873-734X. ; 39:1, s. 27-32
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Tidskriftsartikel (refereegranskat)abstract
- Objective: Hyaluronan (HA) is a major component of the interstitium and has been observed in normal heart valves. The function of HA in heart valves is unknown but contribution to biomechanical function has been proposed. The purpose of this investigation was to study the distribution of HA in relation to calcifications in diseased human aortic valves. Methods: Human aortic valves were collected at aortic valve replacement, of whom nine patients had regurgitation and 13 stenotic disease. The valves were decalcified and stained for the visualisation of HA. The specimens were macroscopically evaluated for magnitude of calcification using image analysis. The microscopic amount and distribution of HA and calcifications were semiquantitatively evaluated using histochemistry. Results: The overall HA staining showed an inverse relationship against the magnitude of observed valve calcifications (p<0.001) and type of disease (p=0.014). Multiple-group comparison revealed regionally reduced HA staining in diffuse and heavy calcified regions inside the valve (both p<0.001) compared with normal-structured parts of the valve. HA was concentrated on the ventricular side of the valve (p=0.002). Conclusions: The content of HA was reduced in calcified aortic valves and had a heterogeneous distribution, potentially contributing to poor valve function. HA may also be involved in the pathophysiological process in degenerative aortic stenosis.
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| 3. |
- Jönsson, Karl, et al.
(författare)
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Glomerular filtration rate in patients with atrial fibrillation on warfarin treatment: A subgroup analysis from the AURICULA registry in Sweden.
- 2011
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Ingår i: Thrombosis Research. - : Elsevier BV. - 1879-2472 .- 0049-3848. ; 128:4, s. 341-345
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Tidskriftsartikel (refereegranskat)abstract
- INTRODUCTION: Numerous associations between chronic kidney disease (CKD) and atrial fibrillation (AF) have been reported and patients with CKD on anticoagulation therapy have an increased risk of bleeding. Currently, new anticoagulant agents are emerging in clinical practice, some of which are excreted by the kidneys. The proportion of AF patients on anticoagulant treatment with reduced renal function is, however, unknown. MATERIALS AND METHODS: Using AURICULA, a Swedish registry for anticoagulation, estimated glomerular filtration rate (eGFR) was investigated in AF patients on warfarin treatment (n=2,603). The study group was compared with a healthy sample from the population (n=2,261). Two different creatinine prediction equations were used for calculating eGFR: the Lund-Malmö (LM) and MDRD Study equation. RESULTS: The fraction of AF patients with eGFR <30 and <45ml/min/1.73m(2) were 8.1% and 22.9% with the LM and 4.3% and 16.3% with the MDRD equation, respectively, and significantly higher than corresponding values in the reference population. GFR decreased with increasing age, where 11.4% and 5.6% of AF patients aged≥75years had eGFR <30ml/min/1.73m(2) according to the LM and MDRD equations, respectively. CONCLUSIONS: Severe renal impairment is common among AF patients on anticoagulant treatment with warfarin, especially at higher ages. Monitoring of renal function should be implemented in clinical practice for AF patients treated with new anticoagulants eliminated by the kidneys.
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| 6. |
- Boivie, Patrik, et al.
(författare)
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Intraluminal aortic manipulation by means of intra-aortic filter, cannulation, and external clamp maneuvers evaluated versus dislodged embolic material.
- 2006
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Ingår i: Journal of Thoracic and Cardiovascular Surgery. - : Elsevier BV. - 0022-5223 .- 1097-685X. ; 131:2, s. 283-289
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Tidskriftsartikel (refereegranskat)abstract
- OBJECTIVES: Aortic atherosclerosis is an important risk factor for cerebrovascular accidents in cardiac surgery. An intra-aortic filter might reduce this risk. We aimed to analyze the risks for emboli associated with intraluminal aortic manipulation and intra-aortic filter handling in relation to cannulation and external clamp maneuvers. METHODS: A model was designed with a cadaver aorta and retrograde perfusion (n = 16). A crossclamp was positioned on the ascending aorta and repeatedly opened under pressure to collect aliquots with dislodged particles. Cannulation was performed after 10 clamp maneuvers, followed by positioning and removing the intra-aortic filter, with each step followed by a washout sequence to collect perfusate. The removed filter was also analyzed. Evaluation was by means of digital image analysis, with differentiation of particles into different spectra. RESULTS: Intra-aortic filter manipulation produced a significant washout of embolic particles; in particular, this was seen for the macroscopic cellular spectrum (P = .006 and P = .002 for filter insertion and removal, respectively). Particles were also found to be collected by the filter (P = .004). In addition, cannulation and aortic crossclamp manipulation generated a notable number of particles (P = .001 and P = .013, respectively). CONCLUSIONS: The intra-aortic filter collects material during aortic manipulation. However, intraluminal aortic manipulation from filter handling can also dislodge particles, possibly related to shedding of intimal debris. This is in addition to substantial amounts of particles that are generated by aortic cannulation and aortic crossclamping.
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| 7. |
- Boivie, Patrik, et al.
(författare)
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Side differences in cerebrovascular accidents after cardiac surgery : a statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization.
- 2005
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Ingår i: Journal of Thoracic and Cardiovascular Surgery. - : Elsevier BV. - 0022-5223 .- 1097-685X. ; 129:3, s. 591-598
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Tidskriftsartikel (refereegranskat)abstract
- BACKGROUND: Aortic manipulation and particle embolization have been identified to cause cerebrovascular accidents in cardiac surgery. Recent data suggest that left-hemispheric cerebrovascular accident (right-sided symptoms) is more common, and this has been interpreted as being caused by aortic cannula stream jets. Our aim was to evaluate symptoms of cerebrovascular accident and side differences from a retrospective statistical analysis. METHODS: During a 2-year period, 2641 consecutive cardiac surgery cases were analyzed. Patients positive for cerebrovascular accident were extracted from a database designed to monitor clinical symptoms. A protocol was used to confirm symptom data with the correct diagnosis in patient records. Patients were subdivided into 3 groups: control, immediate cerebrovascular accident, and delayed cerebrovascular accident. RESULTS: Among pooled patients, immediate and delayed cerebrovascular accidents were 3.0% and 0.9%, respectively. The expected predisposing factors behind immediate cerebrovascular accidents were significant, although the type of operation affected this search. Aortic quality was a strong predictor ( P < .001). The rate of delayed cerebrovascular accident was unaffected by surgery group. Left-sided symptoms of immediate cerebrovascular accident were approximately twice as frequent ( P = .016) as on the contralateral side. This phenomenon was observed for pooled patients and for isolated coronary bypass procedures (n = 1882; P = .025). CONCLUSIONS: Immediate cerebrovascular accident and aortic calcifications are linked. The predominance of left-sided symptoms may suggest that aortic manipulation and anatomic mechanisms in the aortic arch are more likely to cause cerebrovascular accidents than effects from cannula stream jets.
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| 8. |
- Boivie, Patrik, et al.
(författare)
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Size distribution of embolic material produced at aortic cross-clamp manipulation
- 2010
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Ingår i: Scandinavian Cardiovascular Journal. - London, UK : Informa Plc.. - 1401-7431 .- 1651-2006. ; 44:6, s. 367-372
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Tidskriftsartikel (refereegranskat)abstract
- Objectives: The association between aortic atherosclerosis and neurological damage during cardiac surgery is well recognized. The purpose was here to analyze the size distribution of particles produced at cross-clamp manipulation of the ascending aorta. Design: A human cadaveric aortic perfusion model of retrograde design was applied (n 27). With this model, washout samples were collected from the pressurized ascending aorta during cross clamp manipulation. Before the experiment, the aorta was flushed to remove debris and with a baseline sample collected. The cross-clamp was opened to collect ten repeated aliquots with dislodged particles. Collected washout samples were evaluated by digital image analysis and microscopy. Results: Cross-clamping produced a significant output of particles, which was seen for size intervals of 1 mm and smaller (p 0.002 to p 0.022). In all size intervals the particle output correlated with the degree of overall aortic calcification(p 0.002 to p 0.025). The model generated substantially more small-size particles than large debris (p 0.010). Conclusions: Aortic clamping was here verified to dislodge aortic debris which correlated with the degree of observed calcification. Macroscopic particles were few. In contrast, cross-clamping produced substantial numbers of small-size particles. These findings emphasize microembolic risks associated with cross-clamping of atherosclerotic vessels.
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| 9. |
- Claesson Lingehall, Helena, 1965-
(författare)
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Delirium in older people after cardiac surgery : risk factors, dementia, patients’ experiences and assessments
- 2016
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Doktorsavhandling (övrigt vetenskapligt/konstnärligt)abstract
- Background:Delirium is common in older people undergoing cardiac surgery. Delirium is an acute or subacute neuro-psychiatric syndrome, characterized by a change in cognition, disturbances in consciousness; it fluctuates, develops over a short period of time and always has an underlying cause. It is associated with a disturbance in psychomotor activity, and is classified according to different clinical profiles such as hypoactive, hyperactive and mixed delirium. Delirium after cardiac surgery is not harmless, it increases the risk of complications such as prolonged stay in hospital, falls, reduced quality of life, reduced cognitive function and increased mortality.Aim:The overall aim of this thesis was to investigate postoperative delirium in older people undergoing cardiac surgery with Cardiopulmonary Bypass (CPB), focusing on risk factors, dementia and patients’ experiences; and to evaluate an assessment for screening delirium.Methods:This thesis compromises four studies. All participants (n=142) were scheduled for cardiac surgery with use of CPB at the Cardiothoracic Surgery Department, Heart Centre, Umeå University Hospital, Sweden, between February and October 2009. Six structured interviews were conducted preoperatively, day one and day four postoperatively, and in home visits, one, three and five years after surgery (2010, 2012 and 2014). The assessment scales used in Studies I, II and IV were: the Mini-Mental State Examination (MMSE) for cognition, the Organic Brain Syndrome Scale (OBS) for delirium, Geriatric Depression Scale 15 (GDS-15) for depression, Katz staircase with Activities of Daily Living (ADL) for participants’ functional status and the Numerical Rating Scale (NRS) for pain. During the hospital stay, nursing staff used the Swedish version of the Nursing Delirium Screening Scale (Nu-DESC) to assess delirium. Semi-structured interviews were also carried out (III) in the one-year follow up. Delirium, dementia and depression were diagnosed according to the Diagnostic and Statistical Manual of Mental Disorders (DSM IV TR).Results: Out of 142 participants 54.9% (78/142) developed delirium after cardiac surgery (I). Independent risk factors, predisposing and precipitating, associated with delirium were: age, diabetes, gastritis/peptic ulcer, volume load during operation, longer time on ventilator in intensive care, increased temperature and plasma sodium concentration in the intensive care unit. Out of 114 participants thirty (26.3%) developed dementia within the five years of follow-up. It was shown that a lower preoperative MMSE score and postoperative delirium were factors independently associated with development of dementia (II). One year after cardiac surgery, participants diagnosed with postoperative delirium described in detail feelings of extreme vulnerability and frailty. Despite this, the participants were grateful for the care they had received (III). Hypoactive was the most common symptom profile for delirium. The Swedish version of Nu-DESC showed high sensitivity in detecting hyperactive delirium, but low sensitivity in detecting hypoactive delirium (IV).Conclusion:Delirium was common among older patients undergoing cardiac surgery. Both predisposing and precipitating factors contributed to postoperative delirium. Preventive strategies should be considered in future randomized studies. It might also be suggested that cognitive function should be screened for preoperatively and patients who develop delirium should be followed up to enable early detection of symptoms of dementia. Whether prevention of postoperative delirium can reduce the risk of future dementia remains to be studied. To minimise unnecessary suffering, patients and next of kin should be informed about and prepared for the risk of delirium developing during hospitalization. The Swedish version of Nu-DESC should be combined with cognitive testing to improve detection of hypoactive delirium, but further research is needed. Healthcare professionals need knowledge concerning postoperative delirium in order to prevent, detect and treat delirium so as to avoid and relieve the suffering it might cause.
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