To Örebro University

Innominate artery (IA) traumatic injuries are rare but life-threatening, with high mortality and morbidity. Open surgical repair is the treatment of choice but is technically demanding. We describe a case of blunt trauma to the IA with ongoing bleeding, treated successfully by combined (hybrid) endovascular and open surgery. The case demonstrates the immediate usage of modern endovascular and surgical tools as part of endovascular and hybrid trauma management.

Background: Postoperative heart failure remains the major cause of death after cardiac surgery. As N-terminal pro-B-type natriuretic peptide (NT-proBNP) is a predictor for postoperative heart failure, the aim was to evaluate if preoperative NT-proBNP could provide additional prognostic information to the recently launched EuroSCORE II.

Methods: A total of 365 patients with acute coronary syndrome (ACS) undergoing isolated coronary artery bypass graft (CABG) surgery were studied prospectively. Preoperative NT-proBNP and EuroSCORE II were evaluated with regard to severe circulatory failure after operation according to prespecified criteria. To assess what clinical outcomes are indicated by NT-proBNP levels in different risk categories, the patients were stratified according to EuroSCORE II. Based on receiver operating characteristics analysis, these cohorts were assessed with regard to preoperative NT-proBNP below or above 1028 ng litre(-1). The follow-up time averaged 4.4 (0.7) yr.

Results: Preoperative NT-proBNP >= 1028 ng litre(-1) [odds ratio (OR) 9.9,95% confidence interval (CI) 1.01-98.9; P=0.049] and EuroSCORE II (OR 1.24, 95% CI 1.06-1.46; P=0.008) independently predicted severe circulatory failure after operation. In intermediate-risk patients (EuroSCORE II 2.0-10.0), NT-proBNP >= 1028 ng litre(-1) was associated with a higher incidence of severe circulatory failure (6.6% vs 0%; P=0.007), renal failure (14.8% vs 5.4%; P=0.03), stroke (6.6% vs 0.7%; P=0.03), longer intensive care unit stay [37 (35) vs 27 (38) h; P=0.002], and worse long-term survival.

Conclusions: Combining EuroSCORE II and preoperative NT-proBNP appears to improve risk prediction with regard to severe circulatory failure after isolated CABG for ACS. NT-proBNP may be particularly useful in patients at intermediate risk according to EuroSCORE II.

Objectives. The predictive value of preoperative N-terminal pro-B-type natriuretic peptide (NT-proBNP) was evaluated in patients with acute coronary syndrome undergoing coronary artery bypass grafting (CABG). Design. As a substudy to a clinical trial 383 patients with acute coronary syndrome undergoing CABG were studied. 17 patients had a concomitant procedure. NT-proBNP was measured immediately preoperatively and evaluated with regard to in-hospital mortality, and severe circulatory failure postoperatively according to prespecified criteria. Follow-up was 3.2 +/- 0.9 years. Results. In patients with isolated CABG, receiver operating characteristics (ROC) analysis showed an area under the curve (AUC) of 0.82 for in-hospital mortality and 0.87 for severe circulatory failure respectively with a best cut-off for preoperative NT-proBNP of 1028 ng/L. This cut-off level independently predicted severe circulatory failure. Patients with NT-proBNP < 1028 ng/L had significantly better long-term survival (p = 0.004). Preoperative NT-proBNP was higher in patients with concomitant procedure than isolated CABG (2146 +/- 1858 v 887 +/- 1635 ng/L; p = 0.0005). In patients with concomitant procedure ROC analysis showed an AUC of 0.93 for severe circulatory failure with a best cut-off for preoperative NT-proBNP of 3145 ng/L. Conclusions. Preoperative NT-proBNP predicted in-hospital mortality, severe circulatory failure postoperatively and long-term survival in patients undergoing surgery for acute coronary syndrome but a higher threshold was found in patients having concomitant procedures.

Background: Lung cancer is the most frequently diagnosed cancer and one of the leading causes of cancer deaths. Surgery is the primary approach for curative treatment. Postoperative complications are common, and physiotherapy is often routinely provided for their prevention and treatment, even though the evidence is limited. The aim of this study was to examine the effect of in-hospital physiotherapy on postoperative physical capacity, physical activity, and lung function among patients undergoing lung cancer surgery.

Methods: A total of 107 patients undergoing elective thoracic surgery were included in a single-blinded randomized controlled trial, and randomized to a study group, receiving in-hospital physiotherapy treatment, or a control group, not receiving in-hospital physiotherapy treatment. The patients were assessed preoperatively and 3 months after surgery. The in-hospital physiotherapy treatment consisted of early mobilization, ambulation, breathing exercises, and thoracic range of motion exercises. Physical capacity was assessed with the 6-minute walk test. Level of physical activity was objectively assessed with an accelerometer and subjectively assessed with the International Physical Activity Questionnaire Modified for the Elderly.

Results: Physical capacity for the whole sample was significantly decreased 3 months postoperatively compared with preoperative values (P = .047). There were no statistically significant differences between the groups regarding physical capacity, physical activity, spirometric values, or dyspnea. However, patients in the study group increased their level of self-reported physical activity from preoperatively to 3 months postoperatively, while the patients in the control group did not.

Conclusions: No difference in physical capacity, physical activity, or lung function was found 3 months postoperatively in lung cancer surgery patients receiving in-hospital physiotherapy compared with control patients.

OBJECTIVES: Patients undergoing lung cancer surgery are routinely offered physiotherapy. Despite its routine use, effects on postoperative physical recovery have yet not been demonstrated. The aim of this study was to investigate whether physiotherapy could improve postoperative in-hospital physical activity level and physical capacity.

DESIGN: Single-blind randomized controlled trial.

SETTING: Thoracic surgery department at a University Hospital.

PARTICIPANTS: Patients undergoing elective thoracic surgery (n=94) for confirmed or suspected lung cancer were assessed during hospital stay.

INTERVENTION: Daily physiotherapy, consisting of mobilization, ambulation, shoulder exercises and breathing exercises. The control group received no physiotherapy treatment.

OUTCOMES: In-hospital physical activity assessed with the Actigraph GT3X+ accelerometer, six-minute walk test, spirometry and dyspnea scores.

RESULTS: The treatment group reached significantly more accelerometer counts (2010 (1508) vs 1629 (1146), mean difference 495 [95% CI 44 to 1109]), and steps per hour (49 (47) vs 37 (34), mean difference 14 [95% CI 3 to 30]), compared to the control group, during the first three postoperative days. No significant differences in six-minute walk test (percent of preoperative 71% vs 79%, P=0.13), spirometry (FEV1 percent of preoperative 69% vs 69%, P=0.83) or dyspnoea (M-MRC 2 vs 2, P=0.74) between the groups were found.

CONCLUSIONS: Patients receiving in-hospital physiotherapy showed increased level of physical activity during the first days after lung cancer surgery, compared to an untreated control group. However, no effects on the six-minute walk test or spirometric values were found. The clinical importance of an increased physical activity level during the early postoperative period needs to be further evaluated.

CLINICAL TRIAL REGISTRATION NUMBER: NCT01961700.

Objectives: Physical inactivity is common after lung cancer surgery. Patients undergoing lung cancer surgery are routinely offered physiotherapy. Despite its routine use, any effect on postoperative physical activity has not yet been demonstrated. The aim of this study was to investigate whether physiotherapy could improve physical activity during the first days after surgery.

Methods: A total of 94 patients undergoing elective surgery for confirmed or suspected lung cancer were consecutevily included and randomized to treatment group (n=50) or control group (n=44). The treatment group received daily physiotherapy, consisting of mobilization and ambulation, shoulder exercises and breathing exercises. The control group received no physiotherapy. Physical activity was assessed with the Actigraph GT3X+ accelerometer.

Results: The patients in the treatment group reached significantly more counts (1692 vs 1197, p=0.029) and steps per hour (39 vs 25, p=0.013), during the first three days, compared to the control group.

Conclusions: Physical activity during the first three days is increased by physiotherapy treament. The long term effect of in-hospital physiotherapy needs to be further evaluated.

BACKGROUND: Cardiopulmonary bypass and postoperative cardiac dysfunction cause splanchnic hypoperfusion resulting in intra-abdominal anaerobic metabolism and risk for gastrointestinal complications. The intra-abdominal metabolism can be monitored by intraperitoneal measurement of relevant metabolites using microdialysis. The aim of this study was to investigate the intraperitoneal metabolism using microdialysis during and after cardiopulmonary bypass at 34°C.

METHODS: In six patients undergoing elective coronary artery bypass grafting or aortic valve replacement under cardiopulmonary bypass, microdialysis was used to measure intraperitoneal and subcutaneous glucose, lactate, pyruvate, glycerol and glutamate concentrations, intraoperatively and up to 36 hours postoperatively. Arterial and central venous blood gases were analysed as were haemodynamics and the development of complications.

RESULTS: All patients had an ordinary perioperative course and did not develop gastrointestinal complications. The arterial, intraperitoneal and subcutaneous lactate concentrations changed during the perioperative course with differences between compartments. The highest median (interquartile range) concentration was recorded in the intraperitoneal compartment at 1 hour after the end of cardiopulmonary bypass (2.1 (1.9-2.5) mM compared to 1.3 (1.2-1.7) mM and 1.5 (1.0-2.2) mM in the arterial and subcutaneous compartments, respectively). In parallel with the peak increase in lactate concentration, the intraperitoneal lactate/pyruvate ratio was elevated to 33.4 (12.9-54.1).

CONCLUSION: In cardiac surgery, intraperitoneal microdialysis detected changes in the abdominal metabolic state, which were more pronounced than could be shown by arterial blood gas analysis. Despite an uneventful perioperative course, patients undergoing low-risk surgery under cardiopulmonary bypass might be subjected to a limited and subclinical intra-abdominal anaerobic state.

Objective: Adverse outcome after CABG is closely related to postoperative heart failure precipitated by ischemia and myocardial infarction. Restrictive use of inotropes is therefore desirable. Patients with preoperative left ventricular dysfunction are a high-risk group in this respect. To reduce myocardial oxygen expenditure we evolved a metabolic strategy for perioperative care.

Design: Observational study on 104 consecutive patients with severe left ventricular dysfunction undergoing CABG. The metabolic strategy implied physiological measures to minimize myocardial oxygen expenditure including restrictive use of inotropes and specific measures such as extended CPB and metabolic support to facilitate myocardial recovery. Hemodynamic state was primarily assessed by mixed venous oxygen saturation (SvO(2)). Follow-up averaged 9.7 +/- 1.4 years.

Results: LVEF was 0.30 +/- 0.05 (range 0.20-0.37) and 3.5 +/- 1.3 vessels were bypassed. Inotropes were used in 6.7% for weaning from CPB. Increase of s-creatinine by >= 50% compared to preoperative values was observed in 2.9%. Logistic EuroSCORE was 8.3% whereas observed 30-day mortality was 1.0%. Crude 5-year survival was 89.4%.

Conclusions: The metabolic strategy allowed restrictive use of inotropes and was associated with encouraging long-term survival. Renal function was well preserved suggesting that SvO(2) served as an adequate marker of circulation. Randomized trials with metabolic support are warranted.

Myocardial ischemia is a major cause of postoperative heart failure and adverse outcome in coronary artery bypass graft surgery (CABG). Conventional treatment of postoperative heart failure with inotropic drugs may aggravate underlying ischemic injury. Glutamate has been claimed to increase myocardial tolerance to ischemia and promote metabolic and hemodynamic recovery after ischemia. The aim of this work was to investigate if intravenous glutamate infusion given in association with CABG for acute coronary syndrome can reduce mortality and prevent or mitigate myocardial injury and postoperative heart failure. We also wanted to assess neurological safety issues, as a concern with the use of glutamate is that it may act as an excitotoxin under certain conditions.A metabolic strategy for perioperative care was assessed in an observational study on 104 consecutive patients with severe left ventricular dysfunction undergoing CABG. Based on encouraging clinical results, unsurpassed in the literature, the GLUTAMICS-trial was initiated. 861 patients undergoing CABG for acute coronary syndrome were randomly allocated to blinded intravenous infusion of L-glutamicacid solution or saline. The primary endpoint was a composite of postoperative mortality (≤30 days), perioperative myocardial infarction and left ventric ular heart failure in association with weaning from cardiopulmonary bypass. Secondary endpoints included neurological safety issues, degree of myocardial injury,postoperative hemodynamic state, use of circulatory support and cardiac mortality.The event rate was lower than anticipated and the primary endpoint did not differ significantly between the groups. Regarding secondary endpoints there were significant differences compatible with a beneficial effect of glutamate on post-ischemic myocardial recovery. The putative effect of glutamate infusion was seen in more ischemic patients (CCS class IV) and in patients with evident or anticipated LV-failure on weaning from CPB. No evidence for increased incidence of clinical or subclinical neurological injury was found. In conclusion, intravenous glutamate infusion is safe in the dosages employed and could provide a novel and important way of promoting myocardial recovery after ischemic injury.

Background & aimsConcerns have been raised about potential neurological injury related to exogenous glutamate. In cardiac surgery glutamate has been administered as a putative cardioprotective agent by cardioplegia or intravenous infusion. In the GLUTAMICS trial, in addition to surveillance of clinical neurological injuries, a prespecified subgroup was analyzed with regard to postoperative S-100B levels to detect potential subclinical neurological injury related to glutamate infusion.MethodsSixty-nine patients operated on for unstable coronary syndrome were randomized to intravenous infusion of glutamate (n=35) or saline (n=34) perioperatively. Plasma levels of S-100B were obtained on the third postoperative day.ResultsS-100B in the glutamate group and the control group were 0.079±0.034μg/L and 0.090±0.042μg/L respectively (p=0.245). There were no patients with stroke or mortality. Three patients in the control group and two in the glutamate group had postoperative confusion. These patients had significantly elevated S-100B compared with those without confusion (0.132±0.047vs 0.081±0.036μg/L; p=0.003). Overall, 21 patients had S-100B above reference level (≥0.10μg/L) and these patients had significantly more calcifications in the ascending aorta on epiaortic scanning.ConclusionsIntravenous glutamate infusion during surgery for unstable coronary artery disease did not initiate a sustained elevation of plasma S-100B. Thus, no evidence for subclinical neurological injury related to glutamate infusion was found. In contrast, postoperative elevation of plasma S-100B was linked to calcification of the ascending aorta and postoperative confusion.

Objective: Glutamate has been claimed to protect the heart from ischemia and to facilitate metabolic and hemodynamic recovery after ischemia. The GLUTAmate for Metabolic Intervention in Coronary Surgery trial investigated whether an intravenous glutamate infusion given in association with surgery for acute coronary syndrome could reduce mortality and prevent or mitigate myocardial injury and postoperative heart failure.

Methods: In the present prospective, triple-center, double-blind study, 861 patients undergoing surgery for acute coronary syndrome were randomly assigned to an intravenous infusion of glutamate (n = 428) or saline (n = 433) perioperatively.

Results: The incidence of the primary endpoint--a composite of 30-day mortality, perioperative myocardial infarction, and left ventricular heart failure at weaning from cardiopulmonary bypass-was 7.3% versus 5.8% (P = .41) in the glutamate and control groups, respectively. Patients with left ventricular failure at weaning from cardiopulmonary bypass had a shorter median intensive care unit stay (25 vs 92 hours; P = .02) if they were treated with glutamate. In patients with unstable angina (Canadian Cardiovascular Society class IV) undergoing isolated coronary artery bypass grafting (n = 458), the incidence of severe circulatory failure according to the prespecified criteria was significantly lower in the glutamate group (1.3% vs 6.9%; P = .004). On multivariate analysis, glutamate infusion was associated with a reduced risk of developing severe circulatory failure (odds ratio, 0.17; 95% confidence interval, 0.04-0.72; P = .02). A relative risk reduction exceeding 50% for developing severe circulatory failure was seen in most risk groups undergoing isolated coronary artery bypass grafting, with those with diabetes a notable exception.

Conclusions: The primary endpoint did not differ significantly between the groups. The secondary outcomes and post hoc analyses warrant additional studies with regard to the potential beneficial effect of glutamate on postischemic myocardial recovery.

Background: Glutamate has been claimed to protect the heart from ischemia and to facilitate metabolic and hemodynamic recovery after ischemia. The GLUTAMICS-trial investigated if intravenous glutamate infusion given in association with surgery for acute coronary syndrome can reduce mortality and prevent or mitigate myocardial injury and postoperative heart failure. Methods: In this investigator-initiated prospective, double-blind study 861 patients undergoing surgery for acute coronary syndrome in three Swedish Hospitals were randomly assigned to intravenous infusion of glutamate (n=428) or saline (n=433) perioperatively. The primary endpoint was a composite of postoperative mortality (30 days), perioperative myocardial infarction and left ventricular heart failure on weaning from cardiopulmonary bypass. Results: Thirty-day mortality was 0.9 % in the glutamate group and 1.2% in the control group. Cardiac mortality was 0.2% in the glutamate group and 0.9% the control group. The incidence of the composite primary end point was 7.2% in the glutamate group and 5.8% in the control group. None of these differences were statistically significant. Regarding secondary end points significantly fewer patients in the glutamate group were hemodynamically unstable at completion of surgery (0.3% v 1.8%; p=0.035) or in need of intra-aortic balloon pump on arrival to the intensive care unit (0.0% v 1.2%; p=0.026). In patients with severe unstable angina (CCS class IV; n=475) the incidence of severe circulatory failure according to prespecified criteria was significantly lower in the glutamate group (2.6% v 6.6%; p=0.036). Conclusions: The primary endpoint did not differ significantly between the groups. Regarding secondary end points there were significant differences compatible with a beneficial effect of glutamate on myocardial recovery. (ClinicalTrials.gov Identifier: NCT00489827)

Background: Intravenous glutamate reduced the risk of developing severe circulatory failure after isolated coronary artery bypass graft surgery (CABG) for acute coronary syndrome (ACS) in a double-blind randomised clinical trial (GLUTAMICS-ClinicalTrials.gov Identifier: NCT00489827 ). Here our aim was to study if glutamate was associated with reduced the use of inotropes.

Methods: Post-hoc analysis of 824 patients undergoing isolated CABG for ACS in the GLUTAMICS-trial. ICU-records were retrospectively scrutinised including hourly registration of inotropic drug infusion, dosage and total duration during the operation and postoperatively.

Results: ICU-records were found for 171 out of 177 patients who received inotropes perioperatively. Only one fourth of the patients treated with inotropes fulfilled study criteria for postoperative heart failure at weaning from cardiopulmonary bypass (CPB) or later in the ICU. Inotropes were mainly given preemptively to facilitate weaning from CPB or to treat postoperative circulatory instability (bleeding, hypovolaemia). Except for a significantly lower use of epinephrine there were only trends towards lower need of other inotropes overall in the glutamate group. In patients treated with inotropes (glutamate n = 17; placebo n = 13) who fulfilled study criteria for left ventricular failure at weaning from CPB the average duration of inotropic treatment (34 ± 20 v 80 ± 77 h; p = 0.014) and the number of inotropes used (1.35 ± 0.6 v 1.85 ± 0.7; p = 0.047) were lower in the glutamate group.

Conclusions: Intravenous glutamate was associated with a minor influence on inotrope use overall in patients undergoing CABG for ACS whereas a considerable and significant reduction was observed in patients with heart failure at weaning from CPB.