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  • 1.
    Ahlsson, Anders
    et al.
    Örebro University, School of Health and Medical Sciences, Örebro University, Sweden. Örebro University Hospital. Dept Cardiothorac & Vasc Surg, Örebro University Hospital, Örebro, Sweden.
    Fengsrud, Espen
    Dept Cardiol, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Birger
    Örebro University Hospital. Dept Cardiothorac & Vasc Surg, Örebro University Hospital, Örebro, Sweden.
    Positioning of the ablation catheter in total endoscopic ablation2014In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 18, no 1, p. 125-127Article in journal (Refereed)
    Abstract [en]

    Minimally invasive ablation of atrial fibrillation is an option in patients not suitable for or refractory to catheter ablation. Total endoscopic ablation can be performed via a monolateral approach, whereby a left atrial box lesion is created. If the ablation is introduced from the right side, the positioning of the ablation catheter on the partly hidden left pulmonary veins is of vital importance. Using thoracoscopy in combination with multiplane transoesophageal echocardiography, the anatomical position of the ablation catheter can be established. Our experience in over 60 procedures has confirmed this to be a safe technique of total endoscopic ablation.

  • 2.
    Axelsson, Birger
    et al.
    Department of Cardiovascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden; Department of Clinical Medicine, School of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Häggmark, Sören
    Department of Surgical and Perioperative Sciences, Heart Centre and Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Svenmarker, Staffan
    Department of Surgical and Perioperative Sciences, Heart Centre and Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Johansson, Göran
    Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden .
    Gupta, Anil
    Örebro University, School of Medical Sciences. Department of Anesthesiology and Intensive Care, Örebro University Hospital, Örebro, Sweden; Department of Clinical Medicine, Örebro University Hospital, Örebro, Sweden.
    Tydén, Hans
    Örebro University, School of Health Sciences. Department of Cardiovascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden; Department of Clinical Medicine, Örebro University Hospital, Örebro, Sweden.
    Wouters, Patrick
    Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium.
    Haney, Michael
    Department of Surgical and Perioperative Sciences, Anesthesiology and Intensive Care Medicine, Faculty of Medicine, Umeå University, Umeå, Sweden .
    Effects of Combined Milrinone and Levosimendan Treatment on Systolic and Diastolic Function During Postischemic Myocardial Dysfunction in a Porcine Model2016In: Journal of Cardiovascular Pharmacology and Therapeutics, ISSN 1074-2484, E-ISSN 1940-4034, Vol. 21, no 5, p. 495-503Article in journal (Refereed)
    Abstract [en]

    It is not known whether there are positive or negative interactions on ventricular function when a calcium-sensitizing inotrope is added to a phosphodiesterase inhibitor in the clinical setting of acute left ventricular (LV) dysfunction. We hypothesized that when levosimendan is added to milrinone treatment, there will be synergetic inotropic and lusitropic effects. This was tested in an anesthetized porcine postischemic global LV injury model, where ventricular pressures and volumes (conductance volumetry) were measured. A global ischemic injury was induced by repetitive left main stem coronary artery occlusions. Load-independent indices of LV function were assessed before and after ventricular injury, after milrinone treatment, and finally after addition of levosimendan to the milrinone treatment. Nonparametric, within-group comparisons were made. The protocol was completed in 12 pigs, 7 of which received the inotrope treatment and 5 of which served as controls. Milrinone led to positive lusitropic effects seen by improvement in tau after myocardial stunning. The addition of levosimendan to milrinone further increased lusitropic state. The latter effect could however not be attributed solely to levosimendan, since lusitropic state also improved spontaneously in time-matched controls at the same rate during the corresponding period. When levosimendan was added to milrinone infusion, there was no increase in systolic function (preload recruitable stroke work) compared to milrinone treatment alone. We conclude that in this model of postischemic LV dysfunction, there appears to be no clear improvement in systolic or diastolic function after addition of levosimendan to established milrinone treatment but also no negative effects of levosimendan in this context.

  • 3.
    Axelsson, Birger
    et al.
    Örebro University Hospital. Örebro University, School of Medical Sciences.
    Johansson, G.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Abrahamsson, P.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Gupta, Anil
    Örebro University Hospital. Örebro University, School of Health and Medical Sciences, Örebro University, Sweden.
    Tyden, H.
    Anaesthesia and Intensive Care, Department of Cardiovascular and Thoracic Surgery, Örebro University Hospital, Örebro, Sweden.
    Wouters, P.
    Department of Anesthesiology, University Hospital Ghent, Ghent, Belgium.
    Haney, M.
    Department of Surgical and Perioperative Sciences, Faculty of Medicine, Umeå University, Umeå, Sweden.
    Milrinone and levosimendan during porcine myocardial ischemia: no effects on calcium overload and metabolism2013In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 57, no 6, p. 719-728Article in journal (Refereed)
    Abstract [en]

    Background: Although inotropic stimulation is considered harmful in the presence of myocardial ischaemia, both calcium sensitisers and phosphodiesterase inhibitors may offer cardioprotection. We hypothesise that these cardioprotective effects are related to an acute alteration of myocardial metabolism. We studied in vivo effects of milrinone and levosimendan on calcium overload and ischaemic markers using left ventricular microdialysis in pigs with acute myocardial ischaemia.

    Methods: Anaesthetised juvenile pigs, average weight 36kg, were randomised to one of three intravenous treatment groups: milrinone 50g/kg bolus plus infusion 0.5g/kg/min (n=7), levosimendan 24g/kg plus infusion 0.2g/kg/min (n=7), or placebo (n=6) for 60min prior to and during a 45min acute regional coronary occlusion. Systemic and myocardial haemodynamics were assessed, and microdialysis was performed with catheters positioned in the left ventricular wall. 45Ca2+ was included in the microperfusate in order to assess local calcium uptake into myocardial cells. The microdialysate was analysed for glucose, lactate, pyruvate, glycerol, and for 45Ca2+ recovery.

    Results: During ischaemia, there were no differences in microdialysate-measured parameters between control animals and milrinone- or levosimendan-treated groups. In the pre-ischaemic period, arterial blood pressure decreased in all groups while myocardial oxygen consumption remained stable.

    Conclusions: These findings reject the hypothesis of an immediate energy-conserving effect of milrinone and levosimendan during acute myocardial ischaemia. On the other hand, the data show that inotropic support with milrinone and levosimendan does not worsen the metabolic parameters that were measured in the ischaemic myocardium.

  • 4.
    Dogan, Emanuel M.
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.
    Beskow, Linus
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Calais, Fredrik
    Department of Cardiology, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Hörer, Tal M.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiology.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences.
    Resuscitative Endovascular Balloon Occlusion of the Aorta in Experimental Cardiopulmonary Resuscitation: Aortic Occlusion Level Matters2019In: Shock, ISSN 1073-2322, E-ISSN 1540-0514, Vol. 52, no 1, p. 67-74Article in journal (Refereed)
    Abstract [en]

    INTRODUCTION: Aortic occlusion during cardiopulmonary resuscitation (CPR) increases systemic arterial pressures. Correct thoracic placement during the resuscitative endovascular balloon occlusion of the aorta (REBOA) may be important for achieving effective CPR.

    HYPOTHESIS: The positioning of the REBOA in the thoracic aorta during CPR will affect systemic arterial pressures.

    METHODS: Cardiac arrest was induced in 27 anesthetized pigs. After 7 min of CPR with a mechanical compression device, REBOA in the thoracic descending aorta at heart level (zone Ib, REBOA-Ib, n = 9), at diaphragmatic level (zone Ic, REBOA-Ic, n = 9) or no occlusion (control, n = 9) was initiated. The primary outcome was systemic arterial pressures during CPR.

    RESULTS: During CPR, REBOA-Ic increased systolic blood pressure from 86 mmHg (confidence interval [CI] 71-101) to 128 mmHg (CI 107-150, P < 0.001). Simultaneously, mean and diastolic blood pressures increased significantly in REBOA-Ic (P < 0.001 and P = 0.006, respectively), and were higher than in REBOA-Ib (P = 0.04 and P = 0.02, respectively) and control (P = 0.005 and P = 0.003, respectively). REBOA-Ib did not significantly affect systemic blood pressures. Arterial pH decreased more in control than in REBOA-Ib and REBOA-Ic after occlusion (P = 0.004 and P = 0.005, respectively). Arterial lactate concentrations were lower in REBOA-Ic compared with control and REBOA-Ib (P = 0.04 and P < 0.001, respectively).

    CONCLUSIONS: Thoracic aortic occlusion in zone Ic during CPR may be more effective in increasing systemic arterial pressures than occlusion in zone Ib. REBOA during CPR was found to be associated with a more favorable acid-base status of circulating blood. If REBOA is used as an adjunct in CPR, it may be of importance to carefully determine the aortic occlusion level.The study was performed following approval of the Regional Animal Ethics Committee in Linköping, Sweden (application ID 418).

  • 5.
    Mangafic, Samra
    et al.
    Department of Emergency Medicine, Halland’s Hospital, Varberg, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Holzmann, Martin J.
    Department of Internal Medicine, Solna, Karolinska Institutet, Stockholm, Sweden; Functional Area of Emergency Medicine, Karolinska University Hospital, Huddinge, Stockholm, Sweden.
    Arbeus, Mikael
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Bjurman, Christian
    Department of Medicine, Halland’s Hospital, Varberg, Sweden.
    Communication in intensive care units and cardiac wards: A literature review and personal experiences2019In: Journal of Hospital Administration, ISSN 1927-6990, E-ISSN 1927-7008, Vol. 8, no 1Article, review/survey (Refereed)
    Abstract [en]

    Background: Physicians are regularly confronted with a wide range of settings requiring good communication skills. Deficient communication is the main reason for patient complaints.

    Methods: A literature review and personal experiences of communication techniques used by physicians in intensive care units and cardiac wards.

    Results: Good communication can increase medical adherence and motivate patients to life-style changes and therefore improve outcomes, resolve or prevent conflicts, increase patients’ satisfaction with offered health care, decrease anxiety and depressive symptoms, instill hope and also make hospital staff feel better. C

    onclusions: In this article, different models aiming at achieving optimal results in diverse communication situations are described. Healthcare leaders and medical educators should encourage physicians to use the communication techniques presented in this review to optimize the interaction with patients, relatives and colleagues.

  • 6.
    Seilitz, Jenny
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Hörer, Tal M.
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden.
    Skoog, Per
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University Hospital, Örebro, Sweden; Department of Vascular Surgery and Institute of Medicine, Department of Molecular and Clinical Medicine, Sahlgrenska University Hospital and Academy, Gothenburg, Sweden.
    Sadeghi, Mitra
    Örebro University, School of Medical Sciences. Department of Vascular Surgery, Västmanland's Hospital, Västerås, Sweden .
    Jansson, Kjell
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Splanchnic Circulation and Intraabdominal Metabolism in Two Porcine Models of Low Cardiac Output2019In: Journal of Cardiovascular Translational Research, ISSN 1937-5387, E-ISSN 1937-5395, Vol. 12, no 3, p. 240-249Article in journal (Refereed)
    Abstract [en]

    The impact of acute cardiac dysfunction on the gastrointestinal tract was investigated in anesthetized and instrumented pigs by sequential reductions of cardiac output (CO). Using a cardiac tamponade (n = 6) or partial inferior caval vein balloon inflation (n = 6), CO was controllably reduced for 1 h each to 75% (CO75%), 50% (CO50%), and 35% (CO35%) of the baseline value. Cardiac output in controls (n = 6) was not manipulated and maintained. Mean arterial pressure, superior mesenteric arterial blood flow, and intestinal mucosal perfusion started to decrease at CO50% in the intervention groups. The decrease in superior mesenteric arterial blood flow was non-linear and exaggerated at CO35%. Systemic, venous mesenteric, and intraperitoneal lactate concentrations increased in the intervention groups from CO50%. Global and mesenteric oxygen uptake decreased at CO35%. In conclusion, gastrointestinal metabolism became increasingly anaerobic when CO was reduced by 50%. Anaerobic gastrointestinal metabolism in low CO can be detected using intraperitoneal microdialysis.

  • 7.
    Seilitz, Jenny
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery.
    Vidlund, Mårten
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery.
    Norgren, Lars
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Friberg, Örjan
    Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Jansson, Kjell
    Department of Surgery, Faculty of Medicine and Health, Örebro University, Örebro, Sweden.
    Perioperative intraperitoneal metabolic markers in patients undergoing cardiac surgery with cardiopulmonary bypass: an exploratory pilot study2019In: Perfusion, ISSN 0267-6591, E-ISSN 1477-111XArticle in journal (Refereed)
    Abstract [en]

    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.

  • 8.
    Seilitz, Jenny
    et al.
    Örebro University, School of Medical Sciences. Department of Cardiothoracic and Vascular Surgery, Faculty of Health and Medical Sciences, Örebro University, Örebro, Sweden.
    Westerling-Andersson, Kristian
    Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Axelsson, Birger
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Nilsson, Kristofer F.
    Örebro University, School of Medical Sciences. Örebro University Hospital. Department of Cardiothoracic and Vascular Surgery, Örebro University Hospital, Örebro, Sweden.
    Assessment of acute gastrointestinal injury score in postoperative cardiac surgical patients2017In: Acta Anaesthesiologica Scandinavica, ISSN 0001-5172, E-ISSN 1399-6576, Vol. 61, no 8, p. 1044-1044Article in journal (Other academic)
    Abstract [en]

    Background: Gastrointestinal (GI) complications following cardiac surgery are infrequent but feared due to high morbidity and mortality. In 2012 new guidelines for grading acute GI injury (AGI score) in the intensive care setting were presented (1). We aimed to apply the AGI score in postoperative cardiac surgical patients.

    Methods: A total number of 352 adult patients undergoing elective heart surgery with extra-corporeal circulation completed the study. Prospectively, AGI score was assessed daily during the first three post-operative days according to normal GI function (AGI 0), risk of developing GI dysfunction (AGI 1), GI dysfunction (AGI 2), GI failure (AGI 3) and GI failure with severe impact on distant organ function (AGI 4).

    Results: Ninety-eight percent of the patients were assessed to have a daily peak score of ≤1, but only 36% were completely free from GI symptoms. Seven patients received a peak score of 2–3. The two patients with the highest peak and accumulated AGI scores died later due to GI complications.

    Conclusions: Postoperative assessment of AGI score in cardiac surgical patients is feasible. A majority presented with a risk of developing GI dysfunction but did not progress further. Early postoperative GI dys-function might predispose for later GI complications, but a larger study population is needed to further investigate this association.

    Reference:1. Reintam BA et al. Intens Care Med 2012; 38: 384–94.

  • 9.
    Svenmarker, S.
    et al.
    Ctr Heart, Dept Surg & Perioperat Sci, Umeå Univ, Umeå, Sweden.
    Häggmark, S.
    Ctr Heart, Dept Surg & Perioperat Sci, Umeå Univ, Umeå, Sweden.
    Johansson, G.
    Dept Surg & Perioperat Sci Anaesthesiol & Intens, Umeå Univ, Umeå, Sweden.
    Axelsson, Birger
    Örebro University Hospital. Department of Cardiothoracic Surgery and Anaesthesiology, Örebro University Hospital, Örebro, Sweden.
    Wiklund, U.
    Dept Radiat Sci, Umeå Univ, Umeå, Sweden.
    Haney, M.
    Dept Surg & Perioperat Sci Anaesthesiol & Intens, Umeå Univ, Umeå, Sweden.
    Regional changes in cerebral blood flow oxygenation can indicate global changes in cerebral blood flow during coronary artery occlusion in juvenile pigs2014In: Physiological Measurement, ISSN 0967-3334, E-ISSN 1361-6579, Vol. 35, no 7, p. 1439-1450Article in journal (Refereed)
    Abstract [en]

    Near infrared spectroscopy (NIRS) is a widely employed method for assessment of regional cerebral oxygenation (R(c)StO(2)). RcStO(2) values are expected to vary with changes in the relative amount of oxyhaemoglobin. The present experimental study aimed to assess the response of RcStO(2) to controlled alterations of carotid blood flow (CQ). Landrace pigs were anesthetized followed by surgical preparation. Cyclic variations in cardiac output were accomplished by intermittently occluding the main stem of the left coronary artery. A flow measurement probe for assessing CQ was placed around the left carotid artery. One NIRS probe was placed on the left ipsilateral forehead to assess regional cerebral oximetry. Simultaneous registration of CQ and RcStO(2) was conducted. There was a strong correlation for variation in CQ and RcStO(2) signal values. Based on coherence analysis the fraction of power of the RcStO(2) that was coherent with the CQ signal reached 0.84 - 0.12 (P < 0.05) for frequencies lower than 0.1 Hz. The agreement of the sampleto- sample co-variation, as assessed by the Pearson correlation coefficient, was 0.83 +/- 0.08 (P < 0.05). One explanatory component for variations in cerebral oxygenation verified by NIRS should be attributed to variations in the cerebral blood flow.

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