Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass

Greenwood, John C.; Jang, David H.; Spelde, Audrey E.; Gutsche, Jacob T.; Horák, Jiří; Acker, Michael A.; Kilbaugh, Todd J.; Shofer, Frances S.; Augoustides, John; Bakker, Jan; Abella, Benjamin S.

doi:10.1097/shk.0000000000001713

Cited by 22 publications

(17 citation statements)

References 44 publications

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“…This study interpreted that CPB procedure altered microvascular perfusion, and anesthesia partially contributed to the alterations. Greenwood et al further demonstrated the association between impaired microcirculation and POHL in cardiac surgery with CPB [ 20 ], and the inflammatory responses played a role in POHL development [ 21 ]. Mini-CPB could lead to fewer alterations of microperfusion, and its use may clinically improve outcomes in patients with high-risk surgery and in those with longer procedures [ 22 ].…”

Section: Discussionmentioning

confidence: 99%

Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery

Wang

Huang

et al. 2021

BMC Cardiovasc Disord

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Background Hyperlactatemia may be caused by increased production due to tissue hypoxia or non-hypoxia. The aim of this study was first to identify risk factors for postoperative hyperlactatemia (POHL) after Stanford type A acute aortic dissection surgery (AADS) and construct a predictive model, and second to evaluate the impact of POHL on prognosis. Methods This retrospective study involved patients undergoing AADS from January 2016 to December 2019 in Wuhan Union Hospital. Multivariate logistic regression analysis was performed to identify independent risk factors for POHL. A nomogram predicting POHL was established based on these factors and was validated in the original dataset. The receiver operating characteristic curve was drawn to assess the ability of postoperative lactate levels to predict the in-hospital mortality. Results A total of 188 patients developed POHL after AADS (38.6%). Male gender, surgery history, red blood cell transfusion and cardiopulmonary bypass time were identified as independent predictors. The C-index of the prediction model for POHL was 0.72, indicating reasonable discrimination. The model was well calibrated by visual inspection and goodness-of-fit test (Hosmer–Lemeshow χ2 = 10.25, P = 0.25). Decision and clinical impact curves of the model showed good clinical utility. The overall in-hospital mortality rate was 10.1%. Postoperative lactate levels showed a moderate predictive power for postoperative in-hospital mortality (C-index: 0.72). Conclusion We developed and validated a prediction model for POHL in patients undergoing AADS, which may have clinical utility in personal risk evaluation and preventive interventions. The POHL could be a good predictor for in-hospital mortality.

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Section: Discussionmentioning

confidence: 99%

Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery

Wang

Huang

et al. 2021

BMC Cardiovasc Disord

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“…The median lactic acid in our study was 3.6 ± 3.3 mmol/L before surgery and 5.0 ± 5.2 mmol/L after surgery. In our research, preoperative and postoperative lactic acid levels of patients with dissection under CPB were higher than those of other types of surgery 27 . The study of CPB in this paper is more detailed than that in previous papers.…”

Section: Discussionmentioning

confidence: 43%

Predicting postoperative hypoxemia risk factors in the patients after triple‐branched stent graft implantation surgery with acute type A aortic dissection: A retrospective study

Wang

Dai

et al. 2022

Journal of Cardiac Surgery

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Objective To evaluate the risk factors of postoperative hypoxemia in patients after triple‐branched stent graft implantation surgery with acute type A aortic dissection by conducting a nomogram. Methods We evaluated 97 patients with acute type A aortic dissection (2020–2021), who underwent triple‐branched stent graft implantation surgery. The independent risk factors were screened using univariate and multivariate logistic regression. We integrated significant factors as well as potential interference factors to build the nomogram model. The accuracy of the nomogram model was determined by using receiver operating characteristic curves (ROC), decision curve analyses (DCA), and calibration plots. Internal verification was evaluated using bootstrap validation. Results Logistic regression analysis illustrated that the postoperative lactic acid, postoperative creatinine, and intraoperative aortic occlusion time were all independent risk factors for hypoxemia. Age, sex, and body mass index (BMI) were clinically relevant for predicting postoperative hypoxemia. We established a nomogram based on these six risk factors. The ROC (area under the curve [AUC] = 0.765), DCA, and calibration confirmed good discriminatory applicability and accuracy of the nomogram. Bootstrap validation (AUC = 0.76) verified the applicability of the nomogram. Conclusions The nomogram model could serve as a tool for the prediction of postoperative hypoxemia in patients after modified triple‐branched stent graft implantation surgery with acute type A aortic dissection.

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“…Using data from our previous foundational work as well as unpublished pilot data, we anticipate a 1:1 allocation of patients to the high (PVD > 22mm/mm 2 ) and low group (PVD � 22 mm/mm 2 ). We will need a sample size of at least 134 subjects to detect at least a 2-day difference in ventilator and vasopressor-free days (VVFDs) with a β = 0.8, using a one-sided t-test α = 0.05 [5,6]. We will enroll a total of 140 subjects to allow for a 5% loss to follow-up (surgical delay, ICU delay, cancelled surgery, etc.)…”

Section: Sample Size and Powermentioning

confidence: 99%

“…Using these methods, previous literature has concluded that lactic acidosis after cardiac surgery is unlikely related to inadequate oxygen delivery [4]. Unfortunately these inferences fail to consider the presence of regional blood flow derangements caused by pathologic microcirculatory heterogeneity, which are also associated with severity of postoperative lactic acidosis and organ injury [5,6]. To resolve this important clinical discrepancy, a deeper understanding of the determinants of oxygen transport pathways and oxygen utilization during health, shock, and resuscitation are needed.…”

Section: Introductionmentioning

confidence: 99%

Protocol for the MicroRESUS study: The impact of circulatory shock and resuscitation on microcirculatory function and mitochondrial respiration after cardiovascular surgery

et al. 2022

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Background Despite current resuscitation strategies, circulatory shock and organ injury after cardiac surgery occur in 25–40% of patients. Goal-directed resuscitation after cardiac surgery has generated significant interest, but clinical practice to normalize hemodynamic variables including mean arterial pressure, cardiac filling pressures, and cardiac output may not reverse microcirculation abnormalities and do not address cellular dysoxia. Recent advances in technology have made it possible to measure critical components of oxygen delivery and oxygen utilization systems in live human tissues and blood cells. The MicroRESUS study will be the first study to measure microcirculatory and mitochondrial function in patients with circulatory shock and link these findings with clinical outcomes. Methods and analysis This will be a prospective, observational study that includes patients undergoing elective cardiovascular surgery with cardiopulmonary bypass (CPB). Microcirculation will be quantified with sublingual incident dark field videomicroscopy. Mitochondrial respiration will be measured by performing a substrate–uncoupler–inhibitor titration protocol with high resolution respirometry on peripheral blood mononuclear cells at baseline and serial timepoints during resuscitation and at recovery as a possible liquid biomarker. Plasma samples will be preserved for future analysis to examine endothelial injury and other mechanisms of microcirculatory dysfunction. Thirty-day ventilator and vasopressor-free days (VVFDs) will be measured as a primary outcome, along with sequential organ failure assessment scores, and other clinical parameters to determine if changes in microcirculation and mitochondrial respiration are more strongly associated with clinical outcomes compared to traditional resuscitation targets. Discussion This will be the first prospective study to examine both microcirculatory and mitochondrial function in human patients with circulatory shock undergoing cardiac bypass and address a key mechanistic knowledge gap in the cardiovascular literature. The results of this study will direct future research efforts and therapeutic development for patients with shock.

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Low Microcirculatory Perfused Vessel Density and High Heterogeneity are Associated With Increased Intensity and Duration of Lactic Acidosis After Cardiac Surgery with Cardiopulmonary Bypass

Abstract: and low MFIv. Conclusion: Low perfused vessel density and high microcirculatory heterogeneity are associated with an increased intensity and duration of lactic acidosis after cardiac surgery with cardiopulmonary bypass.

Cited by 22 publications

References 44 publications

Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery

Risk factors and in-hospital mortality of postoperative hyperlactatemia in patients after acute type A aortic dissection surgery

Predicting postoperative hypoxemia risk factors in the patients after triple‐branched stent graft implantation surgery with acute type A aortic dissection: A retrospective study

Protocol for the MicroRESUS study: The impact of circulatory shock and resuscitation on microcirculatory function and mitochondrial respiration after cardiovascular surgery

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