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  • 1.
    Budtz-Lilly, Jacob
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery. Aarhus University Hospital, Department of Vascular Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Wanhainen, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Astudillo, Rafael
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Thelin, Stefan
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Mani, Kevin
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Vascular Surgery.
    Technical eligibility for endovascular treatment of the aortic arch after open type A aortic dissection repair2019In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685XArticle in journal (Refereed)
    Abstract [en]

    Objective: To report on the technical eligibility of patients previously treated for Stanford type A aorta dissection (AAD) for endovascular aortic arch repair based on contemporary anatomical criteria for an arch inner-branched stentgraft (AIBS). 

     

    Methods: All patients treated for AAD from 2004-2015 at a single aortic centre were identified. Extent of repair and use of circulatory arrest were reported. Survival and reoperation were assessed using Kaplan Meier and competing risk models. Anatomic assessment was performed using 3-dimensional CT-imaging software. Primary outcome was survival ≥ 1 year and fulfilment of the AIBS anatomical criteria. 

     

    Results: A total of 198 patients were included (158 Debakey I, 32 Debakey II, and 8 Intramural hematoma). Mortality was 30-days: 16.2%, 1-year: 19.2%, 10-years: 45.0%. There were 129 patients with imaging beyond 1 year (mean, 47.8 months), while 89 (69.0%) were AIBS eligible. During follow-up, 19 (14.7%) patients met the threshold criteria for aortic arch treatment, of which 14 (73.7%) would be considered eligible for AIBS. Patients who underwent AAD repair with circulatory arrest and no distal clamp were more often eligible for endovascular repair (88.8%) than those operated with a distal clamp (72.5%), p=0.021. Among patients who did not meet the AIBS anatomical criteria, the primary reasons were mechanical valve (40%) and insufficient proximal seal (30%). 

     

    Conclusion: More than two thirds of post AAD patients repair are technically eligible for endovascular AIBS repair. Development of devices that can accommodate a mechanical aortic valve and a greater awareness of sufficient graft length would significantly increase availability.

  • 2.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Survival after refractory cardiogenic shock is comparable in patients with Impella and veno-arterial extracorporeal membrane oxygenation when adjusted for SAVE score2019In: European heart journal. Acute cardiovascular care., ISSN 2048-8726, Vol. 8, no 4, p. 329-337Article in journal (Refereed)
    Abstract [en]

    Objectives: Survival after different short-term mechanical circulatory support is difficult to compare because various systems are used and patient disease severity is most often not adjusted for. This study compares the outcome after the use of Impella and veno-arterial extracorporeal membrane oxygenation (VA-ECMO) in refractory cardiogenic shock, adjusted for disease severity through the survival after the VA-ECMO (SAVE) score.Methods: Patients with refractory shock treated with either VA-ECMO or Impella between January 2003 and August 2015 were included. Data were analysed to assess short and long-term survival and complications. The SAVE score was calculated for the two groups and outcome was compared adjusted for the SAVE score.Results: There was no difference between VA-ECMO patients (n=46) and Impella patients (n=48) in mean age or renal failure. ECMO patients were more often intubated and had lower diastolic blood pressure at device implantation. ECMO patients had a lower SAVE score (–0.4 (6.5)) compared to Impella patients (4.1 (5.4)). There was no difference in intensive care unit survival between ECMO patients 65% (52–80) or Impella patients 63% (55–79), or long-term survival between groups. When stratified into worse (III–IV) or better SAVE class (I–II) there was no difference in survival between the groups.Conclusions: Short and long-term survival is not measurably different among patients treated with Impella or VA-ECMO due to refractory cardiogenic shock, after adjustment for disease severity through the SAVE score.

  • 3.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    A Modified Glenn Shunt Reduces Right Ventricular Stroke Work During Left Ventricular Assist Device TherapyArticle in journal (Other academic)
  • 4.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    A modified Glenn shunt reduces right ventricular stroke work during left ventricular assist device therapy.2016In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 49, no 3, p. 795-801Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Right ventricular (RV) failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) placement and remains hard to predict. We hypothesized that partial surgical exclusion of the RV with a modified Glenn shunt during LVAD treatment would reduce RV stroke work.

    METHODS: An LVAD was implanted in eight pigs and a modified Glenn shunt was constructed. A conductance pressure-volume catheter was placed in the right ventricle through the apex. Haemodynamic data and pressure-volume loops were obtained at the following time periods: (i) baseline, (ii) open shunt, (iii) LVAD with closed shunt and (iii) LVAD and open shunt.

    RESULTS: During LVAD therapy, the right atrial (RA) pressure increased from 9 mmHg (9-9) to 15 mmHg (12-15), P = 0.01. RV stroke volume increased from 30 ml (29-40) to 51 ml (42-53), P < 0.01. Also, RV stroke work increased to 708 mmHg ml (654-1193) from 535 mmHg ml (424-717), P = 0.04, compared with baseline. During LVAD therapy in combination with a Glenn shunt, the RA pressure decreased from 15 mmHg (12-15) to 10 mmHg (7-11) when compared with LVAD therapy only, P = 0.01. A decrease in RV stroke work from 708 mmHg ml (654-1193) to 465 mmHg ml (366-711), P = 0.04, was seen when the LVAD was combined with a shunt, not significantly different from the baseline value (535 mmHg ml). The developed pressure in the right ventricle decreased from 29 mmHg (26-32) to 21 mmHg (20-24), P < 0.01. The pressure-volume loops of the RV show a significant reduction of RV stroke work during the use of the shunt with LVAD treatment.

    CONCLUSIONS: A modified Glenn shunt reduced RV volumes, RV stroke work and RA pressure during LVAD therapy in an experimental model of heart failure in pigs.

  • 5.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Experimental Venoarterial Extracorporeal Membrane Oxygenation Induces Left Ventricular Dysfunction2016In: ASAIO journal (1992), ISSN 1058-2916, E-ISSN 1538-943X, Vol. 62, no 5, p. 518-524Article in journal (Refereed)
    Abstract [en]

    Venoarterial extracorporeal membrane oxygenation (VA-ECMO) has experienced an increased use in acute cardiac failure. There are some reports on negative effects of VA-ECMO on cardiac function, such as left ventricular (LV) dilatation and cardiac stun, but the support in the literature is scarce. This study investigates the effects of experimental VA-ECMO on LV function in both peripheral and central cannulation. Ten pigs were randomized to VA-ECMO by either peripheral cannulation through the femoral vessels or central cannulation in the right atrium and ascending aorta. Left ventricular performance was measured with pressure-volume catheters during 5 hours of VA-ECMO. The LV enddiastolic and end-systolic volumes increased comparably in both groups during ECMO. Left ventricular ejection fraction, stroke work, and maximum rate of pressure change decreased comparably in both groups as a function of time on ECMO. The site of cannulation had no impact on the LV response to ECMO. In conclusion, VA-ECMO increased LV volumes and reduced LV function, irrespective of cannulation site in this experimental model. Reduced LV ejection fraction and stroke work indicated LV dysfunction during ECMO.

  • 6.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    The Impella® Recover mechanical assist device in acute cardiogenic shock: a single-centre experience of 66 patients2016In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 22, no 4, p. 452-458Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Short-term ventricular assist devices are more frequently used in patients with acute cardiogenic shock. The aim of this study was to evaluate its effect on haemodynamic parameters, as well as the short- and long-term outcome and complication rate associated with the device. METHODS: All patients treated with the ImpellaA (R) Recover device at our centre from 2003 to 2014 (n = 66) were included in this study, and follow-up time was 2.9 (+/- 0.4) years. Data were obtained through patient records and the population register. Patient-related factors, preimplantation and early postimplantation haemodynamic and biochemical parameters were analysed. Characteristics of survivors and non-survivors were compared. RESULTS: The device was implanted in 66 patients and 58% (38/66) were alive at 30 days post-implantation. The mean duration of support was 7.4 (+/- 0.8) days. Mean time in the intensive care unit was 24 (+/- 4) days. Following device implantation, patients' cardiac index improved from 2.1 l/min/m(2) (+/- 0.20) to 3.8 l/min/m(2) (+/- 0.20) at Day 7, mixed venous saturation increased from 56% (+/- 2.0) to 68% (+/- 1.2) and diuresis increased from 69 ml/h (+/- 9) at device insertion to 105 ml/h (+/- 19) at Day 7 on support. Central venous pressure, lactate levels and inotropic support decreased on support. No difference between survivors and non-survivors was established. No correlation was established between preimplant parameters and 30-day mortality. CONCLUSIONS: The ImpellaA (R) Recover device improved haemodynamics in patients with acute cardiogenic shock. Still, 30-day mortality remains high and future studies must focus on the optimal timing of placement of the device.

  • 7.
    Schiller, Petter
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Jönsson, Anders
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Left Ventricular Decompression during Extracorporeal Membrane Oxygenation (ECMO) Treatment does not Reduce Size of Myocardial Infarction in an Experimental ModelManuscript (preprint) (Other academic)
  • 8.
    Vikholm, Per
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Treatment of Right Ventricular Failure through Partial Volume Exclusion: An Experimental Study2015Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Implantation of a left ventricular assist device (LVAD) is a potential treatment in terminal heart failure. Right ventricular (RV) failure is a severe complication in these patients and sometimes requires additional placement of a right ventricular assist device (RVAD). RVAD implantation, however, is an invasive treatment associated with both increased mortality and morbidity. The aim of this thesis was to study whether partial volume exclusion of the RV through a modified Glenn shunt or cavoaortic shunt could treat severe RV failure. The ultimate goal would be to use it as an alternative to a RVAD in RV failure during LVAD therapy.

    Swine were used as the model animal in all studies. In Study I, experimental RV failure was induced by ischemia, and verified by hemodynamic measurements and genetic expression. Treatment with a modified Glenn shunt reduced venous stasis and improved hemodynamics in general. In Study II, experimental RV failure was induced by the same method as in Study I. Treatment with a cavoaortic shunt in addition to LVAD therapy proved to reduce venous stasis and improved hemodynamics in general, which was feasible with preserved oxygen delivery despite cyanotic shunting. In Study III, experimental RV failure was induced by pulmonary banding, and verified by hemodynamic measurements and genetic expression. Treatment with a modified Glenn shunt reduced venous stasis but did not improve hemodynamics in general compared with a control group. In Study IV, the effects of LVAD therapy and subsequent treatment with a modified Glenn shunt on the normal RV function were studied. It demonstrated that LVAD therapy can put strain on the RV by increasing stroke work and end-diastolic volume, and that these effects can be reversed by treatment with a modified Glenn shunt during LVAD therapy.

    In conclusion, partial volume exclusion through a modified Glenn shunt or cavoaortic shunt is a feasible treatment of experimental RV failure. Thus, it could potentially be used as an alternative treatment to a RVAD in severe RV failure during LVAD therapy.

    List of papers
    1. A modified Glenn shunt improves haemodynamics in acute right ventricular failure in an experimental model
    Open this publication in new window or tab >>A modified Glenn shunt improves haemodynamics in acute right ventricular failure in an experimental model
    2013 (English)In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 43, no 3, p. 612-618Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVES:

    Right heart failure is a major cause of morbidity and mortality after left ventricular assist device implantation and is still hard to predict. This study investigated the haemodynamic effect of a modified Glenn shunt on induced right ventricular (RV) failure.

    METHODS:

    Isolated RV failure was induced by coronary ligation in 11 pigs. A modified Glenn shunt was established by a superior vena cava to pulmonary artery connection. Haemodynamic data were obtained at baseline, RV failure, and RV failure and open shunt. Myocardial biopsies were taken to ascertain established heart failure.

    RESULTS:

    RV failure defined as right atrial pressure ≥20 mmHg was achieved in all 11 animals. A reduction in cardiac output (CO) from 3.7 (3.5-4.2) to 2.3 l/min (2.0-2.6) and mean arterial pressure (MAP) from median 72.7 (70.1-82.2) to 55.9 mmHg (52.6-59.8) was seen during heart failure. The median flow in the shunt was 681 ml. Right atrial pressures decreased from 20.3 (19.6-21.1) to 13.4 mmHg (12.7-14.0), and RV pressures decreased from 18.1 (16.4-20.1) to 13.6 mmHg (13.5-14.2) with open shunt (P = 0.001 for both). CO increased to 2.9 l/min (2.4-3.3) when the shunt was in use. Mixed venous oxygen saturation increased with the shunt from 32 (27-38) to 49% (45-56), P = 0.001. Genes associated with heart failure were upregulated during heart failure.

    CONCLUSIONS:

    A modified Glenn shunt improved haemodynamics by reduced right atrial pressure, increased CO, MAP and mixed venous oxygen saturation in an experimental model of induced RV failure.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-188728 (URN)10.1093/ejcts/ezs386 (DOI)000314852500038 ()22761503 (PubMedID)
    Available from: 2012-12-19 Created: 2012-12-19 Last updated: 2017-12-06Bibliographically approved
    2. Cavoaortic shunt improves hemodynamics with preserved oxygen delivery in experimental right ventricular failure during left ventricular assist device therapy
    Open this publication in new window or tab >>Cavoaortic shunt improves hemodynamics with preserved oxygen delivery in experimental right ventricular failure during left ventricular assist device therapy
    2014 (English)In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 147, no 2, p. 625-631Article in journal (Refereed) Published
    Abstract [en]

    OBJECTIVE:

    Right heart failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. This study evaluated the approach of a cavoaortic shunt included in the LVAD circuit, which would aim to relieve venous congestion and improve hemodynamics with preserved oxygen delivery during induced right ventricular failure.

    METHODS:

    Right ventricular failure was induced by coronary ligation in 10 pigs. An LVAD was implanted and a cavoaortic shunt was created from the right atrium and included in the assist circuit. Hemodynamic measures and blood gas analyses were analyzed. Oxygen delivery and oxygen consumption were estimated.

    RESULTS:

    Right atrial pressure decreased from more than 20 mm Hg to 17.2 mm Hg (14.8-18.4) with the LVAD and to 14.1 mm Hg (11.2-15.5) (P < .01) with the LVAD and cavoaortic shunt. Mean arterial pressure increased from 70.9 mm Hg (67.6-79.8) to 81.5 mm Hg (70.8-92.6) (P = .02) with addition of the shunt into the assist circuit. Cardiac output increased from 3.5 L/min (2.6-4.2) to 4.9 L/min (3.5-5.6) (P < .01) with cavoaortic shunting. Oxygen delivery with the cavoaortic shunt was 337 mL/min (±70) as compared with left ventricular assist alone at 258 mL/min (±52) (P < .01). Oxygen consumption was restored during use of the cavoaortic shunt.

    CONCLUSIONS:

    A cavoaortic shunt combined with an LVAD during right ventricular failure reduces central venous pressures, increases systemic arterial pressure, and enables increased cardiac output compared with device therapy alone. This was feasible with preserved oxygen delivery.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-216406 (URN)10.1016/j.jtcvs.2013.02.010 (DOI)000329724700014 ()23477692 (PubMedID)
    Available from: 2014-01-21 Created: 2014-01-21 Last updated: 2017-12-06Bibliographically approved
    3. A modified Glenn shunt reduces venous congestion during acute right ventricular failure due to pulmonary banding: a randomized experimental study
    Open this publication in new window or tab >>A modified Glenn shunt reduces venous congestion during acute right ventricular failure due to pulmonary banding: a randomized experimental study
    2014 (English)In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 18, no 4, p. 418-425Article in journal (Refereed) Published
    Abstract [en]

    Right ventricular failure after left ventricular assist device implantation is a serious complication with high rates of mortality and morbidity. It has been demonstrated in experimental settings that volume exclusion of the right ventricle with a modified Glenn shunt can improve haemodynamics during ischaemic right ventricular failure. However, the concept of a modified Glenn shunt is dependent on a normal pulmonary vascular resistance, which can limit its use in some patients. The aim of this study was to explore the effects of volume exclusion with a modified Glenn shunt during right ventricular failure due to pulmonary banding, and to study the alterations in genetic expression in the right ventricle due to pressure and volume overload. Experimental right ventricular failure was induced in pigs (n = 11) through 2 h of pulmonary banding. The pigs were randomized to either treatment with a modified Glenn shunt and pulmonary banding (n = 6) or solely pulmonary banding (n = 5) as a control group. Haemodynamic measurements, blood samples and right ventricular biopsies for genetic analysis were sampled at baseline, at right ventricular failure (i.e. 2 h of pulmonary banding) and 1 h post-right ventricular failure in both groups. Right atrial pressure increased from 10 mmHg (9.0-12) to 18 mmHg (16-22) (P < 0.01) and the right ventricular pressure from 31 mmHg (26-35) to 57 mmHg (49-61) (P < 0.01) after pulmonary banding. Subsequent treatment with the modified Glenn shunt resulted in a decrease in right atrial pressure to 13 mmHg (11-14) (P = 0.03). In the control group, right atrial pressure was unchanged at 19 mmHg (16-20) (P = 0.18). At right heart failure, there was an up-regulation of genes associated with heart failure, inflammation, angiogenesis, negative regulation of cell death and proliferation. Volume exclusion with a modified Glenn shunt during right ventricular failure reduced venous congestion compared with the control group. The state of right heart failure was verified through genetic expressional changes.

    Keywords
    Right-sided heart failure, Bidirectional Glenn shunt, Assisted circulation, Microarray analysis
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:uu:diva-223874 (URN)10.1093/icvts/ivt547 (DOI)000333271300004 ()
    Available from: 2014-05-09 Created: 2014-04-28 Last updated: 2017-12-05Bibliographically approved
    4. A Modified Glenn Shunt Reduces Right Ventricular Stroke Work During Left Ventricular Assist Device Therapy
    Open this publication in new window or tab >>A Modified Glenn Shunt Reduces Right Ventricular Stroke Work During Left Ventricular Assist Device Therapy
    (English)Article in journal (Other academic) Submitted
    Keywords
    Glenn shunt, Left Ventricular Assit Device Therapy, Right Heart Failure
    National Category
    Surgery
    Research subject
    Medical Science
    Identifiers
    urn:nbn:se:uu:diva-248163 (URN)
    Available from: 2015-03-29 Created: 2015-03-29 Last updated: 2015-07-07Bibliographically approved
  • 9.
    Vikholm, Per
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Ivert, Torbjorn
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden;Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Nilsson, Johan
    Skane Univ Hosp, Dept Clin Sci Cardiothorac Surg, Lund, Sweden.
    Holmgren, Anders
    Umea Univ Hosp, Dept Surg & Perioperat Sci, Umea, Sweden.
    Freter, Wolfgang
    Linkoping Univ Hosp, Dept Med & Hlth Sci, Linkoping, Sweden.
    Temstrom, Lisa
    Sahlgrens Univ Hosp, Dept Cardiothorac Surg, Gothenburg, Sweden.
    Ghaidan, Haider
    Blekinge Hosp, Dept Cardiothorac Surg, Karlskrona, Sweden.
    Sartipy, Ulrik
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden;Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Olsson, Christian
    Karolinska Inst, Dept Mol Med & Surg, Stockholm, Sweden;Karolinska Univ Hosp, Heart & Vasc Theme, Stockholm, Sweden.
    Granfeldt, Hans
    Linkoping Univ Hosp, Dept Med & Hlth Sci, Linkoping, Sweden.
    Ragnarsson, Sigurdur
    Skane Univ Hosp, Dept Clin Sci Cardiothorac Surg, Lund, Sweden.
    Friberg, Orjan
    Orebro Univ Hosp, Fac Med & Hlth, Dept Cardiothorac Surg & Vasc Surg, Orebro, Sweden.
    Validity of the Swedish Cardiac Surgery Registry2018In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 27, no 1, p. 67-74Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Our goal was to validate the Swedish Cardiac Surgery Registry by reviewing the reported cardiac operations to assess the completeness and quality of the registered data and the EuroSCORE II variables. METHODS: A total of 5837 cardiac operations were reported to the Swedish Cardiac Surgery Registry in Sweden during 2015. A randomly selected sample of 753 patient records (13%) was scrutinized by 3 surgeons at all 8 units in Sweden performing open cardiac surgery in adults. RESULTS: Coverage was excellent with 99% [95% confidence interval (CI) 98-99%] of the performed procedures found in the registry. Reported waiting times for surgery were correct in 78% (95% CI 76-79%) of the cases. The main procedural code was correctly reported in 96% (95% CI 95-97%) of the cases. The correlation between reported and monitored logistic EuroSCORE II had a coefficient of 0.79 (95% CI 0.76-0.82), and the median difference in EuroSCORE II was 0% (interquartile range -0.4% to 0.4%). The majority of EuroSCORE II variables had good agreement and coherence; however, New York Heart Association functional class, preoperative renal dysfunction, left ventricular ejection fraction, Canadian Cardiovascular Society Class IV angina and poor mobility were less robust Postoperative complications were rare and in general had a high degree of completeness and agreement. CONCLUSIONS: The reliability of the variables in the national Swedish Cardiac Surgery Registry was excellent. Thus, the registry is a valuable source of data for quality studies and research. Some EuroSCORE II variables require improved and stricter definitions to obtain uniform reporting and high validity.

  • 10.
    Vikholm, Per
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Schiller, Petter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    A modified Glenn shunt reduces venous congestion during acute right ventricular failure due to pulmonary banding: a randomized experimental study2014In: Interactive Cardiovascular and Thoracic Surgery, ISSN 1569-9293, E-ISSN 1569-9285, Vol. 18, no 4, p. 418-425Article in journal (Refereed)
    Abstract [en]

    Right ventricular failure after left ventricular assist device implantation is a serious complication with high rates of mortality and morbidity. It has been demonstrated in experimental settings that volume exclusion of the right ventricle with a modified Glenn shunt can improve haemodynamics during ischaemic right ventricular failure. However, the concept of a modified Glenn shunt is dependent on a normal pulmonary vascular resistance, which can limit its use in some patients. The aim of this study was to explore the effects of volume exclusion with a modified Glenn shunt during right ventricular failure due to pulmonary banding, and to study the alterations in genetic expression in the right ventricle due to pressure and volume overload. Experimental right ventricular failure was induced in pigs (n = 11) through 2 h of pulmonary banding. The pigs were randomized to either treatment with a modified Glenn shunt and pulmonary banding (n = 6) or solely pulmonary banding (n = 5) as a control group. Haemodynamic measurements, blood samples and right ventricular biopsies for genetic analysis were sampled at baseline, at right ventricular failure (i.e. 2 h of pulmonary banding) and 1 h post-right ventricular failure in both groups. Right atrial pressure increased from 10 mmHg (9.0-12) to 18 mmHg (16-22) (P < 0.01) and the right ventricular pressure from 31 mmHg (26-35) to 57 mmHg (49-61) (P < 0.01) after pulmonary banding. Subsequent treatment with the modified Glenn shunt resulted in a decrease in right atrial pressure to 13 mmHg (11-14) (P = 0.03). In the control group, right atrial pressure was unchanged at 19 mmHg (16-20) (P = 0.18). At right heart failure, there was an up-regulation of genes associated with heart failure, inflammation, angiogenesis, negative regulation of cell death and proliferation. Volume exclusion with a modified Glenn shunt during right ventricular failure reduced venous congestion compared with the control group. The state of right heart failure was verified through genetic expressional changes.

  • 11.
    Vikholm, Per
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Schiller, Petter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Preoperative Brain Natriuretic Peptide Predicts Late Mortality and Functional Class but Not Hospital Readmission After Cardiac Surgery2014In: Journal of Cardiothoracic and Vascular Anesthesia, ISSN 1053-0770, E-ISSN 1532-8422, Vol. 28, no 3, p. 520-527Article in journal (Refereed)
    Abstract [en]

    Objectives: N-terminal brain natriuretic peptide (NT-proBNP) is an established biomarker of heart failure and has been found to predict mortality and morbidity after cardiac surgery. The aim of this study was to investigate whether preoperative NT-proBNP can predict postoperative New York Heart Association (NYHA) functional class and hospital readmission in addition to morbidity and mortality. Design: Retrospective. Setting: University hospital. Participants: All patients undergoing aortic valve replacement for aortic stenosis and coronary artery bypass grafting from January to December 2008 (n = 390). Measurements and Main Results: Preoperative NT-proBNP was recorded prospectively. Five-year mortality was obtained through national registries. Postoperative functional class, morbidity, and hospital readmission were obtained through telephone interviews. Patients were divided into quartiles based on preoperative NT-proBNP; the medians of each quartile were 103 ng/L, 291 ng/L, 825 ng/L and 2,375 ng/L. Increased preoperative NT-proBNP was associated with reduced postoperative functional class. In the first quartile, 7% (7/97) were in NYHA functional class III-IV compared to 26% (25/97) in the fourth quartile (p < 0.01). Increased preoperative NT-proBNP was also associated with reduced long-term survival (p < 0.01). The covariate adjusted hazard ratio for mortality in the fourth quartile was 2.9 (1.61-5.08; p < 0.01) compared to the other quartiles. No association was found between preoperative NT-proBNP and postoperative hospital readmission. Conclusions: Increased preoperative NT-proBNP is associated with reduced long-term survival and functional class but not hospital readmission post-cardiac surgery. Thus, NT-proBNP might have additive value to established risk factors in the preoperative assessment of patients undergoing cardiac surgery. (C) 2014 Elsevier Inc. All rights reserved.

  • 12.
    Vikholm, Per
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Schiller, Petter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    A modified Glenn shunt improves haemodynamics in acute right ventricular failure in an experimental model2013In: European Journal of Cardio-Thoracic Surgery, ISSN 1010-7940, E-ISSN 1873-734X, Vol. 43, no 3, p. 612-618Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES:

    Right heart failure is a major cause of morbidity and mortality after left ventricular assist device implantation and is still hard to predict. This study investigated the haemodynamic effect of a modified Glenn shunt on induced right ventricular (RV) failure.

    METHODS:

    Isolated RV failure was induced by coronary ligation in 11 pigs. A modified Glenn shunt was established by a superior vena cava to pulmonary artery connection. Haemodynamic data were obtained at baseline, RV failure, and RV failure and open shunt. Myocardial biopsies were taken to ascertain established heart failure.

    RESULTS:

    RV failure defined as right atrial pressure ≥20 mmHg was achieved in all 11 animals. A reduction in cardiac output (CO) from 3.7 (3.5-4.2) to 2.3 l/min (2.0-2.6) and mean arterial pressure (MAP) from median 72.7 (70.1-82.2) to 55.9 mmHg (52.6-59.8) was seen during heart failure. The median flow in the shunt was 681 ml. Right atrial pressures decreased from 20.3 (19.6-21.1) to 13.4 mmHg (12.7-14.0), and RV pressures decreased from 18.1 (16.4-20.1) to 13.6 mmHg (13.5-14.2) with open shunt (P = 0.001 for both). CO increased to 2.9 l/min (2.4-3.3) when the shunt was in use. Mixed venous oxygen saturation increased with the shunt from 32 (27-38) to 49% (45-56), P = 0.001. Genes associated with heart failure were upregulated during heart failure.

    CONCLUSIONS:

    A modified Glenn shunt improved haemodynamics by reduced right atrial pressure, increased CO, MAP and mixed venous oxygen saturation in an experimental model of induced RV failure.

  • 13.
    Vikholm, Per
    et al.
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Schiller, Petter
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Johansson, Jakob
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Anaesthesiology and Intensive Care.
    Hellgren, Laila
    Uppsala University, Disciplinary Domain of Medicine and Pharmacy, Faculty of Medicine, Department of Surgical Sciences, Thoracic Surgery.
    Cavoaortic shunt improves hemodynamics with preserved oxygen delivery in experimental right ventricular failure during left ventricular assist device therapy2014In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 147, no 2, p. 625-631Article in journal (Refereed)
    Abstract [en]

    OBJECTIVE:

    Right heart failure is a major cause of morbidity and mortality after left ventricular assist device (LVAD) implantation. This study evaluated the approach of a cavoaortic shunt included in the LVAD circuit, which would aim to relieve venous congestion and improve hemodynamics with preserved oxygen delivery during induced right ventricular failure.

    METHODS:

    Right ventricular failure was induced by coronary ligation in 10 pigs. An LVAD was implanted and a cavoaortic shunt was created from the right atrium and included in the assist circuit. Hemodynamic measures and blood gas analyses were analyzed. Oxygen delivery and oxygen consumption were estimated.

    RESULTS:

    Right atrial pressure decreased from more than 20 mm Hg to 17.2 mm Hg (14.8-18.4) with the LVAD and to 14.1 mm Hg (11.2-15.5) (P < .01) with the LVAD and cavoaortic shunt. Mean arterial pressure increased from 70.9 mm Hg (67.6-79.8) to 81.5 mm Hg (70.8-92.6) (P = .02) with addition of the shunt into the assist circuit. Cardiac output increased from 3.5 L/min (2.6-4.2) to 4.9 L/min (3.5-5.6) (P < .01) with cavoaortic shunting. Oxygen delivery with the cavoaortic shunt was 337 mL/min (±70) as compared with left ventricular assist alone at 258 mL/min (±52) (P < .01). Oxygen consumption was restored during use of the cavoaortic shunt.

    CONCLUSIONS:

    A cavoaortic shunt combined with an LVAD during right ventricular failure reduces central venous pressures, increases systemic arterial pressure, and enables increased cardiac output compared with device therapy alone. This was feasible with preserved oxygen delivery.

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