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Objective: Metabolism management plays an essential role during cardiopulmonary bypass (CPB). There are different metabolic management devices integrated to heart-lung machines; the most commonly used and accepted metabolic target is indexed oxygen delivery (DO 2i ) (280 mL/min/m 2 ) and cardiac index (CI) (2.4 L/min/ m 2 ), which can be managed independently or according to other metabolic parameters. Our objective was to compare lactate production during CPB procedures using different metabolic management: DO 2i in relation to indexed oxygen extraction ratio (O 2 ER i ) and CI in relation to mixed venous oxygen saturation (SvO 2 ).Methods: Data on 500 CPB procedures were retrospectively collected in a specialized regional tertiary cardiac surgery center in Italy between September and 2012 and November 2019. In group A, the DO 2i with 280 mL/min/m 2 target in relation to O 2 ER i 25% was used; in group B, CI with 2.4 L/min/m 2 target in relation to SvO 2 75% was used. During CPB, serial arterial blood gas analyses with blood lactate and glucose determinations were obtained. Hyperlactatemia (HL) was defined as a peak arterial blood lactate concentration >3 mmol/L. The postoperative outcome of patients with or without HL was compared.Results: Eight pre-and intraoperative factors were found to be significantly associated with peak blood lactate level during CPB at univariate analysis. HL (>3 mmol/ L) was detected in 15 (6%) patients of group A and in 42 (16.8%) patients of group B (P ¼ .022); hyperglycemia (>160 mg/dL) was found in 23 (9.2%) patients of group A and in 53 (21.2%) patients of group B (P ¼ .038). Patients with HL during CPB had a significant increase in serum creatinine value, higher rate of prolonged mechanical ventilation time and intensive care unit stay. A cutoff of DO 2i <270 mL/min/m 2 in relation to O 2 ER i >35% in group A and a cutoff of CI <2.4 L/min/m 2 in relation to SvO 2 <65% in group B were found to have a positive predictive value of 80% and 75% for HL, respectively. A cutoff of DO 2i >290 mL/min/m 2 in relation to O 2 ER i 24% in group A and a cutoff of CI >2.4 L/min/m 2 in relation to SvO 2 >75% in group B were found to have a negative predictive value of 78% and 62% for HL, respectively.

Background Elevated plasma free hemoglobin is associated with multi-organ injury. In this context, minimally invasive extracorporeal technologies represent a way to reduce this complication following cardiac surgery. Methods We present a pilot study focused on plasma free hemoglobin levels in 40 patients undergoing isolated coronary artery bypass grafting (CABG). The same circuits for minimally invasive extracorporeal circulation (MiECC) were used in all patients. The ECMOLIFE magnetic levitation pump was used in the study group (n = 20), and the AP40 Affinity CP centrifugal blood pump was used in the control group (n = 20). Results In the immediate postoperative period, plasma free hemoglobin (PFH) and lactate dehydrogenase (LDH) were significantly lower in the study group than in the control group (10.6 ± 0.7 vs 19.9 ± 0.3 mg/dL, p = 0.034; and 99.16 ± 1.7 vs 139.17 ± 1.5 IU/L, p = 0.027, respectively). Moreover, patients treated with the magnetic levitation pump showed lower creatinine and indirect bilirubin (0.92 vs 1.29 mg/dL, p = 0.030 and 0.6 ± 0.4 vs 1.5 ± 0.9 mg/dL, p = 0.022, respectively) at 24 h after the procedure, and received fewer transfusions during the whole postoperative period (3 vs 9 red blood cell units (RBC), p = 0.017). Conclusion Our pilot study suggests that the use of magnetically levitated centrifugal pumps for extracorporeal circulation support is associated with a lower risk of hemolysis, though larger studies are warranted to confirm our results.

Background The debate on the best treatment strategy for atrial fibrillation (AF) has expanded following the introduction of the so-called “hybrid procedure” that combines minimally invasive epicardial ablation with endocardial catheter ablation. However, the advantage of the hybrid approach over conventional epicardial ablation remains to be established. Methods From June 2008 to December 2020, 609 surgical AF ablation procedures through a right minithoracotomy were performed at our institution. From 2008 to 2011, a unipolar radiofrequency (RF) device was used, whereas from 2011 to 2020 a bipolar RF device was used. In addition, between September 2016 and April 2017, 60 patients underwent endocardial completion of epicardial linear ablation. In 30 of these latter patients, surgical isolation of the Bachmann’s bundle (BB) was also performed. Starting from 2021, surviving patients at follow-up were asked to undergo electrocardiographic evaluation and left ventricular function assessment and to complete a questionnaire addressing quality of life and predisposing factors for recurrent AF. Results The ablation procedure was completed in all patients. Upon discharge, 30 (4.9%) patients showed recurrence of AF, whereas the remaining patients (95.1%) were in sinus rhythm. All patients in whom a hybrid approach was used either with or without BB ablation were discharged in sinus rhythm. After a mean follow-up of 74 months, 122 (20%) patients developed recurrent AF, including 19.9% in whom a unipolar RF device was used, 21% in whom a bipolar RF device was used, 23% who had undergone a hybrid procedure without BB ablation and 3.3% who had undergone a hybrid procedure with BB ablation. On multivariate analysis, reduced left ventricular ejection fraction, worsening of European Heart Rhythm Association symptom class, and cognitive impairment or depression during follow-up were found to be significantly associated with AF recurrence. Conclusions Surgical AF ablation through a right minithoracotomy is safe and may allow the creation of additional linear lesions, particularly in the BB. The placement of adjunctive linear lesions in the setting of a hybrid procedure can be more effective in reducing the risk for AF recurrence than isolated surgical ablation or hybrid ablation without the addition of further linear lesions, with no incremental risk to the patient.