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F Guarracino

Publications and source records attributed to F Guarracino.

18 recordsLinked to original sources
PubMed2006

Cardiac protection by volatile anaesthetics: a multicentre randomized controlled study in patients undergoing coronary artery bypass grafting with cardiopulmonary bypass.

BACKGROUND AND OBJECTIVES: To evaluate the effects of total intravenous anaesthesia vs. volatile anaesthesia on cardiac troponin release in coronary artery bypass grafting with cardiopulmonary bypass, we performed a multicentre randomized controlled study to compare postoperative cardiac troponin release in patients receiving two different anaesthesia plans. METHODS: We randomly assigned 75 patients to propofol (intravenous anaesthetic) and 75 patients to desflurane (volatile anaesthetic) in addition to an opiate-based anaesthesia for coronary artery bypass grafting. Peak postoperative troponin I release was measured as a marker of myocardial necrosis. RESULTS: There was a significant (P < 0.001) difference in the postoperative median (25th-75th percentiles) peak of troponin I in patients receiving propofol 5,5 (2,3-9,5) ng dL(-1) when compared to patients receiving desflurane 2,5 (1,1-5,3) ng dL(-1). The median (interquartile) troponin I area under the curve analysis confirmed the results: 68 (30.5-104.8) vs. 36.3 (17.9-86.6) h ng dL(-1) (P = 0.002). Patients receiving volatile anaesthetics had reduced need for postoperative inotropic support (24/75, 32.0% vs. 31/75, 41.3%, P = 0.04), and tends toward a reduction in number of Q-wave myocardial infarction, time on mechanical ventilation, intensive care unit and overall hospital stay. CONCLUSIONS: Myocardial damage measured by cardiac troponin release could be reduced by volatile anaesthetics in coronary artery bypass surgery.

Aged↗
PubMed2005

Right ventricular failure: physiology and assessment.

Right ventricular function can be altered in several disease states involving lungs and heart. Severe right ventricular dysfunction is a major determinant of outcome in such situations, and may strongly influence clinical management. The complex geometry of the right ventricle and the different physiology with respect to the left ventricle make the right ventricular failure difficult to define and assess. The response to increased afterload is the main determinant of right ventricle physiology in pathologic conditions. This consists of right ventricular hypertrophy and enlargement, with reduced coronary blood flow to the right ventricular wall, dilation of tricuspid annulus and displacement of interventricular septum. This latter change involves the left ventricular diastolic function, which is reduced by leftward septal shifting. In right ventricle myocardial ischemia and infarction the primum movens of altered right ventricular function is not an increase in afterload, but the ischemic involvement of the right ventricle, more often in the setting of an inferior acute myocardial infarction. The assessment of right ventricular failure is based on thermodilution by pulmonary artery catheter, contrast and radionuclide ventriculography, echocardiography, and magnetic resonance. Among these techniques, thermodilution and echocardiography play a relevant role in clinical scenarios, being readily available and feasible bedside.

Heart Failure↗
PubMed2005

Target controlled infusion: TCI.

Progress in computing technology has allowed the development of target controlled infusion devices, with drugs delivered to achieve specific predicted target blood drug concentrations. Target controlled infusion (TCI) system has been developed as a standardised infusion system for the administration of opioids, propofol and other anaesthetics by target controlled infusion. A set of pharmacokinetic parameters has been selected using computer simulation of a known infusion scheme. The selected model is incorporated into a computer-compatible infusion pump. Clinical trials with such systems have provided appropriate target concentrations for the administration of target controlled infusion of anaesthetic drugs. The technique of TCI strongly influences the development of intravenous anaesthesia and opens a scenario of new and exciting applications in peri-operative anaesthetic management. The launch of ''Diprifusor'' as the first commercially available TCI system for propofol was the cornerstone of a successful research period within the last decade, which evaluated the pharmacokinetic foundations of computer assisted intravenous drug delivery. Nowadays TCI technology is becoming a part of routine anaesthesia technique for the practitioner rather than a research tool for specialists and those who are enthusiasts of intravenous anaesthesia. Besides clinical application in anaesthesia, target controlled systems will play a significant role as research tools in the evaluation of drug interactions in anaesthesia and in the development of new control techniques for the administration of sedative and analgesic drugs in the peri-operative period.

Anesthesia↗
PubMed2004

Reduced compliance of left ventricle.

Diastolic function is essential for efficient systolic performance. A normal diastole allows left ventricle (LV) filling to occur under normal intracavitary pressure. It is an energy dependent process, as such affected by ischemia. Several factors influence diastolic function of the LV: the mitral valve area, the gradient between atrium and ventricle, LV relaxation and compliance, atrial compliance, the presence of sinus rhythm, the end-systolic volume. Echocardiography is the principal diagnostic tool to assess LV diastolic function noninvasively in clinical practice. Doppler evaluation allows to analyse each phase of LV diastole through measurement of transmitral and pulmonary veins flows velocities. Tissue Doppler echocardiography and color M-mode Doppler have also been introduced in the study of diastole. The use of echocardiography in the setting of diastolic dysfunction in ICU and operatory room has relevant implications in the management of haemodynamic instability, in vasoactive d rugs titration, in the detection of myocardial ischemia, and in performing prognostic stratification. These information can guide the management of cardiac patients undergoing cardiac and non cardiac surgery, in the perioperative phase, as well as in the management of critical ICU patients. On this basis evaluating the LV filling properties can contribute to improve the quality of treatments in such challenging situations.

Compliance↗
PubMed2004

[Cardiac protection is a clinical evidence].

AIM: Anaesthetics may have protective effect against myocardial ischemia. We aimed to investigate if sevoflurane administration could exert myocardial protection during following coronary occlusion in patients with coronary artery disease. METHODS: a). EXPERIMENTAL DESIGN: prospective, randomized study. b). SETTING: University Hospital, cardiac surgical operative theatre. c). PATIENTS: 42 patients with coronary artery disease, scheduled to undergo coronary surgery. INCLUSION CRITERIA: severe coronary stenosis of anterior descending coronary artery; no collateral flow on angiography; at least two normokinetic segments in the myocardial region supplied by the vessel being bypassed. PATIENTS were randomized to receive (group S) or not (group C) sevoflurane administration for 15 min just before coronary occlusion. d). INTERVENTIONS: Transoesophageal Tissue Doppler echocardiographic examination of myocardial systolic and early diastolic velocities in both groups basally and 60 s after coronary occlusion by the surgeon. e). MEASURES: systolic and early diastolic velocities were registered by Tissue Doppler from a long-axis view of the interventricular septum or the anterior wall of the left ventricle. RESULTS: In group C a significant reduction of systolic and diastolic intramyocardial velocities was found during myocardial ischemia due to coronary occlusion. CONCLUSION: Treatment with sevoflurane before coronary occlusion seem effective in reducing functional myocardial impairment due to ischemia.

Aged↗
PubMed2003

Pharmacokinetic-based total intravenous anaesthesia using remifentanil and propofol for surgical myocardial revascularization.

BACKGROUND AND OBJECTIVE: We investigated the following aspects of pharmacokinetic-guided total intravenous anaesthesia with remifentanil and propofol in patients undergoing surgical myocardial revascularization: anaesthetic efficacy, haemodynamic effects, impact on extubation of the trachea and analgesia after operation. METHODS: Thirty-two patients undergoing on-pump coronary bypass surgery received intravenous anaesthesia with remifentanil and propofol. Both drugs were dosed and titrated based on computer-assisted pharmacokinetic models to maintain constant plasma concentrations. The propofol target plasma concentration was 1.2 microg mL(-1) throughout the procedure. A remifentanil target plasma concentration of 8 ng mL(-1) was achieved over 2 min for induction. After tracheal intubation, the opioid plasma concentration was reduced to 4 ng mL(-1), and then titrated up to 8 ng mL(-1) during surgery. Postoperative analgesia was managed with remifentanil infusion until 4 h after tracheal extubation, and a continuous infusion of tramadol was started 1 h before the remifentanil was stopped. RESULTS: After induction of anaesthesia, heart rate (-20%) and cardiac index (-6%) decreased significantly. No hypotensive episodes (mean arterial pressure < 60 mmHg) occurred. Intraoperative haemodynamics were stable. Three cases of myocardial ischaemia were detected: two by transoesophageal echocardiography and one with ST-segment monitoring. The duration of postoperative mechanical ventilation of the lungs was 95 +/- 13 min and the time to extubation was 150 +/- 18 min. Postoperative analgesia was satisfactory in all patients. CONCLUSIONS: Pharmacokinetic-based total intravenous anaesthesia with remifentanil and propofol provides adequate anaesthesia during coronary surgery with cardiopulmonary bypass and allows safe early extubation after operation.

Adult↗
PubMed2001

Influence of transesophageal echocardiography on intraoperative decision making for toronto stentless prosthetic valve implantation.

BACKGROUND AND AIM OF THE STUDY: Intraoperative transesophageal echocardiography (TEE) is commonly used during aortic valve surgery. In aortic valve replacement (AVR), this permits measurement of the aortic annulus, study of the anatomy of aortic valve components, and prediction of prosthesis valve size. After cardiopulmonary bypass (CPB), echocardiography is valuable in checking prosthesis function. In this study, we evaluated the impact of intraoperative TEE on the decision-making process of aortic Toronto stentless prosthetic valve (TSPV) implantation. METHODS: Fifty-two consecutive patients undergoing elective AVR were collected prospectively. Multiplane TEE was performed before CPB to determine diameters of the aortic valve annulus and sinotubular junction. This was to evaluate the feasibility of TSPV implantation in the aortic position and to predict prosthesis size. Further TEE evaluation was carried out after CPB to assess prosthetic valve function. RESULTS: TEE allowed measurement of the aortic annulus and sinotubular junction, and enabled correct prediction of prosthesis size. Ultrasonic evaluation also revealed contraindications to TSPV implantation in five patients. In one case, color-Doppler examination led to immediate successful surgical correction of prosthetic incompetence. CONCLUSION: Intraoperative multiplane TEE examination is useful in the decision-making process in AVR with the TSPV by selecting patients suitable for the stentless valve, predicting prosthesis size, and checking prosthesis function.

Aged↗
PubMed2001

Automated protamine dose assay in heparin reversal management after cardiopulmonary by pass.

BACKGROUND: To evaluate the impact of automated Protamine Dose Assay (PDA) performed with Hemochron 8000 (International Technodyne Company, Edison, NJ) on the management of heparin reversal after cardiopulmonary bypass (CPB). PDA was compared with empirical protamine to heparin ratio with regard to calculation of the protamine dose, and the sensitivity of PDA and ACT to residual circulating heparin after protamine administration was investigated too. METHODS DESIGN: prospective and randomized study. SETTING: cardiac surgical center of a General Hospital. PARTICIPANTS: 50 patients undergoing elective cardiac surgery with CPB. INTERVENTIONS: after CPB patients randomly received protamine according to our standard empirical ratio of 1 mg. protamine/100 U. heparin (group S, 24 patients), or to PDA result (group T, 26 patients) based on protamine titration method of determining circulating heparin. After protamine administration ACT and PDA were performed to assess heparin reversal and detect residual circulating heparin. Based on the PDA result, additional protamine was administered in both groups when required. MEASUREMENTS: in both groups basal and post-heparin ACT values, protamine doses, ACT and PDA after protamine administration were measured. RESULTS: The protamine dose was significantly lower (30%) in patients treated according to PDA. In 20% of patients showing normal ACT PDA revealed still circulating heparin, and additional protamine was required. In all other cases ACT and PDA both confirmed heparin reversal. CONCLUSIONS: PDA allowed us to administer a significantly lower amount of protamine. This can reduce incidence of adverse effects of over- and under-infusion of protamine. PDA also proved to be more sensitive than ACT in detecting residual circulating heparin after protamine administration.

Anticoagulants↗
PubMed2001

[The role of transesophageal echocardiography in intraoperative hemodynamic monitoring].

Transesophageal echocardiography (TEE) is a semi-invasive diagnostic tool which allows a unique intraoperative visualization of cardiac chambers and valves. It is mainly used for intraoperative monitoring during cardiac surgery and in cardiopathic patients undergoing major non cardiac surgical procedures. TEE gives a beat-to-beat assessment of cardiac morphology and function, it is less invasive and more readily performed than pulmonary artery catheterization, and it allows an etiological diagnosis of hemodynamic problems. Based on TEE data, the anesthesiologist is able to modify in real time vasoactive therapy and fluid management. TEE data concern: 1) preload: left ventricular endodiastolic area is measured and this is considered an index of volemia; 2) systolic function: the circumferential shortening fraction, which correlates with LV ejection fraction, is measured; 3) onset of ischemia: ischemia is detected as a regional modification of normal kinetics; 4) causes of hemodynamic instability; 5) assessment of sovrahepatic anastomoses during liver transplantation.

Blood Volume↗
PubMed1999

Left ventricular remodeling after aortic valve replacement with the Toronto-SPV prosthesis.

The remarkable hemodynamic features of the aortic Toronto SPV prosthesis have been reported. To assess the efficacy of these characteristics to produce a favorable left ventricular remodeling and to test the limits of the dobutamine stress test to check these results, 25 consecutive patients, who had undergone aortic valve replacement with Toronto SPV, were monitored with dobutamine and exercise stress tests for 1 year. Among the prosthetic and left ventricular morphological and functional parameters evaluated, dobutamine infusion produced an overestimation of prosthetic and left ventricular outflow tract gradients, effective orifice area, and prosthetic resistance compared with the more physiological exercise test (P<.01). These misleading results were probably due to the inotropic and unloading effects of dobutamine in still hypertrophied hearts. Indexed myocardial mass and wall thickness decreased significantly during the follow-up period (P<.01), whereas left ventricular diastolic diameter and ejection fraction showed no significant variations. These data show that the positive left ventricular remodeling is due only to the regression of the hypertrophy and not to the reduction of left ventricular diameters. Based on results from this study, the dobutamine stress test should be avoided to evaluate patients with aortic valve prostheses and still present left ventricular hypertrophy. The Toronto SPV produces a favorable left ventricular remodeling during the first year of follow-up, and is likely to improve.

Aged↗
PubMed1998

The influence of transoesophageal echocardiography on intra-operative decision making. A European multicentre study. European Perioperative TOE Research Group.

The role of transoesophageal echocardiography (TOE) in anaesthesia remains controversial because it is a rapidly evolving technique with few proven benefits and considerable cost. Recently, the Society of Cardiovascular Anaesthesiologists has published practice guidelines for the use of peri-operative TOE. To determine the current role of transoesophageal echocardiography and the relative impact of category-based transoesophageal echocardiographic indications the present study investigated its use in seven Western European countries. The study sample was taken from a prospective cohort of 224 patients with acute or chronic haemodynamic disturbances or at risk of myocardial ischaemia. All patients were monitored with two-lead electrocardiography and radial and pulmonary artery catheters, as well as biplane or multiplane transoesophageal echocardiography. A total of 2232 clinical interventions were made in these patients. The most frequently observed intervention was the administration of a fluid bolus (45% of all interventions). Overall, transoesophageal echocardiography was the most important guiding factor in 560 (25%) interventions. It was the most important monitor in guiding the following therapeutic interventions: anti-ischaemic therapy--207 of 372 interventions (56%); fluid administration--275 of 996 (28%) interventions; vasopressor or inotrope administration--56 of 316 (16%) interventions; vasodilator therapy--six of 142 (4%) interventions and depth of anaesthesia--four of 211 (2%) interventions. We found that transoesophageal echocardiography is frequently influential in guiding clinical decision making and is used most frequently for category II indications but category I indications were associated with more frequent change in management.

Adult↗
PubMed1997

Surgical treatment for life-threatening acute myocardial infarction: a prospective protocol.

OBJECTIVE: In this paper we describe the preliminary results of a prospective operative protocol designed in order to define the role of emergent myocardial revascularization in extensive acute myocardial infarction and in post-infarction cardiogenic shock. METHODS: Entry criteria are: age < 75 years; anterior acute myocardial infarction with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular within 6 h from onset of chest pain; post-infarction cardiogenic shock within 3 h from onset of shock. From November 1994 to July 1995, after emergency coronary arteriography, 23 patients were treated by coronary artery bypass grafting. Fifteen were operated for extensive acute myocardial infarction (group A, mean age 54.1 +/- 9.4 years) and eight for post-infarction cardiogenic shock (group B mean age 65.0 +/- 8.7 years). Mean time from onset was 4.4 +/- 1.3 h in group A and 2.2 +/- 0.8 h in group B. Mean left ventricular ejection fraction was 39.3 +/- 12.7% in group A and 22.6 +/- 3.5% in group B. Six out of eight group B patients needed intraaortic balloon counterpulsation preoperatively, and 2/8 cardiopulmonary resuscitation. RESULTS: Myocardial revascularization consisted in 3.4 +/- 1.1 grafts in group A (vein grafts, except for 8 patients who also received a left internal thoracic artery graft) and 3.3 +/- 1.1 vein grafts in group B. All patients in group B and 3/15 (20%) in group A underwent intraaortic balloon counterpulsation. In-hospital death occurred in 1/15 (6.7%) patients of group A and in 4/8 (50%) patients of group B. At a mean follow-up of 4.1 +/- 3.4 months for group A and 3.9 +/- 2.2 months for group B left ventricular ejection fraction was 43.4 +/- 9.0% in group A and 35.7 +/- 13.1% in group B. CONCLUSIONS: Experience of 9 months with this prospective protocol showed its effectiveness in the management of critically ill patients with acute coronary occlusion leading to low mortality rate in acute myocardial infarction and improved survival rate in post-infarction cardiogenic shock.

Aged↗
PubMed1996

[Emergency surgical revascularization in acute myocardial infarct. The preliminary results of a prospective study].

In this paper we describe 1-year experience with a perspective operative protocol of emergency myocardial revascularization in extensive acute myocardial infarction (AMI). Entry criteria were: age < 75 years; anterior AMI with ST segment elevation > 4 leads, infero-postero-lateral or inferior and right ventricular AMI, within 6 hours from symptom onset. After coronary arteriography, an emergency staff, composed by cardiologists and cardiac surgeons, addresses the patients to coronary artery bypass grafting (CABG) or to percutaneous transluminal coronary angioplasty (PTCA). From November 1994 to November 1995, 35 patients were enrolled: 19 (mean age 54.3 +/- 9.7 years) underwent CABG and 16 were treated with PTCA. Myocardial protection was such as to restore energetic substrates and to prevent reperfusion injury: surgical technique consisted of antegrade-retrograde substrate-enriched blood cardioplegic solution delivery, early cardioplegic delivery on the infarcting area via a saphenous graft, retrograde controlled reperfusion before aortic unclamping and then prolonged reperfusion of the infarcted myocardium. In 8 patients (mean age 50.9 +/- 8.6 years), with anterior AMI and stable hemodynamics, a left internal thoracic artery graft was used, performing the prolonged controlled reperfusion retrogradely before aortic unclamping. In hospital death occurred in 1/19 (5.3%) patients because of cerebral hemorrhage. At a mean follow-up of 5.1 +/- 3.7 months 17 patients (94.4%) were in NYHA functional class I-II and 1 patient (5.6%) complained of effort angina, that was well controlled with medical therapy. Left ventricular ejection fraction calculated by echocardiography preoperatively, before discharge and at follow-up was respectively 39.3 +/- 12.7, 43.1 +/- 8.9 and 43.4 +/- 9.0%. In the last 8 consecutive patients thermodilution and transesophageal echocardiography monitoring were performed preoperatively and 12 hours after CABG: in all cases ejection fraction and cardiac index increased after CABG, from 42.2 +/- 13.5 to 48.6 +/- 14.3% (p = 0.01) and from 2.8 +/- 0.5 to 3.4 +/- 0.6 l/min/m2 (p = 0.005), respectively. The preliminary results show the effectiveness of this perspective protocol in the management of critically ill patients with extensive AMI.

Clinical Protocols↗
PubMedDate not supplied

[Diastolic dysfunction in cardiac surgery intensive care. Study methods, changes and prognosis].

The natural history of patients with coronary artery disease and diastolic dysfunction who underwent coronary artery bypass grafting (CABG) is not well known. The aims of our study were to evaluate the incidence of diastolic dysfunction, its evolution after CABG and its possible correlation with adverse in-ICU prognosis. We studied 88 consecutive patients scheduled for CABG with not severely depressed left ventricular function (ejection fraction > 35%) and multivessels disease. Buckberg cardioplegia was used for myocardial protection. Diastolic function was investigated by recording mitral and venous pulmonary flow by transesophageal Doppler echocardiography (TEE). TEE examination was performed in operative room pre and post-bypass, at ICU arrival and after three months. Diastolic dysfunction was defined as mild, moderate and severe. Adverse in ICU events were defined as: use of inotropic drugs or ventricular mechanical support, an ICU stay > 24 hours, perioperative myocardial infarction and death. The study group was compared with a control group. T-Student test was used; a p < 0.05 was considered significant. A reduced diastolic function was present in 77% of patients at baseline examination. Diastolic dysfunction did not worsen significantly after hypothermic cardiac arrest and reperfusion. It persisted during ICU stay and normalized after three months from CABG in the majority of patients (85%). Diastolic failure was not associated with an adverse ICU prognosis (adverse events: 18 versus 13%; p = ns).

Aged↗