Application Of Goal-directed Perfusion Management In Valvular Surgery For Infective Endocarditis

Background:Infective endocarditis(IE)has become an increasingly prevalent disease in recent years,and as a life-threatening emergency,it has many complications and a high mortality rate.Patients with fever are often treated as a common cold and delayed in the initial stages of the disease.Choosing the right time to operate on a patient with IE who has had a recent stroke can be difficult for the cardiac surgery team of cardiac surgeons and anesthesiologists and perfusionists,with reports of up to 40%or more of these patients.Previous studies have suggested that a delay of 2 to 4 weeks significantly reduces the risk of surgery,but more recent studies have shown that patients with clear indications for surgery,such as poorly controlled infection,severe hemodynamic disturbances,and a high risk of re-embolization in patients at low risk of hemorrhagic transformation(intracardiac bulky organisms>1 cm in diameter and at risk of dislodgement at any time).To address this challenge,it has been proposed that a multidisciplinary team be assembled to determine the optimal timing of surgery for these patients,including assessment of hemodynamic status,risk of new or recurrent embolism,or risk of neurological deterioration due to valve surgery.The accuracy of the decision.For patients with IE who have been decided to require surgery,some of the most troubling issues for the perfusionist when planning a cardiopulmonary bypass(CPB)diversion include:what perfusion flow(PF)to use,what myocardial protection strategy to use,what mean arterial pressure(MAP),and the degree of cooling and rewarming gradient to be used.All of these issues are unified by the need to achieve optimal perfusion of the body’s tissues while minimizing postoperative complications(organ embolic events).In recent years,there has been a difference between the traditional perfusion strategy(traditional perfusion strategy)guided by perfusion flow(PF),haematocrit(Hct),mixed venous oxygen saturation(SvO2),and other indices.The goal-directed perfusion(GDP)approach,which is guided by traditional perfusion strategies(TP)such as flow,mixed venous oxygen saturation(SvO2),and haematocrit(Hct),has been developed.The patient’s current oxygen delivery(DO2)and oxygen consumption(VO2)are analyzed by the relationship between flow,mixed venous oxygen saturation(SvO2),haematocrit(Hct),etc.Oxygen delivery indexed to Body Surface Area(DO2I)and mean Oxygen delivery indexed to body surface area(DO2I)and mean arterial pressure(MAP)are used as the core to dynamically adjust the relationship between flow,Hct and MAP,which has been used in aortic coarctation and coronary artery bypass grafting under extracorporeal circulation,but its use in IErelated cardiac surgery has not been reported,and its safe and reliable implementation still needs to be studied.Objective:We defined our center as a lowto medium volume cardiac center based on the total number of procedures in the past 5 years,summarized the composition ratio of the types of procedures in the past 5 years,analyzed the relevant factors affecting red blood cell infusion during CPB in IE patients and their predictive value,and provided a reference for red blood cell infusion during CPB in IE patients in small and medium volume cardiac centers;compared the traditional extracorporeal circulation management strategy with the goal-directed extracorporeal circulation management strategy in the intraoperative situation of red blood cell infusion during perioperative circulation in IE patients and various early postoperative recovery indexes,and evaluated the safety of the GDP strategy.Methods and materials:In this study,a total of 167 patients who underwent heart valve-related surgery under extracorporeal circulation between January 2017 and December 2021 in the Department of Cardiovascular Surgery,Southern Hospital of Southern Medical University were selected for retrospective analysis,and a total of 167 patients who were diagnosed with infective endocarditis and underwent surgical intervention according to the modified DUKE criteria or according to the clinician’s order,were divided into blood-using group and non-blood-using group according to whether red blood cells were transfused during extracorporeal circulation.The area under the curve(AUC)was calculated using the receiver operating characteristic curve(ROC)and the predictive ability of the corresponding factors was examined.The predictive ability of the corresponding factors was examined,and the threshold value was calculated according to the Youden Index(YI).Patients were divided into conventional group(group C)and GDP group(group G)according to the management strategy of extracorporeal circulation,and a 1:1 propensity score matching method(PSM)was used to screen the matched cohort and compare the preoperative and intraoperative data.Serum lactate(mmol/L,Lacl to Lac7)and haematocrit(%,Hct1 to Hct7)at the following 7 points:T1-after induction of anesthesia;T2-after aortic block;T3-before the end of extracorporeal circulation;T4-immediately after returning to ICU;T5-6h after returning to ICU;T6-12h after returning to ICU;and T7-24h after returning to ICU,to analyze and compare the early recovery indicators of the two groups.Results:A total of 1486 valve-related surgeries were performed in our center in 5 years,among which 580 cases were transfused with PRBC in CPB,with a transfusion rate of 39.03%.A total of 167 patients conforming to the diagnosis of IE were included,131 in the transfusion group,accounting for 22.58%of all valve-related procedures,and 36 in the non-transfusion group.A univariate binary logistic regression equation was performed for each of the pre-CPB and early CPB-related indexes in both groups and found that gender(OR=0.247,95%CI:0.082-0.743,P=0.013),HCT1(OR=0.726,95%CI:0.652-0.808,P=0),body weight(OR=0.968,95%CI:0.938-0.998,P=0.039),height(OR=0.95,95%CI:0.907-0.996,P=0.034),body surface area(OR=0.026,95%CI:0.002 to 0.266,P=0.002),non-Delnido myocardial protective arrest fluid(OR=2.486,95%CI:1.396 to 4.428,P=0.002),access nodules(OR=0.999,95%CI:0.999 to 1),P=0.035),ultrafiltration volume(OR=1.001,95%CI:1.001-1.002),P=0.019),highest MAP in transfer(OR=0.928,95%CI:0.8750.983,P=0.011),mean MAP in transfer(OR=0.924,95%CI:0.869-0.981,P=0.01),European Cardiovascular Surgery Risk Factor Score(EuroScore Ⅱ)(OR=1.56,95%CI:1.222 to 1.991,P<0.01)as influential factors affecting red blood cell infusion in IE patients under transfer,and inclusion of the above factors in a multifactorial binary logistic regression model(stepwise method)showed that nonDelnido myocardial protective stopping solution(OR=2.773,95%CI:1.055 to 7.292,P=0.039),EuroScore II(OR=1.501,95%CI:1.038 to 2.71,P=0.031)were independent risk factors for red blood cell infusion in CPB,while HCT1(OR=0.675,95%CI:0.535 to 0.807,P<0.01)was an independent protective factor.By subject characteristic curve analysis,Hctl and EuroScore II were statistically significant in predicting the need for red blood cell transfusion in CPB,with Hctl(AUC=0.898,sensitivity 83.3%,specificity 84%,YI=0.673,cut-off value=30.5),EuroScore II(AUC=0.764,sensitivity 72.2%,specificity of 75%,YI=0.472,and cut-off value=3.5).The 167 patients with IE were divided into 71 patients in the conventional group(group C)and 96 patients in the GDP group(group G)according to the management strategy of extracorporeal circulation in the transfer,and a total of 130 patients were finally included in the study after PSM matching.The final grouping was group C(n=65)and group C(n=65).The baseline data of the two groups were comparable and no statistical difference was found after comparison.The use of modified ultrafiltration(MUF)(x2=34.07,P<0.01)and non-Delnido cardioplegia solution(x2=23.48,P<0.01)was significantly higher in group G than in group C.Repeated-measures ANOVA showed consistent trends in Hct and Lac changes in both groups,and there was no statistically significant comparison between the two groups at different time points.Patients in both groups had a higher rate of postoperative red blood cell transfusion,reopening of the chest to stop bleeding,postoperative pulmonary infection,continuous renal replacement therapy use,stroke,the worst 24-h postoperative vasoactive intrope score(VIS).There were no statistical differences in the postoperative recovery indicators such as Vasoactive intrope score(VIS),total hospitalization days,etc.Four cases in Group C used Intra-Aortic Balloon Pump(IABP)and two cases used Extracorporeal membrane oxygenation(ECMO)after surgery,and one case in Group G used IABP.The rest of the early postoperative recovery indicators were not statistically different(each P>0.05).There were 5 cases death(7.7%)in Group C while 7 cases death(10.8%)in Group G.And the comparison of mortality rates between the two groups was not statistically significant(χ2=0.367,P=0.763).Conclusion:Patients undergoing valve surgery for infective endocarditis still have a high morbidity and mortality rate and a high intraoperative PRBC transfusion requirement.For small to medium volume cardiac centers with a tight blood supply,the preoperative Hct and European Cardiovascular Surgery Risk Score can better predict the extent of intraoperative blood requirements,according to which the surgical team can adjust the patient to a more optimal state as much as possible before surgery,and the perfusionist can develop a corresponding diversion plan and adopt a GDP management strategy accordingly.The use of GDP management strategies does not increase early postoperative complications or morbidity and mortality,and may reduce the use of postoperative mechanical circulatory assistance.