- Email: [email protected]
Hypoxic and hyperoxic preconditioning in myocardial protection against ischemia-reperfusion injury: experimental study
S6
ABSTRACT PRESENTATIONS
individual dependent and CA may deteriorate at mean ABP much higher than 50 mmHg (1). The goal of the study is to detect impaired CA during cardiac surgery with CPB and find its relation with the rate of POCD. Methods. The prospective observational study was conducted at Kaunas Klinikos, the Hospital of Lithuanian University of Health Sciences. The patients undergoing elective CABG surgery without preoperative neurological disorders were included. In addition to standard monitoring CA was monitored using “Vittamed” non-invasive monitor (2). The method is based on intracranial blood volume (IBV) measurement. Neurological function was evaluated by MMSE and HAD scales before and after cardiac surgery. Results and Discussion. 10 patients were enrolled in the study. All patients were ASA III class, NYHA III class; their average age was 70 years. The mean duration of CPB was 84.10 min.; mean MAP during CPB was 63.35 mmHg. All patients had periods of impaired CA. The mean longest period lasted 6.5 min. Average total duration of CA impairment was 25.98 min. (29.57 % of CPB duration). MMSE and HAD scales revealed POCD on the 7th postoperative day in 2 patients. The total time of CA impairment correlate with POCD (po0.02). The analysis revealed that mean ABP and duration of CPB were not related of CA disorders. Conclusions. CA impairment episodes occur during cardiac surgery with CPB. Our results show that total duration of CA impairment correlate with POCD. However, futher studies are needed to find the influence of CA impairment on POCD. Aknowlegment: The study is funded by Lithuanian Science Council.
Urinary TIMP-2 and IGFBP7 levels were quantified by ELISA assay using a commercially available ELISA kit using polyclonal antibodies (NephroCheck™ Test, Astute Medical, San Diego, CA, USA). The Test was developed to simultaneously measure the two biomarkers (urine [TIMP-2]*[IGFBP7]). [TIMP-2]*[IGFBB7] indicates the multiplication of both biomarkers. Results. We recruited and analyzed 110 patients. Of the 110 patients, 12 (13%) developed postoperative AKI Stage 1 as defined by the KDIGO criteria. There was no significant difference at the baseline values of the AKI and the patients who did not developed AKI. In the No AKI group there was no significant difference in the urinary TIMP-2 * IGFBP-7 concentrations at 1 hour. The concentration of TIMP-2 * IGFBP-7 decreased significantly at 4 hours and was still decreased after 24 hours. In contrast, in the AKI group there was an significant increase in urinary TIMP-2 * IGFBP-7 concentrations only at 1 hour after starting cardiopulmonary bypass. There was significant decrease of TIMP-2 * IGFBP-7 at 4 hours, the urinary TIMP-2 * IGFBP-7 concentrations turned to baseline level after 24 hours. The ROC curves for the absolute value of TIMP-2 * IGFBP-7, the difference of TIMP-2 * IGFBP-7 between 1h value and baseline, respectively the quotient between 1 h value and baseline. The quotient between these two values showed the best correlation for the prediction of the CSA-AKI. Conclusion. Novel biomarkers are feasible for the prediction of the Acute Kidney injury stage 1 in cardiac surgery patients.
REFERENCES 1. Siepe M, et al: Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium, Eur J Cardiothorac Surg 40(1):200-207, 2011. 2. Ragauskas A, et al: Clinical study of continuous non– invasive cerebrovascular autoregulation monitoring in neurosurgical ICU // Acta Neurochir Suppl 95:367-370, 2005.
Hypoxic and hyperoxic preconditioning in myocardial protection against ischemia-reperfusion injury: experimental study
OP-12 Novel biomarkers (TIMP-2 and IGFBP7) of renal cell damage for the prediction of the cardiac surgery associated acute kidney injury - a feasibility study T. Mayer1, O. Reuthebuch2, M. Grapow2, P. Matt2, M. Scholz3, M. Seeberger1, D. Bolliger1, Jens Fassl1 1 Department of Anaesthesiology and Intensive Care Medicine, University Basel, 2Department of Cardiac Surgery, Basel, Switzerland, 3University Leipzig, Institute of Medical Informatics, Statistics and Epidemiology, Leipzig, Germany
Background. The incidence of acute kidney injury after cardiac surgery (CSA-AKI) has a wide variety. The severity of CSA-AKI ranges from subclinical injury to the requirement for renal replacement therapy, which has substantial impact on mortality and morbiditiy. We tested new biomarkers for the prediction of CSA-AKI. Material and Methods. We prospectively enrolled 110 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Five milliliters of fresh urine was obtained through the urinary catheter at four time points from each patient: after induction of general anaesthesia and before surgical incision, one hour after onset of CPB and again at 4 and 24 hours after completion of CPB. A total of 440 urine samples were collected.
OP-13
Irina Mandel1, Y. Podoxenov1, I. Suhodolo2, A. Podoxenov1, Y. Svirko1, N. Kamenschikov1, S. Mikheev1, A. Sementsov1, A. Dzuman2, L. Maslov1 1 Research Institute For Cardiology, Department of Anaesthesiology and Intensive Care, Tomsk, Russian Federation, 2Siberian State Medical University, Tomsk, Russian Federation
Introduction. Hypoxic preconditioning phenomena provides evidence for adaptive responses to ischemia that have important implications for treatment/prevention of myocardial infarction (1). In the period before cardiopulmonary bypass (CPB), hyperoxia may also precondition myocardium (2). But comparative effects of these methods were not investigated yet. Method. In our prospective study we included 20 rabbits divided into four groups: hypoxic preconditioning (HypP), n¼5; hyperoxic preconditioning (HyperP), n¼5; hypoxic-hyperoxic preconditioning (HHP), n¼5; control, n¼5. All animals were anesthetized by sevoflurane and mechanically ventilated through nasotracheal tube. In HypP we exposed rabbits to two series of 10% oxygen for 10 min with 5 min reoxygenation. In HyperP rabbits were exposed to 80% oxygen for 30 min. In HHP rabbits were exposed to two series of 10% oxygen for 10 min with 5 min reoxygenation followed by 80% oxygen for 30 min. Then we started CPB. We induced acute myocardial infarction by ligation of left descending artery. After 45 min of ischemia we allowed reperfusion for 60 min. We performed light microscopy of myocardium and measured ischemic area to risk area (IA/RA) ratio by method described by Neckar J. et al. (3). Results. IA/RA decreased in HypP group by 23%, in HyperP group by 26%, in HHP group by 32% in comparison with control group (p¼0.009, Kruskal-Wallis test). Acid-based status, blood
S7
ABSTRACT PRESENTATIONS
lactate and glucose levels were stable during all methods of preconditioning. We observed group ventricular arrhythmia in control group more often than in preconditioned animals. Incidence of ventricular fibrillation were less in HHP group (p¼0.07, X2 test). Light microscopy of myocardium reveals less myofibril degeneration in HHP group as compared to other groups. Discussion. Hypoxic, hyperoxic preconditioning and the combination of these methods have the infarct-limiting effect. Hypoxic-hyperoxic preconditioning induces the highest tolerance of the myocardium to the effects of ischemia and reperfusion injury. REFERENCES 1. Cai Zh, Manalo DJ, Wei G: Hearts From Rodents Exposed to Intermittent Hypoxia or Erythropoietin Are Protected Against Ischemia-Reperfusion Injury. Circulation 108:79-85, 2003. 2. Young RW: Hyperoxia: a review of the risks and benefits in adult cardiac surgery. J Extra Corpor Technol 44(4):241-249, 2012. 3. Neckar J, Papousek F, Novakova O, Ost’adal B, Kolar F: Cardioprotective effects of chronic hypoxia and ischaemic preconditioning are not additive. Basic Res Cardiol 97:161167, 2002.
Poster Session PS01 Wednesday, May 11, 2016 14:30-16:00, Poster Exhibition Lounge P-01 Comparison of perioperative myocardial protection with use of Lidocaine after coronary arter bypass graft surgery Omer Faruk Savluk, D. Guzelmeric, I. Sýncar, Y Yavuz, D. Cevirme, E. Gurcu, K. Ogus, A. Erkýlýnc, T. Kocak Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turke Introduction. It is provides bloodless and motionless surgical field to facilitating surgery that the heart to arrest with cardioplegic solution during cardiac surgery (1). Ongoing studies for improve myocardial protection that various materials such as lidocaine, β-blocker, calcium channel blocker have been introduced in to the cardioplegic solution (2). The aim of our study was to compare the effect of lidocaine with different application on myocardial protection. Methods. In this study 102 patients that scheduled for coronary artery bypass graft surgery were randomly divided in to three groups. Group I; Control group (N¼25) hyper potassium cold blood cardioplegia, Group II; (N¼35) 20 mcg/kg/min lidocaine infusion before aorta canulation and hyper potassium cold blood cardioplegia, Group III; (N¼42) 1mg/kg lidocaine added in hyper potassium cold blood cardioplegia solution. Troponin-I, creatinine kinase-MB (CK-MB) were assessed before operation and postoperative 6, 12, 24 and 48 hours. And as secondary extubation time and duration of time in intensive care unit were assessed. Results. Lidocaine infusion and lidocaine added in cardioplegia treated patients compared with patients of control group PO 12,24,48.hr the increase of troponin-I and CK-MB was
significantly less than control group (po0,05). As secondary extubation time and duration of stay in intensive care unit were in other two groups shorter than control group (po0,05). Discussion. We showed that in cardiac surgery the use of lidocaine effect on myocardial protection. And also the positive effect on mortality and morbidity with short of extubation time and duration of stay in intensive care unit.
Troponin-I (ng/ml)
Group I
Group II
preoperative
0,19 ⫾ 0,49
0,18 ⫾ 0,39
Group III 0,1 ⫾ 0,28
P 0,59
Postoperative 6.hr
3,95 ⫾ 5,96
2,84 ⫾ 1,98
2,69 ⫾ 1,72
0,37
Postoperative 12.hr Postoperative 24.hr
6,39 ⫾ 12,3 4,89 ⫾ 11,27
2,19 ⫾ 1,52 1,21 ⫾ 0,68
2,11 ⫾ 1,75 1,24 ⫾ 0,85
0,03 0,042
Postoperative 48.hr
3,64 ⫾ 7,83
1,35 ⫾1,33
0,86 ⫾ 0,8
0,047
Extubation time (hr)
11 ⫾ 4,3
7,6 ⫾ 2,4
8,4 ⫾ 5,6
0,008
Duration of stay (hr)
54,8 ⫾ 35,3
39 ⫾ 21,6
30 ⫾ 11,4
0,001
REFERENCES 1. Hearse DJ, Garlic PB, Humprey SM: Ischemic Contracture of the myocardium: mechanism and prevention. Am J Cardiol 39:986993, 1977. 2. Mach F, Lovis C, Chevrolet J-C, et al: Rapid bedside whole blood cardiospesific Troponin-T immunoassay for the diagnosis of acute myocard infarction. Am J Cardiol 75:842-845, 1995. P-02 Anaesthesia for cardiac surgery procedures without a central venous catheter Sandeep P. Tambe, PK. Ryhammer, RP Bhavsar, P. Jhul-Olsen, E. Sloth Aarhus University Hospital, Department of Anaesthesia and Intensive Care, Aarhus, Denmark Introduction. Central venous catheters (CVC) are widely used during cardiac surgery for vasocative or inotropic infusions. CVC’s are expensive and not without risk. With the ultrasound (US) techniques peripheral vascular access is possible in every patient. Thus, we aimed to evaluate the feasibility of US guided peripheral venous cannulation as the only venous access in a selected group of patients scheduled for cardiac surgery. Methods. Patients scheduled for eitherJ-insicion off pump coronary artery bypass (JOPCAB) or femoral transcatheter aortic valve implantation (TAVI) procedures were included. A radial artery and venous cannuals in each arm (1.2-1.6 mm) were inserted under US guidance using the dynamic needle tip positioning (DNTP) technique (1). Brachial or basilic veins were cannulated at the judgment of the anesthetists. Both cannuals were connected to a crystalloid drip with a fixed rate of 30 drops/second when vasocative or inotropic agents were infused. JOPCAB procedures were performed under general anaesthesia whereas femoral TAVI under light sedation with remifentanil. Results. From November 2015 to December 2016, the regime was tested in 30 JOPCAB and 7 femoral TAVI patients. 3 JOPCAB procedures were converted to full sternotomi due to surgical challenges. One patient underwent re-operation because of bleeding. None of the patients needed a supplementary CVC during the entire perioperative period. There
ABSTRACT PRESENTATIONS
individual dependent and CA may deteriorate at mean ABP much higher than 50 mmHg (1). The goal of the study is to detect impaired CA during cardiac surgery with CPB and find its relation with the rate of POCD. Methods. The prospective observational study was conducted at Kaunas Klinikos, the Hospital of Lithuanian University of Health Sciences. The patients undergoing elective CABG surgery without preoperative neurological disorders were included. In addition to standard monitoring CA was monitored using “Vittamed” non-invasive monitor (2). The method is based on intracranial blood volume (IBV) measurement. Neurological function was evaluated by MMSE and HAD scales before and after cardiac surgery. Results and Discussion. 10 patients were enrolled in the study. All patients were ASA III class, NYHA III class; their average age was 70 years. The mean duration of CPB was 84.10 min.; mean MAP during CPB was 63.35 mmHg. All patients had periods of impaired CA. The mean longest period lasted 6.5 min. Average total duration of CA impairment was 25.98 min. (29.57 % of CPB duration). MMSE and HAD scales revealed POCD on the 7th postoperative day in 2 patients. The total time of CA impairment correlate with POCD (po0.02). The analysis revealed that mean ABP and duration of CPB were not related of CA disorders. Conclusions. CA impairment episodes occur during cardiac surgery with CPB. Our results show that total duration of CA impairment correlate with POCD. However, futher studies are needed to find the influence of CA impairment on POCD. Aknowlegment: The study is funded by Lithuanian Science Council.
Urinary TIMP-2 and IGFBP7 levels were quantified by ELISA assay using a commercially available ELISA kit using polyclonal antibodies (NephroCheck™ Test, Astute Medical, San Diego, CA, USA). The Test was developed to simultaneously measure the two biomarkers (urine [TIMP-2]*[IGFBP7]). [TIMP-2]*[IGFBB7] indicates the multiplication of both biomarkers. Results. We recruited and analyzed 110 patients. Of the 110 patients, 12 (13%) developed postoperative AKI Stage 1 as defined by the KDIGO criteria. There was no significant difference at the baseline values of the AKI and the patients who did not developed AKI. In the No AKI group there was no significant difference in the urinary TIMP-2 * IGFBP-7 concentrations at 1 hour. The concentration of TIMP-2 * IGFBP-7 decreased significantly at 4 hours and was still decreased after 24 hours. In contrast, in the AKI group there was an significant increase in urinary TIMP-2 * IGFBP-7 concentrations only at 1 hour after starting cardiopulmonary bypass. There was significant decrease of TIMP-2 * IGFBP-7 at 4 hours, the urinary TIMP-2 * IGFBP-7 concentrations turned to baseline level after 24 hours. The ROC curves for the absolute value of TIMP-2 * IGFBP-7, the difference of TIMP-2 * IGFBP-7 between 1h value and baseline, respectively the quotient between 1 h value and baseline. The quotient between these two values showed the best correlation for the prediction of the CSA-AKI. Conclusion. Novel biomarkers are feasible for the prediction of the Acute Kidney injury stage 1 in cardiac surgery patients.
REFERENCES 1. Siepe M, et al: Increased systemic perfusion pressure during cardiopulmonary bypass is associated with less early postoperative cognitive dysfunction and delirium, Eur J Cardiothorac Surg 40(1):200-207, 2011. 2. Ragauskas A, et al: Clinical study of continuous non– invasive cerebrovascular autoregulation monitoring in neurosurgical ICU // Acta Neurochir Suppl 95:367-370, 2005.
Hypoxic and hyperoxic preconditioning in myocardial protection against ischemia-reperfusion injury: experimental study
OP-12 Novel biomarkers (TIMP-2 and IGFBP7) of renal cell damage for the prediction of the cardiac surgery associated acute kidney injury - a feasibility study T. Mayer1, O. Reuthebuch2, M. Grapow2, P. Matt2, M. Scholz3, M. Seeberger1, D. Bolliger1, Jens Fassl1 1 Department of Anaesthesiology and Intensive Care Medicine, University Basel, 2Department of Cardiac Surgery, Basel, Switzerland, 3University Leipzig, Institute of Medical Informatics, Statistics and Epidemiology, Leipzig, Germany
Background. The incidence of acute kidney injury after cardiac surgery (CSA-AKI) has a wide variety. The severity of CSA-AKI ranges from subclinical injury to the requirement for renal replacement therapy, which has substantial impact on mortality and morbiditiy. We tested new biomarkers for the prediction of CSA-AKI. Material and Methods. We prospectively enrolled 110 adult patients undergoing elective cardiac surgery with cardiopulmonary bypass. Five milliliters of fresh urine was obtained through the urinary catheter at four time points from each patient: after induction of general anaesthesia and before surgical incision, one hour after onset of CPB and again at 4 and 24 hours after completion of CPB. A total of 440 urine samples were collected.
OP-13
Irina Mandel1, Y. Podoxenov1, I. Suhodolo2, A. Podoxenov1, Y. Svirko1, N. Kamenschikov1, S. Mikheev1, A. Sementsov1, A. Dzuman2, L. Maslov1 1 Research Institute For Cardiology, Department of Anaesthesiology and Intensive Care, Tomsk, Russian Federation, 2Siberian State Medical University, Tomsk, Russian Federation
Introduction. Hypoxic preconditioning phenomena provides evidence for adaptive responses to ischemia that have important implications for treatment/prevention of myocardial infarction (1). In the period before cardiopulmonary bypass (CPB), hyperoxia may also precondition myocardium (2). But comparative effects of these methods were not investigated yet. Method. In our prospective study we included 20 rabbits divided into four groups: hypoxic preconditioning (HypP), n¼5; hyperoxic preconditioning (HyperP), n¼5; hypoxic-hyperoxic preconditioning (HHP), n¼5; control, n¼5. All animals were anesthetized by sevoflurane and mechanically ventilated through nasotracheal tube. In HypP we exposed rabbits to two series of 10% oxygen for 10 min with 5 min reoxygenation. In HyperP rabbits were exposed to 80% oxygen for 30 min. In HHP rabbits were exposed to two series of 10% oxygen for 10 min with 5 min reoxygenation followed by 80% oxygen for 30 min. Then we started CPB. We induced acute myocardial infarction by ligation of left descending artery. After 45 min of ischemia we allowed reperfusion for 60 min. We performed light microscopy of myocardium and measured ischemic area to risk area (IA/RA) ratio by method described by Neckar J. et al. (3). Results. IA/RA decreased in HypP group by 23%, in HyperP group by 26%, in HHP group by 32% in comparison with control group (p¼0.009, Kruskal-Wallis test). Acid-based status, blood
S7
ABSTRACT PRESENTATIONS
lactate and glucose levels were stable during all methods of preconditioning. We observed group ventricular arrhythmia in control group more often than in preconditioned animals. Incidence of ventricular fibrillation were less in HHP group (p¼0.07, X2 test). Light microscopy of myocardium reveals less myofibril degeneration in HHP group as compared to other groups. Discussion. Hypoxic, hyperoxic preconditioning and the combination of these methods have the infarct-limiting effect. Hypoxic-hyperoxic preconditioning induces the highest tolerance of the myocardium to the effects of ischemia and reperfusion injury. REFERENCES 1. Cai Zh, Manalo DJ, Wei G: Hearts From Rodents Exposed to Intermittent Hypoxia or Erythropoietin Are Protected Against Ischemia-Reperfusion Injury. Circulation 108:79-85, 2003. 2. Young RW: Hyperoxia: a review of the risks and benefits in adult cardiac surgery. J Extra Corpor Technol 44(4):241-249, 2012. 3. Neckar J, Papousek F, Novakova O, Ost’adal B, Kolar F: Cardioprotective effects of chronic hypoxia and ischaemic preconditioning are not additive. Basic Res Cardiol 97:161167, 2002.
Poster Session PS01 Wednesday, May 11, 2016 14:30-16:00, Poster Exhibition Lounge P-01 Comparison of perioperative myocardial protection with use of Lidocaine after coronary arter bypass graft surgery Omer Faruk Savluk, D. Guzelmeric, I. Sýncar, Y Yavuz, D. Cevirme, E. Gurcu, K. Ogus, A. Erkýlýnc, T. Kocak Kartal Kosuyolu High Education and Training Hospital, Istanbul, Turke Introduction. It is provides bloodless and motionless surgical field to facilitating surgery that the heart to arrest with cardioplegic solution during cardiac surgery (1). Ongoing studies for improve myocardial protection that various materials such as lidocaine, β-blocker, calcium channel blocker have been introduced in to the cardioplegic solution (2). The aim of our study was to compare the effect of lidocaine with different application on myocardial protection. Methods. In this study 102 patients that scheduled for coronary artery bypass graft surgery were randomly divided in to three groups. Group I; Control group (N¼25) hyper potassium cold blood cardioplegia, Group II; (N¼35) 20 mcg/kg/min lidocaine infusion before aorta canulation and hyper potassium cold blood cardioplegia, Group III; (N¼42) 1mg/kg lidocaine added in hyper potassium cold blood cardioplegia solution. Troponin-I, creatinine kinase-MB (CK-MB) were assessed before operation and postoperative 6, 12, 24 and 48 hours. And as secondary extubation time and duration of time in intensive care unit were assessed. Results. Lidocaine infusion and lidocaine added in cardioplegia treated patients compared with patients of control group PO 12,24,48.hr the increase of troponin-I and CK-MB was
significantly less than control group (po0,05). As secondary extubation time and duration of stay in intensive care unit were in other two groups shorter than control group (po0,05). Discussion. We showed that in cardiac surgery the use of lidocaine effect on myocardial protection. And also the positive effect on mortality and morbidity with short of extubation time and duration of stay in intensive care unit.
Troponin-I (ng/ml)
Group I
Group II
preoperative
0,19 ⫾ 0,49
0,18 ⫾ 0,39
Group III 0,1 ⫾ 0,28
P 0,59
Postoperative 6.hr
3,95 ⫾ 5,96
2,84 ⫾ 1,98
2,69 ⫾ 1,72
0,37
Postoperative 12.hr Postoperative 24.hr
6,39 ⫾ 12,3 4,89 ⫾ 11,27
2,19 ⫾ 1,52 1,21 ⫾ 0,68
2,11 ⫾ 1,75 1,24 ⫾ 0,85
0,03 0,042
Postoperative 48.hr
3,64 ⫾ 7,83
1,35 ⫾1,33
0,86 ⫾ 0,8
0,047
Extubation time (hr)
11 ⫾ 4,3
7,6 ⫾ 2,4
8,4 ⫾ 5,6
0,008
Duration of stay (hr)
54,8 ⫾ 35,3
39 ⫾ 21,6
30 ⫾ 11,4
0,001
REFERENCES 1. Hearse DJ, Garlic PB, Humprey SM: Ischemic Contracture of the myocardium: mechanism and prevention. Am J Cardiol 39:986993, 1977. 2. Mach F, Lovis C, Chevrolet J-C, et al: Rapid bedside whole blood cardiospesific Troponin-T immunoassay for the diagnosis of acute myocard infarction. Am J Cardiol 75:842-845, 1995. P-02 Anaesthesia for cardiac surgery procedures without a central venous catheter Sandeep P. Tambe, PK. Ryhammer, RP Bhavsar, P. Jhul-Olsen, E. Sloth Aarhus University Hospital, Department of Anaesthesia and Intensive Care, Aarhus, Denmark Introduction. Central venous catheters (CVC) are widely used during cardiac surgery for vasocative or inotropic infusions. CVC’s are expensive and not without risk. With the ultrasound (US) techniques peripheral vascular access is possible in every patient. Thus, we aimed to evaluate the feasibility of US guided peripheral venous cannulation as the only venous access in a selected group of patients scheduled for cardiac surgery. Methods. Patients scheduled for eitherJ-insicion off pump coronary artery bypass (JOPCAB) or femoral transcatheter aortic valve implantation (TAVI) procedures were included. A radial artery and venous cannuals in each arm (1.2-1.6 mm) were inserted under US guidance using the dynamic needle tip positioning (DNTP) technique (1). Brachial or basilic veins were cannulated at the judgment of the anesthetists. Both cannuals were connected to a crystalloid drip with a fixed rate of 30 drops/second when vasocative or inotropic agents were infused. JOPCAB procedures were performed under general anaesthesia whereas femoral TAVI under light sedation with remifentanil. Results. From November 2015 to December 2016, the regime was tested in 30 JOPCAB and 7 femoral TAVI patients. 3 JOPCAB procedures were converted to full sternotomi due to surgical challenges. One patient underwent re-operation because of bleeding. None of the patients needed a supplementary CVC during the entire perioperative period. There