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Clinical Trial Details — Status: Completed

Administrative data

NCT number NCT00863044
Other study ID # 08-1032
Secondary ID
Status Completed
Phase Phase 4
First received March 16, 2009
Last updated March 15, 2016
Start date November 2009
Est. completion date June 2012

Study information

Verified date March 2016
Source Montreal Heart Institute
Contact n/a
Is FDA regulated No
Health authority Canada: Health Canada
Study type Interventional

Clinical Trial Summary

This study is to test the safety of high frequency-low volume ventilation during off pump coronary artery bypass as reflected in the near infrared spectroscopy values for cerebral oxygenation.


Description:

Ventilatory protocol: Patients will be randomized to either the apnea group or the HFV group. In the HFV group the patients will be ventilated using a tidal volume of 1.5 ml per kg and a respiratory rate of 100 per minute for as long as the surgeon needs to perform the distal anastomosis of the coronaries.The same surgeon will perform all surgeries. In the Control group, ventilation will be stopped for the duration of the anastomosis as it's done currently. At all other times during the surgery, the ventilatory parameters will be adjusted to maintain a PaCO2 between 40 and 45 mmHg.

The anesthesia protocol for the off pump coronary artery bypass will be as follows: premedication will be left at the discretion of the anesthesiologist. In the operating room, the patient will be instrumented with a radial arterial line before induction. Induction will consist of a bolus of 1.0 mcg per Kg of Sufentanil. Anesthesia will be maintained with 1mcg per Kg per hour of Sufentanil. One per cent Isoflurane will be used as hemodynamic parameters allow. Rocuronium 0.7 mg per Kg will be used to facilitate endotracheal intubation. Following endotracheal intubation the patients will monitored with a pulmonary artery catheter and a femoral arterial line. A perfusionist will be on standby at all times for possible conversion to extracorporeal circulation.

Measures to effect:

Routine baseline laboratory investigations will be performed at admission of the patient to the ward.

Hemodynamic parameters:

Arterial blood pressure, heart rate, pulmonary artery pressure, right ventricular pressure will be recorded five minutes intervals throughout the surgery.

Ventilatory parameters and blood gases:

End tidal CO2 and pulse oxymetry will be recorded at five minutes intervals throughout the surgery.

Arterial blood gases will be performed after induction, before and after each distal coronary anastomosis and when judged necessary. The type and time for each anastomosis will be noted.

C-reactive protein and brain natriuretic peptide:

Measurements of CRP and BNP will be perform at admission, after induction of anesthesia, in the intensive care unit after the surgery and 24 hrs after admission to the intensive care unit.

We will use the serum for measure of CRP.CRP will be measured using the Dade Behring N High Sensitivity CRP assay (Dade Behring Diagnostics,Marburg,Germany) on the BN ProSpec Nephelometer (Dade Behring Diagnostics).The assay will use monoclonal anti-CRP antibodies coated to polystyrene particles and a human calibrator traceable to the WHO reference material. We will use the Heparinised Plasma for measure of NT Pro-BNP.NT Pro-BNP will be measure by electrochemiluminescence immunoassay using the Roche Pro BNP assay (Roche Diagnostics , Mannheim,Germany) on the ElecSys 2010 analyzer (Roche Diagnostics).This assay will use two polyclonal antibodies in a sandwich format.

Cerebral Oximetry Monitoring:

Cerebral oxymetry (rSO2) using near infrared spectroscopy (NIRS, Invos 5100; Somanetics Corporation, Troy, MI) will be performed on all patients. After cleaning adjacent skin area with alcohol, an adhesive optode pad will be placed over each front-temporal area. Resting baseline rSO2 values will be obtained after waiting at least 1 min after placement of sensors once values had stabilized, with patient resting quietly and receiving 3-5 L of O2/min by nasal cannula. Continuous rSO2 values will be store on a floppy disk with a 15 s update for the duration of the intraoperative period. With application of the chest dressing, and before leaving the OR, monitoring will be discontinued and optodes will be removed.

Transesophageal echocardiographic (TEE) measurements:

A comprehensive TEE examination will be performed for all patients as it's done routinely(25). Specific TEE measurements as recommended be the ASE will be perform before and after distal coronary anastomosis(26). RVMPI will be defined as the sum of isovolumic contraction time and isovolumic relaxation time divided by the ejection time and the normal value is 0.28±0.04). RV MPI will be measured using both pulse wave and tissue Doppler imaging from a deep transgastric view and upper esophageal view. Right ventricular FAC % will be measure in 4 chambers view and calculated as RV change in area in diastole minus RV change in area in Systole divided by the calculated RV area in Diastole (37).

Analysis of HR and BP variability:

Baseline HR and BP variability will be analysed using wavelet transformation (27). The extraction of characteristic frequencies, or specific oscillations, of a signal that is composed of the consecutive R-R intervals for HR variability analysis, or consecutive systolic blood pressures for BP variability analysis, is used. The analysis will be made using MATLAB® and the dedicated toolbox software Wavelab. High frequency power of the HR variability is indicative of changes in parasympathetic nervous system. Total power of the BP variability signal is used as a measure of sympathetic outflow.


Recruitment information / eligibility

Status Completed
Enrollment 80
Est. completion date June 2012
Est. primary completion date December 2011
Accepts healthy volunteers No
Gender Both
Age group 19 Years and older
Eligibility Inclusion Criteria:

- Age > 18 years.

- Patients able to give consent with knowledge of french or english language.

Exclusion Criteria:

- Patients undergoing emergency surgery.

- Patients with an intra aortic balloon pump.

Study Design

Allocation: Randomized, Endpoint Classification: Safety Study, Intervention Model: Parallel Assignment, Masking: Open Label, Primary Purpose: Treatment


Related Conditions & MeSH terms


Intervention

Procedure:
Apnea
Ventilation will be stopped for the duration of the anastomosis as it's done currently. At all other times during the surgery, the ventilatory parameters will be adjusted to maintain a PaCO2 between 40 and 45 mmHg.
High frequency ventilation
The patients will be ventilated using a tidal volume of 1.5 ml per Kg and a respiratory rate of 100 per minute for as long as the surgeon needs to perform the distal anastomosis of the coronaries.

Locations

Country Name City State
Canada Montreal Heart Institute Montreal Quebec

Sponsors (1)

Lead Sponsor Collaborator
Montreal Heart Institute

Country where clinical trial is conducted

Canada, 

References & Publications (32)

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European Cardiovascular disease 2006 - 1-4, NT BNP in stable coronary artery diease

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John Murkin et al : Monitoring Brain oxygen saturation during coronary artery bypass surgery: A Randomised prospective study.

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Malouf JF, Enriquez-Sarano M, Pellikka PA, Oh JK, Bailey KR, Chandrasekaran K, Mullany CJ, Tajik AJ. Severe pulmonary hypertension in patients with severe aortic valve stenosis: clinical profile and prognostic implications. J Am Coll Cardiol. 2002 Aug 21;40(4):789-95. — View Citation

Mishra M, Chauhan R, Sharma KK, Dhar A, Bhise M, Dhole S, Omar A, Kasliwal RR, Trehan N. Real-time intraoperative transesophageal echocardiography--how useful? Experience of 5,016 cases. J Cardiothorac Vasc Anesth. 1998 Dec;12(6):625-32. — View Citation

Oberg PA, Sjöstrand U. Studies of blood-pressure regulation. I. Common-carotid-artery clamping in studies of the carotid-sinus baroreceptor control of the systemic blood pressure. Acta Physiol Scand. 1969 Mar;75(3):276-86. — View Citation

Pichot V, Gaspoz JM, Molliex S, Antoniadis A, Busso T, Roche F, Costes F, Quintin L, Lacour JR, Barthélémy JC. Wavelet transform to quantify heart rate variability and to assess its instantaneous changes. J Appl Physiol (1985). 1999 Mar;86(3):1081-91. — View Citation

Puls A, Pollok-Kopp B, Wrigge H, Quintel M, Neumann P. Effects of a single-lung recruitment maneuver on the systemic release of inflammatory mediators. Intensive Care Med. 2006 Jul;32(7):1080-5. Epub 2006 May 9. — View Citation

Ratzenhofer-Komenda B, Prause G, Offner A, Smolle-Jüttner FM. Intraoperative application of high frequency ventilation in thoracic surgery. Acta Anaesthesiol Scand Suppl. 1996;109:149-53. — View Citation

Reich DL, Bodian CA, Krol M, Kuroda M, Osinski T, Thys DM. Intraoperative hemodynamic predictors of mortality, stroke, and myocardial infarction after coronary artery bypass surgery. Anesth Analg. 1999 Oct;89(4):814-22. — View Citation

Rouby JJ, Simonneau G, Benhamou D, Sartene R, Sardnal F, Deriaz H, Duroux P, Viars P. Factors influencing pulmonary volumes and CO2 elimination during high-frequency jet ventilation. Anesthesiology. 1985 Nov;63(5):473-82. — View Citation

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Tremblay NA, Hardy JF, Perrault J, Carrier M. A simple classification of the risk in cardiac surgery: the first decade. Can J Anaesth. 1993 Feb;40(2):103-11. — View Citation

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* Note: There are 32 references in allClick here to view all references

Outcome

Type Measure Description Time frame Safety issue
Primary cerebral oxygen saturation during surgery Yes
Secondary hemodynamic parameters during surgery Yes
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