South Med J  2002 Mar;95(3):321-3 

Cardiac surgery in patients with moderate renal impairment.

Gibbs ER, Christian KG, Drinkwater DC Jr, Pierson RN 3rd, Bender HW Jr, Merrill
WH.

Surgical Service, Department of Veterans Affairs Medical Center, Nashville, Tenn
37212, USA.

BACKGROUND: There is a paucity of information concerning the results of cardiac
surgery in patients with moderate impairment of renal function. We reviewed our
recent experience to determine the results of operation and the long-term
outcome. METHODS: Since January 1992, we have performed cardiac surgical
procedures utilizing total cardiopulmonary bypass on 57 adult patients with
preoperative serum creatinine values > or = 2.0 mg/dL and no history of
dialysis. Operative procedures done were coronary artery bypass (39 patients),
repeated coronary artery bypass (2), valve replacement with or without coronary
artery bypass (12), and other procedures (4). RESULTS: No operative deaths
occurred. There were 3 hospital deaths. Only 5 patients required perioperative
dialysis; in 5 additional patients, chronic dialysis was begun from 4 to 24
months postoperatively. The surviving patients who were not receiving dialysis
had a mean creatinine value of 2.4 mg/dL at most recent follow-up. CONCLUSIONS:
Adult patients with moderate renal impairment can safely have major cardiac
procedures. The majority of patients maintain stable renal function
postoperatively. The overall results of cardiac surgery in this patient
population are good.

Ann Thorac Surg  2002 Mar;73(3):953-5 

Successful repair of intraoperative aortic dissection detected by
transesophageal echocardiography.

Varghese D, Riedel BJ, Fletcher SN, Al-Momatten MI, Khaghani A.

Department of Cardiothoracic Surgery and Anesthetics, Harefield Hospital,
Middlesex, United Kingdom. david@varghese.freeserve.co.uk

Aortic dissection is a rare but devastating complication of cardiac surgery.
Early intraoperative diagnosis and management are essential for a favorable
outcome. We describe the case of a 69-year-old man with worsening dyspnea who
was admitted for mitral valve replacement having previously had a mitral valve
repair. Precardiopulmonary bypass transesophageal echocardiography confirmed
mitral regurgitation and showed mild atherosclerotic changes in the descending
aorta. Following successful replacement of the mitral valve, an attempt to wean
from cardiopulmonary bypass failed. This was characterized by acute onset
hypovolemia. The transesophageal echocardiography showed the presence of
features of acute aortic dissection involving only the descending aorta without
identifying the entry point. The tear was successfully repaired by direct suture
within the lumen.

Ann Thorac Surg  2002 Mar;73(3):843-8 

Is there a place for preconditioning during cardiac operations in humans?

Pouzet B, Lecharny JB, Dehoux M, Paquin S, Kitakaze M, Mantz J, Menasche P.

Department of Cardiovascular Surgery, Groupe Hjspitalier Bichat-Claude Bernard,
Paris, France.

BACKGROUND: Activation of the kinase cascade (protein kinase C (PKC), tyrosine
kinase (TK), and mitogen-activated protein kinase (MAPK) is a key feature of the
transduction pathway, elicited by preconditioning signals and mediating their
cardioprotective effects. We assessed whether such an activation occurred during
cardiac operations and could thus represent a target for cardioprotective
strategies. METHODS: A total of 20 patients undergoing coronary artery bypass
grafting surgery were studied. During the first 10 minutes of cardiopulmonary
bypass (CPB), 10 were treated with sevoflurane (2.5 minimum alveolar
concentration), an inhalational anesthetic that mimics preconditioning through a
similar activation of the kinase cascade. Ten case-matched patients undergoing
10 minutes of sevoflurane-free CPB served as controls. Right atrial biopsies
were taken before and 10 minutes after CPB and were then processed for the
measurement of PKC, TK, and p38 MAPK activities by enzyme assay techniques.
Troponin I was also monitored over the first 2 postoperative days. RESULTS:
Compared with pre-CPB values, PKC and p38 MAPK activities (in nanomoles per
milligram of protein per minute and arbitrary units, respectively) increased
significantly and to the same extent in both groups: PKC, from 20.7+/-0.7 to
29.9+/-3.9 in controls (p = 0.037) and from 18.4+/-1.1 to 23.9+/-1.8 in
sevoflurane (p = 0.016); p38 MAPK, from 88.6+/-8.5 to 312.9+/-66.2 in controls
(p = 0.005) and from 114.6+/-14.7 to 213.4+/-51.8 in sevoflurane (p = 0.045).
Conversely, sevoflurane triggered a significant increase in TK activity (from
68.5+/-1.4 to 83.7+/-2.9 picomoles per milligram of protein per minute p =
0.0015) which did not occur in controls (from 67.5+/-1.9 to 76.8+/-4.2 picomoles
per milligram of protein per minute, p = 0.09). Likewise, the peak postoperative
value of troponin I was not different between controls and sevoflurane-treated
patients (3.4+/-0.6 vs 2.4+/-0.4, p = 0.21). CONCLUSIONS: Cardiopulmonary bypass
triggers an activation of the kinase cascade that is mechanistically linked to
opening of potassium channels. The direct opening of these channels by the
anesthetic sevoflurane does not increase kinase activation further, nor does it
improve markers of cell necrosis, thus suggesting that pharmacologically
targeting potassium channels may overlap the preconditioning-like effects of CPB
alone.

Nucl Med Commun  2002 Mar;23(3):275-82 

Determining the influence of biocompatible oxygenators during cardiopulmonary
bypass by 99m Tc-DTPA aerosol assessment of pulmonary permeability.

Dixon KL, Agrawal SK, Chan KM.

1Department of Nuclear Medicine and 2Department of Cardiothoracic Surgery,
Walsgrave Hospital, Coventry and Warwickshire Teaching Hospitals, UK.

SUMMARY: Changes in pulmonary permeability provide a partial measure of the
clinical impact of biocompatible oxygenator use during cardiopulmonary bypass
surgery. Previous research has shown that the clearance rate of 99mTc-labelled
diethylene triamine penta-acetic acid (99mTc-DTPA) aerosol from the lungs is
increased following cardiopulmonary bypass, resulting from an increase in
pulmonary permeability. The aerosol clearance rate has been shown to return to
normal after a period of 7 days. A blind trial was set up to assess the clinical
impact of a biocompatible, Trillium-coated oxygenator compared with a standard
oxygenator. In a group of 25 patients 99mTc-DTPA aerosol studies were carried
out prior to cardiopulmonary bypass surgery for mitral valve surgery. Repeat
studies were undertaken 3-4h and 24-28h after surgery. Analysis of the rates of
pulmonary clearance reproduced the trends seen in earlier research. There was
however no statistically significant difference in the variation of serial
clearance times between the groups of patients undergoing surgery using the
Trillium-coated oxygenators and those using the standard oxygenators.

Eur J Cardiothorac Surg  2002 Mar;21(3):440-6 

Myocardial injury in hypertrophic hearts of patients undergoing aortic valve
surgery using cold or warm blood cardioplegia.

Ascione R, Caputo M, Gomes WJ, Lotto AA, Bryan AJ, Angelini GD, Suleiman MS.

Bristol Heart Institute, University of Bristol, BS2 8HW, Bristol, UK

Objectives: Myocardial protection techniques during cardiac surgery have been
largely investigated in the clinical setting of coronary revascularisation. Few
studies have been carried out on patients with left ventricular hypertrophy
where the choice of delivery, and temperature of cardioplegia remain
controversial. This study investigates metabolic changes and myocardial injury
in hypertrophic hearts of patients undergoing aortic valve surgery using
antegrade cold or warm blood cardioplegia. Methods: Thirty-five patients were
prospectively randomised to intermittent antegrade cold or warm blood
cardioplegia. Left ventricular biopsies were collected at 5min following
institution of cardiopulmonary bypass, 30min after cross-clamping the aorta and
20min after cross-clamp removal, and used to determine metabolic changes during
surgery. Metabolites (adenine nucleotides, amino acids and lactate) were
measured using high pressure liquid chromatography and enzymatic techniques.
Postoperative myocardial troponin I release was used as a marker of myocardial
injury. Results: Ischaemic arrest was associated with significant increase in
lactate and alanine/glutamate ratio only in the warm blood group. During
reperfusion, alanine/glutamate ratio was higher than preischaemic levels in both
groups, but the extent of the increase was considerably greater in the warm
blood group. Troponin I release was markedly (P<0.05, Meanplus minusSD) lower at
1, 24 and 48h postoperatively in the cold compared to the warm blood group
(0.51plus minus0.37, 0.37plus minus0.22 and 0.27plus minus0.19 vs. 0.75plus
minus0.42, 0.73plus minus0.51 and 0.54plus minus0.38ng/ml for cold vs. warm
group, respectively). Conclusions: Cold blood cardioplegia is associated with
less ischaemic stress and myocardial injury compared to warm blood cardioplegia
in patients with aortic stenosis undergoing valve replacement surgery. Both
cardioplegic techniques, however, confer sub-optimal myocardial protection.

Resuscitation  2002 Mar;52(3):255-63 

Cold water submersion and cardiac arrest in treatment of severe hypothermia with
cardiopulmonary bypass.

Wollenek G, Honarwar N, Golej J, Marx M.

Department of Cardiothoracic Surgery, University and General Hospital of Vienna,
Wahringer Gurtel 18--20, A-1090, Vienna, Austria

In the paediatric population, submersion injury with drowning or near-drowning
represents a significant cause of morbidity and mortality. This study reviews
retrospectively our own experiences and the literature on the use of
cardiopulmonary bypass (CPB) to rewarm paediatric victims of cold water
submersion who suffer severe hypothermia (<28 degreesC) and cardiac arrest
(asystole or ventricular fibrillation). In addition to three children treated at
our institution, nine other victims were found in the literature. In this cohort
of 12 children aged between 2 and 12 years, there was a tendency to better
outcome with lower core temperature at the beginning of extracorporeal
circulation (mean temperature in nine survivors, 20 degreesC; in three
non-survivors, 25.5 degreesC). The lowest temperature survived was 16 degreesC.
Neither base excess, pH nor serum potassium levels were reliable prognostic
factors. The lowest base excess in a survivor was minus sign36.5 mmol/l, the
lowest pH 6.29. We consider CPB as the method of choice for resuscitation and
rewarming of children with severe accidental hypothermia and cardiac arrest
(asystole or ventricular fibrillation). Compared with adults, children,
especially smaller ones, require special consideration with regard to
intravenous cannulation as drainage can be inadequate using femoral--femoral
cannulation. In hypothermic children we advocate, therefore, emergency median
sternotomy. Until more information regarding prognostic factors are available,
children who are severely hypothermic and clinically dead after submersion in
cold water---even if for an unknown length of time---should receive
cardiopulmonary resuscitation (CPR) and be transported without delay to a
facility with capabilities for CPB instituted via a median sternotomy.

J Thorac Cardiovasc Surg  2002 Mar;123(3):539-543 

Does tranexamic acid reduce desmopressin-induced hyperfibrinolysis?

Ozal E, Kuralay E, Bingol H, Cingoz F, Ceylan S, Tatar H.

Gulhane Military Medical Academy Cardiovascular Surgery Department Etlik,
Ankara, Turkey.

OBJECTIVE: Desmopressin releases tissue-type plasminogen activator, which
augments cardiopulmonary bypass--associated hyperfibrinolysis, causing excessive
bleeding. Combined use of desmopressin with prior administration of the
antifibrinolytic drug tranexamic acid may decrease fibrinolytic activity and
might improve postoperative hemostasis. METHODS: This prospective randomized
study was carried out with 100 patients undergoing coronary artery bypass
operations between April 1999 and November 2000 in Gulhane Military Medical
Academy. Patients were divided into 2 groups. Desmopressin (0.3 &mgr;g/kg) was
administrated just after cardiopulmonary bypass and after protamine infusion in
group 1 (n = 50). Both desmopressin and tranexamic acid (before the skin
incision at a loading dose of 10 mg/kg over 30 minutes and followed by 12 hours
of 1 mgcenter dotkg(minus sign1)center doth(minus sign1)) were administrated in
group 2 (n = 50). RESULTS: Significantly less drainage was noted in group 2
(1010 plus minus 49.9 mL vs 623 plus minus 41.3 mL, P =.0001). Packed red blood
cells were transfused at 2.1 plus minus 0.5 units per patient in group 1 versus
0.9 plus minus 0.3 units in group 2 (P =.0001). Fresh frozen plasma was
transfused at 1.84 plus minus 0.17 units per patient in group 1 versus 0.76 plus
minus 0.14 units in group 2 (P =.0001). Only 24% of patients in group 2 required
donor blood or blood products compared with 74% of those in the isolated
desmopressin group (group 1, P =.00001). Group 1 and group 2 findings were as
follows: postoperative fibrinogen, 113 plus minus 56.3 mg/dL versus 167 plus
minus 45.8 mg/dL (P =.0001); fibrin split product, 21.2 plus minus 2.3 ng/mL
versus 13.5 plus minus 3.4 ng/mL (P =.0001); and postoperative hemoglobin level,
7.6 plus minus 1.2 g/dL versus 9.1 plus minus 1.2 g/dL (P =.0001). CONCLUSION:
Tranexamic acid administration significantly reduces desmopressin and
bypass-induced hyperfibrinolysis. Combined use of tranexamic acid and
desmopressin decreases both postoperative blood loss and transfusion
requirement.

J Thorac Cardiovasc Surg  2002 Mar;123(3):451-458 

Newborn patients exhibit an unusual pattern of interleukin 10 and interferon
gamma serum levels in response to cardiac surgery.

Alcaraz AJ, Sancho L, Manzano L, Esquivel F, Carrillo A, Prieto A, Bernstein ED,
Alvarez-Mon M.

Department of Pediatrics and Pediatric Surgery, Pediatric Intensive Care Unit,
Hospital General Universitario Gregorio Maranon Service of Medicine/ Clinical
Immunology and Oncology, Hospital Universitario Principe de Asturias, University
of Alcala, Alcala de Henares Service of Internal Medicine, Hospital
Universitario Ramon y Cajal, University of Alcala and Laboratory of Clinical
Immunology, Department of Medicine, University of Alcala, Alcala de Henares,
Madrid, Spain.

OBJECTIVE: The aim of this study was to determine the clinical significance of
serum levels of interleukin 10 and interferon gamma in pediatric patients
undergoing cardiopulmonary bypass. METHODS: We divided the patients into 2
groups: 8 neonates and 19 nonnewborn children. Interleukin 10 and interferon
gamma serum levels were quantified before sternotomy, at admission to the
pediatric intensive care unit (30 minutes postoperatively), 24 hours after the
onset of the operation, and 3 days after the operation. RESULTS: Newborn
patients displayed significantly greater amounts of serum interleukin 10 than
older children, not only in regard to the peak level achieved but also at every
postoperative time point analyzed. In contrast, no significant changes in
interferon gamma serum levels were observed in neonates at any time point,
whereas nonnewborn pediatric patients showed a significant increase in
interferon gamma serum concentrations immediately after the operation. This
unusual pattern of cytokine response in newborn patients was not associated with
modifications in cortisol serum levels. Furthermore, although neonates had
significantly different surgical and clinical variables than did the nonnewborn
pediatric patients, the variation in interleukin 10 production in neonates could
not be accounted for by differences in the magnitude of surgical injury. In the
group of neonates, there were significant positive correlations between peak
interleukin 10 serum levels and both partial pressure of arterial
oxygen/fraction of inspired oxygen ratio and postoperative body weight gain.
CONCLUSIONS: Newborn patients undergoing cardiopulmonary bypass exhibit a
distinctive biologic response pattern characterized by high levels of serum
interleukin 10 without changes in serum interferon gamma. This cytokine
imbalance could have potential clinical implications.

PMID: 11882815 [PubMed - as supplied by publisher]

Eur J Cardiothorac Surg  2002 Mar;21(3):434-9 

Redox behavior of cytochrome oxidase and neurological prognosis in 66 patients
who underwent thoracic aortic surgery.

Kakihana Y, Matsunaga A, Tobo K, Isowaki S, Kawakami M, Tsuneyoshi I, Kanmura Y,
Tamura M.

Division of Intensive Care Medicine, Kagoshima University Hospital, 8-35-1
Sakuragaoka, 890-8520, Kagoshima, Japan

Objective: Using near-infrared spectroscopy (NIRS), we have developed a new
approach to the measurement of the redox state of cytochrome oxidase (cyt. ox.)
in the brain. Our previous animal study showed that oxygen-dependent redox
changes in cyt. ox. occur only when oxygen delivery is badly impaired.
Therefore, in this study, we retrospectively examined the relationship between
the redox behavior of cyt. ox. (measured by NIRS) during an operation and the
neurological outcome in patients. Methods: We studied 66 patients undergoing
thoracic aortic surgery with cardiopulmonary bypass. Cerebral oxygenation was
monitored by NIRS, and relative values for the concentrations of oxy-Hb,
deoxy-Hb, and the redox state of cyt. ox. in the brain were calculated using our
developed algorithm. Results: Retrospective assessment revealed three different
types of cyt. ox. behavior: (1) no change (type-A) in 34 cases (51.5%), (2) a
temporary reduction, with a subsequent return to the pre-surgery baseline level
(type-B) in 29 cases (43.9%), or (3) a marked and prolonged reduction (type-C)
in only three cases (4.5%). Nine of the 66 patients (13.6%; one type-A, five
type-B, and all three type-C patients) showed evidence of postoperative brain
injury (in the type-A patient, the injury proved to be localized and far from
the monitoring site). The relationship between the occurrence of such an injury
and the type of cyt. ox. behavior seen during the operation was highly
significant (P<0.0001; chi-square test for independence). Conclusions: Our data
suggest that the redox behavior of cyt. ox. during an operation is a good
(though not perfect) predictor of postoperative cerebral outcome, and that
overall tissue oxygen sufficiency can be confirmed by near-infrared measurement
of cyt. ox.