Eur J Cardiothorac Surg. 2007 Apr 11; [Epub ahead of print] 

New ultrasonic radiation reduces cerebral emboli during extracorporeal
circulation.

Sauren LD, la Meir M, Palmen M, Severdija E, van der Veen FH, Mess WH, Maessen
JG.

Cardiovascular Research Institute Maastricht, Department of Cardiothoracic
Surgery, Academic Hospital Maastricht, The Netherlands.

Objective: Cardiac surgery is associated with intraoperative cerebral emboli,
which can result in postoperative neurological complications. A new ultrasonic
transducer (EmBlockertrade mark) can be positioned on the ascending aorta and
activation of the EmBlockertrade mark is expected to divert emboli to the
descending aorta, thereby decreasing emboli in the cerebral arteries. In this
preliminary animal study, safety and efficiency of this technology were
examined. Methods: In 14 pigs (+/-70kg), a median sternotomy was performed and
the EmBlockertrade mark was positioned on the aorta ascendens at the level of
the bifurcation of the aorta and the innominate artery. In one animal
temperature measurements were performed. During these measurements, the
EmBlockertrade mark was activated for four periods of 120s of high power
(1.5W/cm(2)) and for four periods of 600s of low power (0.5W/cm(2)). In the
safety study (n=6), the EmBlockertrade mark was activated twice the expected
clinical duration (eight periods of 120s of high power and, subsequently, one
period of 20min of low power). Tissue samples (control and sonicated) were
collected after 1 week for histopathological evaluation (aorta, trachea,
esophagus, vagus nerves). In the efficiency study (n=7), extracorporeal
circulation was installed. Emboli (air and solid (1200, size 500mum-750mum))
were introduced in the proximal ascending aorta and the EmBlockertrade mark was
alternately activated with high power for solid emboli injections and low power
for air emboli injections. Transcranial Doppler (TCD) was used to analyse middle
cerebral artery blood flow for occurrence of embolic signals, which were
manually counted offline. Results: Histopathology revealed no difference between
control and sonicated tissue. There is a rise in temperature during
EmBlockertrade mark activation, but in all measured tissues it was within
limits; less then 42 degrees C for 2min in the aorta wall directly under the
EmBlockertrade mark. Use of the EmBlockertrade mark significantly reduced emboli
in the cerebral arteries in an animal model; air emboli with 65% (left) and 69%
(right) and solid emboli with 49% (left) and 50% (right). Conclusions: The new
ultrasound technology can safely be applied and is capable of reducing emboli in
the cerebral arteries during extracorporeal circulation. Use of the
EmBlockertrade mark in cardiac surgery bears the potential to lower the risk of
postoperative neurological complications. Clinical feasibility studies are in
progress.

J Heart Lung Transplant. 2007 Apr;26(4):331-8. 

Early institution of extracorporeal membrane oxygenation for primary graft
dysfunction after lung transplantation improves outcome.

Wigfield CH, Lindsey JD, Steffens TG, Edwards NM, Love RB.

Department of Cardiothoracic Surgery, University of Wisconsin, Madison,
Wisconsin, USA. cwigfield@btinternet.com

BACKGROUND: Primary graft dysfunction (PGD) after lung transplantation (LTx)
carries a significant mortality and clinical management is controversial.
Extracorporeal membrane oxygenation (ECMO) has been used infrequently for
recovery from acute lung injury (ALI) in this setting. We reviewed our
experience with ECMO after primary LTx. METHODS: The present study is a
retrospective analysis of all LTx patients between 1991 and 2004. Twenty-two
patients sustained severe PGD with subsequent placement on ECMO. We analyzed
indications and 30-day, 1-year and 3-year mortality. Complications and incidence
of multiple-organ failure (MOF) were determined. Critical appraisal of the
evidence available to date was performed. RESULTS: A total of 297 LTxs were
performed during the study period, with 97.5%, 88.6% and 73.8% survival at 30
days, 1 year and 3 years, respectively. Twenty-two patients (7.9%) had severe
allograft dysfunction leading to ECMO support. Twelve patients received
single-lung (SLTx), 8 double-lung (BLTx), 1 single-lung/kidney (SLKTx) and 1
heart/lung (HLTx) transplantation. Thirty-day, 1-year and 3-year survival of LTx
recipients with ECMO support post-operatively were 74.6%, 54% and 36%,
respectively. MOF was the predominant cause of death (58.3%) in patients on ECMO
support for PGD. CONCLUSIONS: Our data suggest that, in addition to prolonged
ventilation and pharmacologic support, ECMO should be considered as a bridge to
recovery from PGD in lung transplantation. Early institution of ECMO may lead to
diminished mortality in the setting of ALI despite the high incidence of MOF.
Late institution of ECMO was associated with 100% mortality in this
investigation.

Anesth Analg. 2007 Apr;104(4):766-73. 

Comment in:
    Anesth Analg. 2007 Apr;104(4):759-61.

The effects of levosimendan in cardiac surgery patients with poor left
ventricular function.

De Hert SG, Lorsomradee S, Cromheecke S, Van der Linden PJ.

Department of Anesthesiology, University of Antwerp, University Hospital
Antwerp, Belgium. stefan.dehert@ua.ac.be

BACKGROUND: Patients with poor left ventricular function often require inotropic
drug support immediately after cardiopulmonary bypass. Levosimendan improves
cardiac function by a novel mechanism of action compared to currently available
drugs. We hypothesized that, in patients with severely compromised ventricular
function, the use of levosimendan would be associated with better postoperative
cardiac function than with inotropic drugs that increase myocardial oxygen
consumption. METHODS: Thirty patients with a preoperative ejection fraction < or
=30% scheduled for elective cardiac surgery with cardiopulmonary bypass were
randomized to two different inotropic protocols: milrinone 0.5 mg x kg(-1) x
min(-1) or levosimendan 0.1 mg x kg(-1) x min(-1), started immediately after the
release of the aortic crossclamp. The treatment was masked to the observers. All
patients received dobutamine 5 mg x kg(-1) x min(-1). RESULTS: Stroke volume was
similar between groups initially after surgery, but it declined 12 h after
surgery in the milrinone group but not in the levosimendan group (P < 0.05
between groups) despite similar filling pressures. Total dose, duration of
inotropic drug administration and norepinephrine dose were lower in the
levosimendan group than in the milrinone group (P < 0.05). The duration of
tracheal intubation was shorter in the former group compared with the milrinone
group (P = 0008). Three patients in the milrinone group but none in the
levosimendan group died within 30 days of surgery. CONCLUSION: In cardiac
surgery patients with a low preoperative ejection fraction, stroke volume was
better maintained with the combination of dobutamine with levosimendan than with
the combination of dobutamine with milrinone.

J Thorac Cardiovasc Surg. 2007 May;133(5):1344-53, 1353.e1-3. Epub 2007 Mar
19. 

Patient characteristics are important determinants of neurodevelopmental outcome
at one year of age after neonatal and infant cardiac surgery.

Gaynor JW, Wernovsky G, Jarvik GP, Bernbaum J, Gerdes M, Zackai E, Nord AS,
Clancy RR, Nicolson SC, Spray TL.

Division of Cardiothoracic Surgery, The Cardiac Center at The Children's
Hospital of Philadelphia, Philadelphia, PA 19104, USA. gaynor@email.chop.edu

OBJECTIVE: Many studies of neurodevelopmental outcomes after neonatal and infant
cardiac surgery have focused on potentially modifiable risk factors for adverse
outcomes, primarily intraoperative management strategies and the use of deep
hypothermic circulatory arrest. There is increasing evidence that
patient-specific factors are more important determinants of outcome. METHODS: We
investigated predictors of neurodevelopmental outcomes at 1 year of age after
neonatal and infant cardiac surgery in a subgroup of infants enrolled in a
prospective study of apolipoprotein E (APOE) genotype and neurodevelopmental
outcome. Children with a variety of 2-ventricle cardiac defects repaired with
only 1 operation with cardiopulmonary bypass and no more than 1 episode of deep
hypothermic circulatory arrest were included. Neurodevelopmental outcomes at 1
year of age included the Bayley Scales of Infant Development-II, which yield 2
indices, the Mental Developmental Index and the Psychomotor Developmental Index.
RESULTS: Two hundred forty-seven infants underwent surgical repair between
October 1998 and April 2003 with 1 hospital death and 3 deaths before 1 year of
age. Neurodevelopmental evaluation was performed in 188 (77%) of 243 survivors,
including 56 patients with tetralogy of Fallot, 39 with transposition of the
great arteries with intact ventricular septum, 34 with ventricular septal
defects, and 59 with other defects. The median age at operation was 56 days
(1-186 days), including 72 (38%) neonates. Confirmed or suspected genetic
syndromes were present in 59 (31%) of 188 infants. Deep hypothermic circulatory
arrest was used in 67 (35%) infants with a median duration of 34 minutes (1-80
minutes). For the entire cohort, the mean Mental Developmental Index was 90.6
+/- 14.9 and the mean Psychomotor Developmental Index was 81.6 +/- 17.2. For
patients without genetic syndromes, the mean Mental Developmental Index was 93.7
+/- 13.6 and the mean Psychomotor Developmental Index was 85.1 +/- 14.6. For the
entire cohort, predictors of lower scores for both the Mental Developmental
Index and Psychomotor Developmental Index were presence of a confirmed or
suspected genetic syndrome, lower birth weight, and presence of the APOE
epsilon2 allele (all P < .04). Black race was associated with higher scores on
the Psychomotor Developmental Index (P = .018). Lower nasopharyngeal temperature
during cardiopulmonary bypass was associated with a lower score on the
Psychomotor Developmental Index (P = .03) and was the only intraoperative factor
that was a significant predictor of either the Mental or Psychomotor
Developmental Index. CONCLUSIONS: The strongest predictors of a worse
neurodevelopmental outcome at 1 year of age were patient-specific factors
including presence of a genetic syndrome, low birth weight, and presence of the
APOE epsilon2 allele. Patient-specific factors eclipsed the use and duration of
deep hypothermic circulatory arrest as predictors of worse neurodevelopmental
outcomes.

Ann Thorac Surg. 2007 May;83(5):1610-4. 

Reoperation for giant false aneurysm of the thoracic aorta: how to reenter the
chest?

Bachet J, Pirotte M, Laborde F, Guilmet D.

Departement de Pathologie Cardiaque, Institut Mutualiste Montsouris, Paris,
France. jean.bachet@imm.fr

BACKGROUND: Giant false or pseudoaneurysm of the aorta is a rare but dreadful
complication occurring several months or years after cardiac or aortic surgery.
We describe a surgical approach that allowed safe reentry in the chest in five
patients, with a mean follow-up of almost seven years. METHODS: From December
1991 to October 1999, five patients aged 34 to 74 years (mean age, 55 +/- 11.6
years), who had previously undergone a total of nine operations in other
institutions, required reoperation for giant false aneurysm of the ascending
aorta in a mean delay of 22.6 +/- 20.3 months (3 months to 6 years) after the
last surgical procedure. In order to avoid major mediastinal wound and patient's
exsanguination during resternotomy, the following technique has been used:
femoral artery cannulation; right atrial cannulation through the femoral vein;
femoro-femoral full-flow cardiopulmonary bypass; rectal temperature lowered to
25 degrees C; direct cannulation and cross-clamping of both carotid arteries
through a direct cervical approach, and selective cerebral perfusion with cold
blood (10 degrees C to 12 degrees C); circulatory arrest of the main circuit;
chest opening; and mediastinal division. RESULTS: Despite the fact that the
false aneurysm was entered in all patients, reopening of the chest has been safe
in all cases. In four cases, the aortic repair consisted of complete graft
replacement (Dacron) of the compromised aortic segment (ascending aorta in two;
both ascending aorta and aortic arch in two). In one case, reimplantation of the
left coronary ostium and closure of a fistula with the left ventricle was
carried out. One patient with ongoing mediastinitis died from intractable
septicemia and multiorgan failure. Presently, two patients are in excellent
condition; one suffers from light neurologic sequelae (oculomotor nerves palsy)
and one patient had a nonrelated stroke one year postoperatively. CONCLUSIONS:
The technique of separate carotid cannulation and selective antegrade brain
perfusion with cold blood during circulatory arrest at moderate core hypothermia
has, in our opinion, many advantages. In addition to allowing harmless opening
of the chest in the presence of most dangerous mediastinal false aneurysms, it
implies no general deep hypothermia, reduced duration of cardiopulmonary bypass,
and circulatory arrest of the lower part of the body, and safe and permanent
brain protection throughout chest opening and mediastinal division. It has
allowed us to safely reoperate on patients who are generally considered as a
major surgical risk.

Artif Organs. 2007 Apr;31(4):290-300. 

Comparing oxygen transfer performance between three membrane oxygenators: effect
of temperature changes during cardiopulmonary bypass.

Jegger D, Tevaearai HT, Mallabiabarrena I, Horisberger J, Seigneul I, von
Segesser LK.

Department of Cardiovascular Surgery, Centre Hospitalier Universitaire Vaudois
(CHUV), Lausanne, Switzerland. David.Jegger@chuv.ch

Recently, a new oxygenator (Dideco 903 [D903], Dideco, Mirandola, Italy) has
been introduced to the perfusion community, and we set about testing its oxygen
transfer performance and then comparing it to two other models. This evaluation
was based on the comparison between oxygen transfer slope, gas phase arterial
oxygen gradients, degree of blood shunting, maximum oxygen transfer, and
diffusing capacity calculated for each membrane. Sixty patients were randomized
into three groups of oxygenators (Dideco 703 [D703], Dideco; D903; and Quadrox,
Jostra Medizintechnik AG, Hirrlingen, Germany) including 40/20 M/F of 68.6 +/-
11.3 years old, with a body weight of 71.5 +/- 12.1 kg, a body surface area
(BSA) of 1.84 +/- 0.3 m(2), and a theoretical blood flow rate (index 2.4 times
BSA) of 4.4 +/- 0.7 L/min. The maximum oxygen transfer (VO(2)) values were 313
mL O(2)/min (D703), 579 mL O(2)/min (D903), and 400 mL O(2)/min (Quadrox), with
the D903 being the most superior (P < 0.05). Oxygen (O(2)) gradients were 320 mm
Hg (D703), 235 mm Hg (D903), and 247 mm Hg (Quadrox), meaning D903 and Quadrox
are more efficient versus the D703 (P < 0.05). Shunt fraction (Qs/Qt) and
diffusing capacity (DmO(2)) were comparable (P = ns). Diffusing capacity values
indexed to BSA (DmO(2)/m(2)) were 0.15 mL O(2)/min/mm Hg/m(2) (D703), 0.2 mL
O(2)/min/mm Hg/m(2) (D903), and 0.18 mL O(2)/min/mm Hg/m(2) (Quadrox) with D903
outperforming D703 (P < 0.0005). During hypothermia (32.0 +/- 0.3 degrees C),
there was a lower absolute and relative VO(2 )for all three oxygenators (P =
ns). The O(2) gradients, DmO(2) and DmO(2)/m(2), were significantly lower for
all oxygenators (P < 0.01). Also, Qs/Qt significantly rose for all oxygenators
(P < 0.01). The oxygen transfer curve is characteristic to each oxygenator type
and represents a tool to quantify oxygenator performance. Using this parameter,
we demonstrated significant differences among commercially available
oxygenators. However, all three oxygenators are considered to meet the oxygen
needs of the patients.

Crit Care. 2007 Apr 15;11(2):R45 [Epub ahead of print] 

Minimally invasive cardiopulmonary bypass: does it really change the outcome?

Ranucci M, Isgro G.

Department of Cardiovascular Anesthesia and Intensive Care, IRCCS Policlinico S,
Donato, Via Morandi 30, San Donato Milanese (Milan) - 20097, Italy.
cardioanestesia@virgilio.it.

ABSTRACT: INTRODUCTION: Many innovative cardiopulmonary bypass (CPB) systems
have recently been proposed by the industry. With few differences, they all
share a philosophy based on priming volume reduction, closed circuit with
separation of the surgical field suction, centrifugal pump, and biocompatible
circuit and oxygenator. These minimally invasive CPB (MICPB) systems are
intended to limit the deleterious effects of a conventional CPB. However, no
evidence exists with respect to their effectiveness in improving the
postoperative outcome in a large population of patients. This study aimed to
verify the clinical impact of an MICPB in a large population of patients
undergoing coronary artery revascularization. METHODS: We conducted a
retrospective analysis of 1,663 patients treated with an MICPB. The control
group (conventional CPB) was extracted from a series of 2,877 patients according
to a propensity score analysis. RESULTS: Patients receiving an MICPB had a
shorter intensive care unit (ICU) stay, had lower peak postoperative serum
creatinine and bilirubin levels, and suffered less postoperative blood loss.
Within a multivariable model, MICPB is independently associated with lower rates
of atrial fibrillation (odds ratio [OR] 0.83, 95% confidence interval [CI] 0.69
to 0.99) and ventricular arrhythmias (OR 0.45, 95% CI 0.28 to 0.73) and with
higher rates of early discharge from the ICU (OR 1.31, 95% CI 1.06 to 1.6) and
from the hospital (OR 1.46, 95% CI 1.18 to 1.8). Hospital mortality did not
differ between groups. CONCLUSION: MICPBs are associated with reduced morbidity.
However, these results will need to be confirmed in a large, prospective,
randomized, controlled trial.

J Cardiothorac Surg. 2007 Apr 10;2:17. 

Factors associated with excessive bleeding in cardiopulmonary bypass patients: a
nested case-control study.

Jimenez Rivera JJ, Iribarren JL, Raya JM, Nassar I, Lorente L, Perez R, Brouard
M, Lorenzo JM, Garrido P, Barrios Y, Diaz M, Alarco B, Martinez R, Mora ML.

Intensive Care Unit, University Hospital of Canary Islands, La Laguna, Spain.
jjjimenez_rivera@yahoo.es.

ABSTRACT: INTRODUCTION: Excessive bleeding (EB) after cardiopulmonary bypass
(CPB) may lead to increased mortality, morbidity, transfusion requirements and
re-intervention. Less than 50% of patients undergoing re-intervention exhibit
surgical sources of bleeding. We studied clinical and genetic factors associated
with EB. METHODS: We performed a nested case-control study of 26 patients who
did not receive antifibrinolytic prophylaxis. Variables were collected
preoperatively, at intensive care unit (ICU) admission, at 4 and 24 hours
post-CPB. EB was defined as 24-hour blood loss of >1 l post-CPB. Associations of
EB with genetic, demographic, and clinical factors were analyzed, using
SPSS-12.2 for statistical purposes. RESULTS: EB incidence was 50%, associated
with body mass index (BMI)< 26.4 (25-28) Kg/m2, (P = 0.03), lower preoperative
levels of plasminogen activator inhibitor-1 (PAI-1) (P = 0.01), lower body
temperature during CPB (P = 0.037) and at ICU admission (P = 0.029), and
internal mammary artery graft (P = 0.03) in bypass surgery. We found a
significant association between EB and 5G homozygotes for PAI-1, after adjusting
for BMI (F = 6.07; P = 0.02) and temperature during CPB (F = 8.84; P = 0.007).
EB patients showed higher consumption of complement, coagulation, fibrinolysis
and hemoderivatives, with significantly lower leptin levels at all postoperative
time points (P = 0.01, P < 0.01 and P < 0.01). CONCLUSION: Excessive
postoperative bleeding in CPB patients was associated with demographics,
particularly less pronounced BMI, and surgical factors together with serine
protease activation.

 Liver Transpl. 2007 Apr 10; [Epub ahead of print] 

Early and late outcome of cardiac surgery in patients with liver cirrhosis.

Filsoufi F, Salzberg SP, Rahmanian PB, Schiano TD, Elsiesy H, Squire A, Adams
DH.

Department of Cardiothoracic Surgery, Mount Sinai Hospital, New York.

Liver cirrhosis is a major risk factor in general surgery. Few studies have
reported on the outcome of cardiac surgery in these patients. Herein we report
our recent experience in this high-risk patient population according to the
Child-Turcotte-Pugh classification and Model for End-Stage Liver Disease (MELD)
score. Between January 1998 and December 2004, 27 patients (mean age 58 +/- 10
yr, 20 male) with cirrhosis who underwent cardiac surgery were identified.
Patients were in Child-Turcotte-Pugh class A (n = 10), B (n = 11), and C (n = 6)
and mean MELD score was 14.2 +/- 4.2. Operative mortality was 26% (n = 7).
Stratified mortality according to Child-Turcotte-Pugh class was 11%, 18%, and
67% for class A, B, and C, respectively. No mortality occurred in patients who
had revascularization without the use of cardiopulmonary bypass (n = 5). The
1-yr survival was 80%, 45%, and 16% for Child-Turcotte-Pugh class A, B, and C,
respectively (P = 0.02). Major postoperative complications occurred in 22%, 56%,
and 100% for Child-Turcotte-Pugh class A, B, and C, respectively.
Child-Turcotte-Pugh classification was a better predictor of hospital mortality
(P = 0.02) compared to MELD score (P = 0.065). In conclusion, our results
suggest that cardiac surgery can be performed safely in patients with
Child-Turcotte-Pugh class A and selected patients with class B. Operative
mortality remains high in class C patients. Careful patient selection is
critical in order to improve surgical outcome in patients with cirrhosis. Liver
Transpl, 2007. (c) 2007 AASLD.

Scand Cardiovasc J. 2007 Apr;41(2):102-8. 

Insulin resistance after cardiopulmonary bypass in the elderly patient.

Rapp-Kesek D, Stridsberg M, Andersson LG, Berne C, Karlsson T.

Department of Surgical Sciences, Section of Anaesthesiology and Intensive Care,
University Hospital. Uppsala. Sweden.

Objectives. Preoperative carbohydrate administration attenuates insulin
resistance. We studied effects of preoperative oral carbohydrate loading in
elderly patients undergoing coronary artery bypass grafting. Design. Eighteen
patients were assigned either to get a carbohydrate drink or to be controls.
Perioperatively, glucose was administered. A gastric emptying test was
performed. Glucose and insulin concentrations were measured. Levels of glucose,
insulin and stress hormones were studied pre-, per- and postoperatively. Results
and discussion. Preoperative carbohydrate loading did not affect stress
hormones. Gastric residual after the carbohydrate drink was 11+/-3%
(mean+/-SEM). Glucose concentration was lower before anaesthesia induction in
the carbohydrate group, possibly due to increased insulin release. Insulin
levels differed at baseline, induction and day six. All patients returned to
baseline on day six. Conclusions. The study group was insulin resistant on
postoperative day one and two. The effects were explainable by the traumatic
stress response. No adverse effect was noted from the carbohydrate drink. If
glucose is administered intravenously during surgery, there is no obvious
advantage of preoperative carbohydrate loading on insulin resistance or stress
hormone response.