TOP TEN SELECTED PAPERS - June 2009

1

Artif Organs. 2009 Jun 28. [Epub ahead of print]

Beneficial Effect of Preventative Intra-Aortic Balloon Pumping in High-Risk
Patients Undergoing First-Time Coronary Artery Bypass Grafting-A Single Center
Experience.

Gong Q, Xing J, Miao N, Zhao Y, Jia Z, Li J, Chen Y, Gao Q, Liu A, Sun Z, Liu X, 
Ji B.

Department of Cardiopulmonary Bypass, Beijing Anzhen Hospital, Capital Medical
University, Beijing, China.

Abstract Although intra-aortic balloon pumping (IABP) has been used widely as a
routine cardiac assist device for perioperative support in coronary artery bypass
grafting (CABG), the optimal timing for high-risk patients undergoing first-time 
CABG using IABP is unknown. The purpose of this investigation is to compare
preoperative and preventative IABP insertion with intraoperative or postoperative
obligatory IABP insertion in high-risk patients undergoing first-time CABG. We
reviewed our IABP patients' database from 2002 to 2007; there were 311 CABG
patients who received IABP treatment perioperatively. Of 311 cases, 41 high-risk 
patients who had first-time on-pump or off-pump CABG (presenting with three or
more of the following criteria: left ventricular ejection fraction less than
0.45, unstable angina, CABG combined with aneurysmectomy, or left main stenosis
greater than 70%) entered the study. We compared perioperatively the clinical
results of 20 patients who underwent preoperative IABP placement (Group 1) with
21 patients who had obligatory IABP placement intraoperatively or postoperatively
during CABG (Group 2). There were no differences in preoperative risk factors,
except left ventricular aneurysm resection, between the two groups. There were no
differences in indications for high-risk patients between the two groups. The
mean number of grafts was similar. There were no significant differences in the
need for inotropes, or in cerebrovascular, gastrointestinal, renal, and infective
complications postoperatively. There were no IABP-related complications in either
group. Major adverse cardiac event (severe hypotension and/or shock, myocardial
infarction, and severe hemodynamic instability) was higher in Group 2 (14 [66.4%]
vs. 1 [5%], P < 0.0001) during surgery. The time of IABP pumping in Group 1 was
shorter than in Group 2 (72.5 +/- 28.9 h vs. 97.5 +/- 47.7 h, P < 0.05). The
duration of ventilation and intensive care unit stay in Group 1 was significantly
shorter than in Group 2, respectively (22.0 +/- 1.6 h vs. 39.6 +/- 2.1 h, P <
0.01 and 58.0 +/- 1.5 h vs. 98.5 +/- 1.9 h, P < 0.005). There were no differences
in mortality between the two groups (n = 1 in Group 1 and n = 3 in Group 2).
Preoperative and preventative insertion of IABP can be performed safely in
selected high-risk patients undergoing CABG, with results comparable to those in 
patients who received obligatory IABP intraoperatively and postoperatively.
Therefore, earlier IABP support as part of surgical strategy may help to improve 
the outcome in high-risk first-time CABG patients.

Semin Cardiothorac Vasc Anesth. 2009 Jun;13(2):106-12. Epub 2009 Jul 17.

Endovascular treatment of blunt traumatic thoracic aortic injury.

Nicolaou G.

Department of Anesthesia and Perioperative Medicine, London Health Sciences
Centre, Victoria Hospital, University of Western Ontario, London, Ontario,
Canada. george.nicolaou@lhsc.on.ca.

Blunt traumatic thoracic aortic injury (BTTAI) is a lethal injury associated with
a prehospital mortality of 80% to 90%. Patients arriving in the emergency room
and considered appropriate to undergo emergency open surgical repair still have a
mortality rate of 15% to 30% because of severe associated injuries. Conventional 
open surgical repair requires a left thoracotomy, single lung ventilation,
aortic-cross clamping and unclamping, with or without the adjunct use of partial 
or full cardiopulmonary bypass and systemic heparinization. All this leads to
significant physiological stress and surgical trauma resulting in perioperative
complications such as major blood loss, coagulopathy, myocardial infarction,
stroke, respiratory failure, renal failure, bowel infarction, and paraplegia.
Despite advances in anesthesia, critical care medicine, and surgical techniques, 
a recent meta-analysis showed no definite improvement in operative mortality over
the past decade, following open surgical repair in patients with BTTAI.
Endovascular repair of BTTAI does not require a thoracotomy, single lung
ventilation, aorticcross clamping and unclamping, or systemic heparinization. As 
a result, endovascular repair of BTTAI has emerged as an effective, minimally
invasive treatment alternative, especially in patients with severe concomitant
injuries, which may be prohibitive to open surgical repair. Recent published
studies have shown that endovascular repair of BTTAI is associated with lower
morbidity, mortality, stroke, and paraplegia/paraparesis rates, when compared
with open surgical repair of BTTAI.

Middle East J Anesthesiol. 2009 Jun;20(2):199-206.

The impact of intraoperative transoesophageal echocardiography on decision-making
during cardiac surgery.

Mahdy S, Brien BO, Buggy D, Griffin M.

Department of Anaesthesia, Intensive Care and Pain Management, Mater
Misericordiae University Hospital, Eccles Street, Dublin 7, Ireland.
smahdy2005@yahoo.co.uk

BACKGROUNDS: Real time intraoperative transoesophageal echocardiograpgy (TOE) has
an expanding role in peri-operative management and surgical decision making.
OBJECTIVES: Studies of the effect of transoesophageal echocardiography (TOE) on
intraoperative decision making commonly emphasise major changes in operative
plans. We examined more subtle effects using a novel scale, recording influences 
on management as follows: Level 1: TOE had no effect on management, confirmed and
quantified known pathology. Level 2: TOE altered hemodynamic and/or anesthetic
management. Level 3: TOE evaluated the adequacy of surgical intervention/or
repair. Level 4: TOE led to an alteration in the surgical plan. We compared the
impact of TOE as an aid to intra-operative management in coronary artery bypass
cases with other types of cardiac surgery. METHODS: Retrospective, observational 
study in a single centre, university-affiliated hospital included 319 patients
undergoing cardiac surgery and suitable for TOE. TOE was performed in each
patient before and after the institution of cardiopulmonary by-pass. Normal and
abnormal echocardiographic findings as well as immediate outcomes of the surgical
procedure were recorded using a standard database form. Instances where TOE lead 
to alteration in operative management were documented. The findings were also
compared with those documented on preoperative echocardiography. RESULTS: In 141 
CABG patients TOE had a level 1 impact in 73%, level 2 impact in 11.6%, levels 3 
and 4 in 7% and 7.8% respectively. In 178 non CABG patients these values were 2%,
1.6%, (p < 0.05), 72.4% (p < 0.05) and 23.6% (p < 0.05) respectively. CONCLUSION:
The impact of TOE in CABG procedures, while significantly less than that in
non-CABG surgical procedures, remains substantial.

J Cardiothorac Vasc Anesth. 2009 Jun 22. [Epub ahead of print]

Effects of Fenoldopam Mesylate on Central Hemodynamics and Renal Flow in Patients
Undergoing Cardiac Surgery: Color Doppler Echocardiographic Evaluation.

Meco M, Cirri S.

Cardiac Surgery and Anesthesia and Intensive Care Department, Instituto Clinico
Sant'Ambrogio, Milan, Italy.

OBJECTIVE: The purpose of this study was to evaluate the effect of 0.1 mug/kg/min
of fenoldopam mesylate on renal flow and central hemodynamics measured by
echocardiography in hemodynamically stable patients with preserved renal function
undergoing cardiac surgery. DESIGN: Experimental observational study. SETTING:
Single-institutional community hospital study. PARTICIPANTS: Thirty patients
undergoing cardiac surgery. INTERVENTION: Fenoldopam mesylate infusion (0.1
mug/kg/min) in patients undergoing cardiopulmonary bypass. MEASUREMENTS AND MAIN 
RESULTS: Doppler measurements of renal blood flow and echocardiographic
hemodynamic determinations after Doppler echocardiography measured flux
velocities of the main, segmental, and interlobar and interlobular right renal
arteries. The authors calculated the resistive index of all the renal segments
studied. Moreover, the authors measured the flux of the main renal artery and its
diameter as well as the main hemodynamic variables. All the measurements have
been performed in the intensive care unit setting at baseline and 20 minutes
after the infusion of 0.1 mug/kg/min of fenoldopam mesylate. Fenoldopam mesylate 
infusion significantly increased blood flow in all renal compartments, thus
improving the resistive index. The study shows that fenoldopam mesylate infusion 
does not induce any significant change of the heart rate or arterial pressure,
cardiac output, preload, or wall stress. CONCLUSIONS: In hemodynamically stable
cardiac surgery patients with preserved renal function, an infusion of 0.1
mug/kg/min of fenoldopam mesylate has no influence on systemic blood pressure
while increasing renal blood flow.

Eur J Cardiothorac Surg. 2009 Jun 17. [Epub ahead of print]

Early and late predictors of mortality following on-pump coronary artery bypass
graft surgery in the elderly as compared to a younger population.

Naughton C, Feneck RO, Roxburgh J.

Department of Cardiothoracic Surgery, Guys & St. Thomas Hospital NHS Foundation
Trust, London, UK.

Objective: To identify independent factors associated with early (30-day)
mortality and in surviving patients, identify factors for late (1-year) mortality
following primary coronary artery bypass graft (CABG) surgery and to test the
interaction with age. Methods: An analysis of a single centre's data contribution
to the Society for Cardiothoracic Surgery in Great Britain and Ireland database
was performed. Data on consecutive patients aged >/=75 years (n=659) and aged
60-74 years (n=3024) undergoing primary CABG surgery (1999-2005) were analysed.
One-year mortality data were collected using the Office of National Statistics
(ONS) tracking system. Factors associated with early and late mortality were
identified using Cox regression; hazard ratios (HRs) and 95% confidence intervals
(CIs) are presented. Results: The proportion of patients aged >/=75 years
increased by 10% over 5 years (2000-2005). One-year mortality in the elderly
showed a significant linear decrease from 15% to 7% (p=0.01) while mortality in
the younger cohort remained static at 2-4%. Early mortality in the elderly group 
was 5% compared to 1.8% in the younger group (p<0.001), while late mortality was 
4.1% vs 1.8%, respectively (p<0.001). Factors independently associated with early
mortality were age >/=75 years, HR 2.0 (95% CI 1.28, 3.11); female gender; angina
(CSS III-IV); and cardiopulmonary bypass duration >97minutes. Arrhythmia and
renal impairment were risk factors common in both early and late mortality models
common to both early and late mortality. Risk factors for late mortality also
included ventricular ejection fraction <30%, non-elective surgery and
arteriopathy. Age was not an independent risk factor for late mortality.
Conclusion: Mortality in elderly patients showed a substantial improvement, but
remained over twice that of younger patients. The difference in factors
associated with early and 1-year morality suggests the need for effective short- 
and long-term strategies, particularly in the management of chronic diseases such
as heart and renal failure.

Can J Cardiol. 2009 Jun;25(6):e179-86.

[Percutaneous extracorporeal life support in acute severe hemodynamic collapses: 
single centre experience in 100 consecutive patients]

[Article in French]

Vanzetto G, Akret C, Bach V, Barone G, Durand M, Chavanon O, Hacini R, Bouvaist
H, Machecourt J, Blin D.

Clinique Universitaire de Cardiologie, Grenoble, France.
gvanzetto@chu-grenoble.fr

BACKGROUND: Extracorporeal life support (ECLS) is a circulatory assistance device
that is increasingly used in adults undergoing cardiopulmonary arrest (CPA) or
hemodynamic collapse when conventional therapies fail. OBJECTIVES: To assess the 
feasibility and outcomes of 100 consecutive arteriovenous percutaneous ECLS
procedures at the Grenoble University Hospital between January 2002 and September
2007. METHODS: Monocentric descriptive registry with one-year prospective
follow-up. RESULTS: An ECLS device was successfully used in 93% of patients. Its 
indication was cardiogenic shock in 50% of the cases, CPA in 38% of the cases and
unsuccessful weaning of cardiopulmonary bypass (CPB) after cardiothoracic surgery
in 12% of the cases. Direct complications of ECLS were observed in 56% of
patients, the most frequent being hemorrhage at the intravenous puncture site
requiring red blood cell transfusions (26%), and lower limb ischemia (19%).
Weaning from ECLS was achieved in 33 patients (44% cardiogenic shocks, 13% CPAs, 
50% CPB weaning failures) and 20 patients were discharged from the hospital (26% 
cardiogenic shocks, 10.5% CPAs and 25% CPB weaning failures). All are still
living without any serious sequelae (mean follow-up period of 16.8 months).
CONCLUSION: The use of ECLS in CPA patients, especially with cardiogenic shock,
is feasible with satisfactory survival rates, given the extreme severity of their
initial state.

Blood. 2009 Jun 16. [Epub ahead of print]

Protamine sulphate downregulates thrombin generation by inhibiting factor V
activation.

Ni Ainle F, Preston RJ, Jenkins PV, Nel HJ, Johnson JA, Smith OP, White B, Fallon
PG, O'Donnell JS.

Haemostasis Research Group, Institute of Molecular Medicine, St James's Hospital,
Trinity College Dublin, Dublin, Ireland.

Protamine sulphate is a positively-charged polypeptide widely used to reverse
heparin-induced anticoagulation. Paradoxically, prospective randomized trials
have shown that protamine administration for heparin neutralization is associated
with increased bleeding, particularly following cardiothoracic surgery with
cardiopulmonary bypass. The molecular mechanism(s) through which protamine
mediates this anticoagulant effect have not been defined. In vivo administration 
of pharmacological doses of protamine to BALB/c mice significantly reduced plasma
thrombin generation and prolonged tail bleeding time (from 120 to 199 sec).
Similarly, in pooled normal human plasma, protamine caused significant
dose-dependent prolongations of both PT and APTT. Protamine also markedly
attenuated tissue-factor initiated thrombin generation in human plasma, causing a
significant decrease in endogenous thrombin potential (41+/-7%). As expected,
low-dose protamine effectively reversed the anticoagulant activity of
unfractionated heparin in plasma. However, elevated protamine concentrations were
associated with progressive dose-dependent reduction in thrombin generation. To
assess the mechanism by which protamine mediates down-regulation of thrombin
generation, the effect of protamine on factor V activation was assessed.
Protamine was found to significantly reduce the rate of FV activation by both
thrombin and factor Xa. Protamine mediates its anticoagulant activity in plasma
by down-regulation of thrombin generation via a novel mechanism, specifically
inhibition of factor V activation.

Eur J Anaesthesiol. 2009 Jun 12. [Epub ahead of print]

The effect of acute autologous blood transfusion on coagulation dysfunction after
cardiopulmonary bypass.

Zisman E, Eden A, Shenderey A, Meyer G, Balagula M, Ammar R, Pizov R.

aDepartments of Anesthesiology & Critical Care Medicine, Israel bCardiothoracic
Surgery, Carmel Lady Davis Medical Center, Israel cThe Technion-Israel Institute 
of Technology, Haifa, Israel.

OBJECTIVE: To evaluate the influence of acute autologous blood transfusion on
postcardiopulmonary bypass coagulation disturbances evaluated by
thromboelastography (TEG) as a point-of-care test. METHODS: This prospective
randomized controlled study included consecutive patients who underwent elective 
cardiac surgery with cardiopulmonary bypass. The patients in group A underwent
acute autologous blood transfusion with acute normovolemic haemodilution and
those in group H received homologous blood, if needed, and served as controls.
RESULTS: A total of 62 patients, from 68 enrolled, completed the study: 27 in
group A and 35 in group H. Both groups had similar prolongation of prothrombin
time and partial thromboplastin time, decreased platelets count and changes in
postoperative thromboelastographic variables. There were no differences between
them for postoperative bleeding, blood transfusions or haemoglobin values. There 
was significant prolongation of the R value of TEG (without heparinase) in both
groups at 4 h after surgery compared with the immediate postoperative values:
from 11.3 +/- 4.2 to 12.3 +/- 5.5 mm, P < 0.05 for group A and from 9.9 +/- 3.7
to 12.5 +/- 5.4 mm, P < 0.01 for group H. The R values of TEG with and without
heparinase differed significantly (P < 0.05) at 4 h postoperatively. CONCLUSION: 
Autologous blood transfusion of 15% estimated blood volume did not affect
postcardiopulmonary bypass coagulopathy, nor did it decrease blood loss or
homologous blood and its products transfusion in the early postoperative period. 
TEG is a valuable measure for detecting coagulation dysfunction with a potential 
role in the postoperative management of cardiac patients.

Med Princ Pract. 2009;18(4):300-4. Epub 2009 Jun 2.

Determinant factors of renal failure after coronary artery bypass grafting with
on-pump technique.

Ahmadi H, Karimi A, Davoodi S, Movahedi N, Marzban M, Abbasi K, Salehi Omran A,
Shirzad M, Abbasi SH, Tazik M.

Department of Cardiovascular Surgery, Medical Sciences, Tehran Heart Center,
University of Tehran, North Kargar Street, Tehran, Iran. dr.ahmadi2006@yahoo.com

OBJECTIVE: The aim of the present study was to investigate the determinant
factors of acute renal failure (ARF) after isolated on-pump coronary artery
bypass grafting (CABG). SUBJECTS AND METHODS: This was a retrospective study of
13,315 adult patients who underwent isolated CABG with cardiopulmonary bypass
(CPB) in Tehran Heart Center from May 2002 to May 2007. The exclusion criteria
were age <18, concomitant cardiac and/or noncardiac surgical operations, history 
of renal failure before surgery, and chronic renal failure requiring dialysis.
Preoperative and operative variables were measured, and a multivariate logistic
regression model was constructed to identify the independent risk factors for
developing renal failure after on-pump CABG. RESULTS: Of the 13,315 patients,
3,347 (25.4%) and 90,883 (74.6%) were females and males, respectively, with a
mean age of 58.63 +/- 9.48 years. ARF was detected in 85 (0.6%) of the patients
with isolated on-pump CABG. The mean age of the patients was 58.63 +/- 9.48
years, and 25.5% of them were female. The multivariate logistic regression
analysis identified age (OR = 1.035; p = 0.002), female gender (OR = 1.622; p =
0.037), history of peripheral vascular disease (PVD) (OR = 2.579; p = 0.042),
diabetes mellitus (OR = 1.918; p < 0.001), emergent and urgent surgery (OR =
1.744 and OR = 7.901, respectively; p = 0.003), CPB time >70 min (OR = 1.944; p =
0.007), and intra-aortic balloon pump (IABP) insertion (OR = 10.181; p < 0.001)
as the independent risk factors for ARF. CONCLUSION: The data showed that age,
female gender, positive history of diabetes and PVD, urgent and emergent surgery,
CPB time >70 min, and need for IABP were the independent determinant factors of
ARF after on-pump CABG. Copyright (c) 2009 S. Karger AG, Basel.

Ann Thorac Surg. 2009 Jun;87(6):1859-65.

Cardiopulmonary bypass increases postoperative glycemia and insulin consumption
after coronary surgery.

Knapik P, Nadziakiewicz P, Urbanska E, Saucha W, Herdynska M, Zembala M.

Department of Cardiac Anesthesia, Silesian Centre for Heart Diseases, Zabrze,
Poland. kardanest@sum.edu.pl

BACKGROUND: Perioperative hyperglycemia should be avoided in patients undergoing 
coronary surgery. The aim of our study was to find out what the influence of
cardiopulmonary bypass is on postoperative glycemia and insulin consumption in
patients with and without diabetes mellitus undergoing coronary artery surgery
and whether a marked hyperglycemia in the early postoperative period is among the
factors associated with early mortality and morbidity. METHODS: We
retrospectively reviewed all patients who underwent first-time coronary artery
surgery in our institution during the 11-month period. Among 814 patients, 239
patients (29.4%) had diabetes and 575 patients (70.6%) were nondiabetic. Blood
glucose levels were registered every 2 hours in all patients during the first 24 
postoperative hours. Outcomes were difficult glycemic control (postoperative
blood glucose levels >11.0 mmol/L despite aggressive insulin treatment), hospital
mortality, and morbidity (defined as any postoperative complication such as
stroke, renal failure, wound infection, perioperative myocardial infarction,
ventilation > 24 hours, sepsis, and multiorgan failure). RESULTS: Glycemic
control was significantly worse in patients who underwent coronary artery bypass 
grafting, in comparison with off-pump coronary artery bypass grafting surgery,
particularly in nondiabetic patients. Patients with difficult glycemic control
had more serious postoperative complications resulting in higher mortality (2.5% 
versus 0.4%; p = 0.02). In the multivariate analysis, difficult glycemic control 
was significantly associated with a female sex (odds ratio [OR], 2.36), presence 
of diabetes (OR, 2.22), and the usage of cardiopulmonary bypass (OR, 1.81).
Mortality was significantly associated with the left ventricular ejection
fraction less than 0.35 (OR, 7.38), difficult glycemic control (OR, 7.06), and
previous stroke (OR, 5.66). Difficult glycemic control was also significantly
associated with postoperative morbidity (OR, 1.87). CONCLUSIONS: Cardiopulmonary 
bypass increases postoperative glycemia and insulin consumption in both diabetic 
and nondiabetic patients. The use of cardiopulmonary bypass during coronary
artery surgery in diabetic women is associated with a more difficult glycemic
control in the early postoperative period. Difficult glycemic control is
significantly associated with early mortality and morbidity in patients
undergoing coronary artery surgery.