TOP TEN SELECTED PAPERS - November 2009

1

Artif Organs. 2009 Nov;33(11):993-1001.

Comparison of pumps and oxygenators with pulsatile and nonpulsatile modes in an
infant cardiopulmonary bypass model.

Haines NM, Wang S, Kunselman A, Myers JL, Undar A.

Pediatric Cardiac Research Laboratories, Department of Pediatrics, Hershey, PA
17033-0850, USA.

As the evidence mounts in favor of pulsatile perfusion during CPB, it is
necessary to investigate the effect of circuit components on the quality of
pulsatility delivered throughout the circuit. We compared two bloodpumps, the
Jostra HL-20 heart-lung machine and the MEDOS DELTASTREAM DP1 Bloodpump, and two 
oxygenators, the Capiox Baby RX05 and the MEDOS HILITE 800LT, in terms of mean
arterial pressure, energy equivalent pressure, surplus hemodynamic energy, total 
hemodynamic energy, and pressure drop over the oxygenators using a blood analog. 
The pumps and oxygenators were combined in unique circuits and tested in
nonpulsatile and pulsatile modes, at two flow rates (500 and 800 mL/min), and
three rotational speed differentials when using the MEDOS DELTASTREAM DP1
Bloodpump for 144 trials in total. The Jostra Roller pump produced some
pulsatility in nonpulsatile mode and better pulsatility in pulsatile mode than
the MEDOS DP1 Bloodpump at a rotational speed differential of 2500 rpm, but not
at 3500 or 4500 rpm. The MEDOS DP1 Bloodpump produced almost no pulsatility in
nonpulsatile mode. Pressure drops over the Capiox Baby RX05 were markedly higher,
at 92.5 +/- 0.4 mm Hg with the MEDOS DP1 Bloodpump at 800 mL/min and 4500 rpm in 
pulsatile mode, than those of the MEDOS HILITE 800LT oxygenator, which was 67.0
+/- 0.1 mm Hg at the same settings. These results suggest that careful selection 
of each circuit component, based on the individual clinical case and component
specifics, are necessary to achieve the best quality of pulsatility.

Artif Organs. 2009 Nov;33(11):909-14.

Perioperative monitoring of thromboelastograph on hemostasis and therapy for
cyanotic infants undergoing complex cardiac surgery.

Cui Y, Hei F, Long C, Feng Z, Zhao J, Yan F, Wang Y, Liu J.

Department of Cardiopulmonary Bypass, Cardiovascular Institute and Fuwai
Hospital, CAMS and PUMS, Beijing, China.

This study investigated features and treatments of perioperative coagulopathies
in cyanotic infants with complex congenital heart disease (CCHD). Thirty-six
infants with cyanotic CCHD were involved and divided into two groups: In group H 
(n = 20), hematocrit (HCT) > 54%, and in group L (n = 16), HCT < 54%. Blood was
sampled at anesthesia induction (T1), rewarming to 36 degrees C (T2), after
heparin neutralization (T3), and 4 h after operation (T4). The hemostatic changes
were evaluated by thromboelastograph (TEG). After surgery, group H was treated
with fibrinogen-combined platelets (PLT), while group L was treated with PLT
only. We observed the effect at T4. At T1, the hemostatic function in group H,
deteriorating with the increase of HCT (P < 0.01), was obviously lower than that 
in group L (P < 0.01), but the PLT function was still complete. In group H, the
hemostatic function at T2 decreased with a significant drop of PLT function (P < 
0.01) and had little change of functional fibrinogen (Ffg) (P > 0.05). At T3,
compared with T2, there were improvements in hemostatic function and Ffg (P <
0.01, respectively) without increase of PLT (P > 0.05) in group H. After therapy,
PLT function in both groups restored to T1 level (P > 0.05); Ffg at T4 was
significantly better than at T1 (P < 0.01) in group H, but Ffg at T4 with still
normal function was lower than at T1 in group L (P < 0.01). Whole hemostatic
function at T4 was back to normal and had no differences between two groups. So, 
we proposed that fibrinogen and PLT transfusion in combination should be better
for infants with high HCT CCHD, but PLT alone might be enough for low HCT ones.

Int J Artif Organs. 2009 Nov;32(11):802-10.

Clinical and biomaterial evaluation of a new condensed dual-function
extracorporeal circuit in reoperation for coronary artery bypass surgery.

Gunaydin S, McCusker K, Vijay V.

Department of Cardiovascular Surgery, University of Kirikkale, Kirikkale -
Turkey.

Purpose: This prospective, randomized study compared the clinical performance of 
three types of circuits: a newly introduced, fully-coated, interchangeable
open-closed circuit with a dual configuration (hard shell with a bypass shunt),
reduced length, and reduced prime of less than 800 cc (CondECC); a completely
coated circuit (ECC); and a similar uncoated, open circuit with standard length
and prime (CONT). Methods: 75 patients undergoing reoperation for coronary
revascularization were randomly allocated into three groups (N=25): Group 1:
CondECC with shortened tubing, components and an open-closed configuration of low
priming volume with a centrifugal pump and a shunt which bypassed the reservoir
for closed configuration; Group 2: ECC with a roller pump and hard-shell
reservoir; Group 3: CONT. Blood samples for CBC, inflammatory mediators
[Interleukin-2 (IL-2), Complement-3a (C3a)] and flow cytometry (CD11b/CD18) were 
collected after induction (T1) and heparin administration (T2), 15 min after
cardiopulmonary bypass (CPB) (T3), before cessation of CPB (T4), 15 min after
reversal (T5), and the first postoperative day (T6). Results: Leukocyte counts
demonstrated significant increases at T4, T5 in CONT but remained stable in ECC
and CondECC (p<0.05). Platelets were preserved better at T4, T5 in both ECC and
CondECC study groups (p<0.05). IL-2 and C3a levels were significantly lower at
T3, T4, T5 in CondECC and T4, T5 in ECC (p<0.05). Blood protein adsorption
analysis demonstrated increased amount of microalbumin on CONT fibers (p<0.05).
Conclusions: The CondECC is a flexible, dual-function, open/closed configuration 
system that was easy to use, safe and achieved better biocompatibility when
compared to coated and uncoated conventional circuits.

 Thorac Cardiovasc Surg. 2009 Dec;57(8):460-3.

The impact of pre- and postoperative renal dysfunction on outcome of patients
undergoing coronary artery bypass grafting (CABG).

Litmathe J, Kurt M, Feindt P, Gams E, Boeken U.

Department of Thoracic- and Cardiovascular Surgery, Heinrich-Heine University,
Duesseldorf, Germany. jens-litmathe@t-online.de

OBJECTIVE: Acute changes in renal function after elective coronary bypass surgery
represent a challenging clinical problem. In this study, we evaluated
perioperative risk factors for the development of postoperative renal dysfunction
(PRD), and the impact of such an event on the perioperative course. Additionally,
we investigated the influence of preoperatively mildly increased serum creatinine
on perioperative mortality and morbidity. METHODS: We retrospectively analyzed
data of 2511 patients undergoing isolated CABG between 2004 and 2007 with a
preoperative serum creatinine < or = 2.2 mg/dL. There were 592 patients with a
preoperative serum creatinine of between 1.4 and 2.2 mg/dl (mild renal
dysfunction group) and 1919 patients with a serum creatinine < 1.4 mg/dl.
Perioperative risk factors for PRD were analyzed by multivariate regression
analysis. RESULTS: Global in-hospital mortality was 3.1 %.The incidence of PRD
was 6.2 %. Mortality for patients who had PRD was 7.8 vs. 2.9 % for patients who 
did not ( P < 0.05). PRD increased the length of hospital stay by 3.7 days (12.2 
vs. 15.9; P < 0.05). Multivariate logistic regression identified the following
variables as independent predictors of PRD: age, angina class III/IV, diabetes
mellitus, prolonged cardiopulmonary bypass time, and preoperative serum
creatinine. With regard to preoperative renal function, we found that operative
mortality was higher in the mild renal dysfunction group (5.7 % vs. 2.5 %; P <
0.05). New dialysis/hemofiltration (5.1 % vs. 1.2 %; P < 0.05) and postoperative 
stroke (5.1 % vs. 1.6 %; P < 0.05) were also more common in these patients.
CONCLUSIONS: Mild renal dysfunction preoperatively is an important predictor of
outcome after CABG. In these patients, PRD dramatically increases mortality,
morbidity and length of hospital stay. Copyright Georg Thieme Verlag KG Stuttgart
. New York.

Anesth Analg.. [Epub ahead of print]

Impaired Autoregulation of Cerebral Blood Flow During Rewarming from Hypothermic 
Cardiopulmonary Bypass and Its Potential Association with Stroke.

Joshi B, Brady K, Lee J, Easley B, Panigrahi R, Smielewski P, Czosnyka M, Hogue
CW Jr.

From the *Department of Anesthesiology and Critical Care Medicine, The Johns
Hopkins University School of Medicine, Baltimore, Maryland; and.

Background: Patient rewarming after hypothermic cardiopulmonary bypass (CPB) has 
been linked to brain injury after cardiac surgery. In this study, we evaluated
whether cooling and then rewarming of body temperature during CPB in adult
patients is associated with alterations in cerebral blood flow (CBF)-blood
pressure autoregulation. Methods: One hundred twenty-seven adult patients
undergoing CPB during cardiac surgery had transcranial Doppler monitoring of the 
right and left middle cerebral artery blood flow velocity. Eleven patients
undergoing CPB who had arterial inflow maintained at >35 degrees C served as
controls. The mean velocity index (Mx) was calculated as a moving, linear
correlation coefficient between slow waves of middle cerebral artery blood flow
velocity and mean arterial blood pressure. Intact CBF-blood pressure
autoregulation is associated with an Mx that approaches 0. Impaired
autoregulation results in an increasing Mx approaching 1.0. Comparisons of
time-averaged Mx values were made between the following periods: before CPB
(baseline), during the cooling and rewarming phases of CPB, and after CPB. The
number of patients in each phase of CPB with an Mx >4.0, indicative of impaired
CBF autoregulation, was determined. Results: During cooling, Mx (left, 0.29 +/-
0.18; right, 0.28 +/- 0.18 [mean +/- sd]) was greater than that at baseline
(left, 0.17 +/- 0.21; right, 0.17 +/- 0.20; P /=0.4
during the cooling phase of CPB and 68 (53%) had an average Mx >/=0.4 during
rewarming. Nine of the 11 warm controls had an average Mx >/=0.4 during the
entire CPB period. There were 7 strokes and 1 TIA after surgery. All strokes were
in patients with Mx >/= 0.4 during rewarming (P = 0.015). The unadjusted odds
ratio for any neurologic event (stroke or transient ischemic attack) for patients
with Mx >/= 0.4 during rewarming was 6.57 (95% confidence interval, 0.79 to 55.0,
P < 0.08). Conclusions: Hypothermic CPB is associated with abnormal CBF-blood
pressure autoregulation that is worsened with rewarming. We found a high rate of 
strokes in patients with evidence of impaired CBF autoregulation. Whether a
pressure-passive CBF state during rewarming is associated with risk for ischemic 
brain injury requires further investigation.

J Clin Anesth. 2009 Nov;21(7):502-7.

Aprotinin use during cardiac surgery: recent alterations and effects on blood
product utilization.

Strouch ZY, Drum ML, Chaney MA.

Department of Anesthesia and Critical Care, University of Chicago Medical Center,
Chicago, IL 60637, USA.

OBJECTIVE: To investigate a single institution's changing use of aprotinin and
subsequent effects on intraoperative blood product utilization (red blood
cells/fresh frozen plasma) and postoperative clinical bleeding requiring
reoperation. DESIGN: Retrospective study. SETTING: Single university institution 
(University of Chicago). MEASUREMENTS: Data from 499 adult patients undergoing
cardiac surgery requiring cardiopulmonary bypass (CPB) over a two-year period
(February 2005 - January 2007) were reviewed. The first 12 months (Feb 2005 - Jan
2006, Group 2005-2006) of data were compared with that from the second 12-month
period (Feb 2006 - Jan 2007, Group 2006-2007). Information regarding patient
demographics, surgical procedures, aprotinin use (none, half-dose, full-dose),
and blood product use during CPB was retrospectively retrieved and analyzed. MAIN
RESULTS: When Group 2006-2007 data was compared with that from Group 2005-2006,
full-dose aprotinin use had significantly decreased (58% to 17%, P < 0.001),
non-use of aprotinin significantly increased (18% to 47%, P < 0.001), while fresh
frozen plasma (FFP) utilization during CPB significantly increased (24% to 36%, P
= 0.004). Red blood cell (RBC) transfusion rates remained stable (67% - 69%) yet 
rates of RBC and FFP transfusion during CPB significantly increased (23% to 34%, 
P = 0.003). There was also a trend toward increased unplanned reoperations for
excessive clinical bleeding (0 pts in Group 2005-2006, three pts in Group
2006-2007). CONCLUSIONS: As the institution's use of high-dose aprotinin has
significantly decreased, the number of patients requiring FFP and FFP/RBC
combinations during CPB has significantly increased. Furthermore, a trend toward 
increasing incidence of unplanned reoperations for excessive clinical bleeding
was noted.

Transfusion.. [Epub ahead of print]

Prolonged elevation of plasma argatroban in a cardiac transplant patient with a
suspected history of heparin-induced thrombocytopenia with thrombosis.

Genzen JR, Fareed J, Hoppensteadt D, Kurup V, Barash P, Coady M, Wu YY.

From the Department of Laboratory Medicine, the Department of Anesthesiology, and
the Department of Surgery, Cardiothoracic, Yale University School of Medicine,
New Haven, Connecticut; Loyola University Chicago, Thrombosis and Hemostasis
Research Laboratories, Loyola University Medical Center, Maywood, Illinois; Brown
University School of Medicine, Cardiac Surgery, University Cardiovascular
Associates, Rhode Island Hospital, Providence, Rhode Island; and the Department
of Pathology and Laboratory Medicine, Weill Cornell Medical College, New
York-Presbyterian Hospital, New York, New York.

BACKGROUND: Direct thrombin inhibitors (DTIs) provide an alternative method of
anticoagulation for patients with a history of heparin-induced thrombocytopenia
(HIT) or HIT with thrombosis (HITT) undergoing cardiopulmonary bypass (CPB). In
the following report, a 65-year-old critically ill patient with a suspected
history of HITT was administered argatroban for anticoagulation on bypass during 
heart transplantation. The patient required massive transfusion support (55 units
of red blood cells, 42 units of fresh-frozen plasma, 40 units of cryoprecipitate,
40 units of platelets, and three doses of recombinant Factor VIIa) for severe
intraoperative and postoperative bleeding. STUDY DESIGN AND METHODS: Plasma
samples from before and after CPB were analyzed postoperatively for argatroban
concentration using a modified ecarin clotting time (ECT) assay. RESULTS:
Unexpectedly high concentrations of argatroban were measured in these samples
(range, 0-32 microg/mL), and a prolonged plasma argatroban half life (t(1/2)) of 
514 minutes was observed (published elimination t(1/2) is 39-51 minutes [

Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2009 Nov;34(11):1126-31.

[Protective effect of aminophylline on cerebral injury during cardiopulmonary
bypass in infants.]

[Article in Chinese]

Pan S, Lin G, Jiang H, Huang R.

Department of Thoracic Surgery, Fuzhou Pulmonary Hospital, Fuzhou Fujian
350000,China.

Objective To investigate the protective effect of aminophylline on cerebral
injury induced by cardiopulmonary bypass (CPB) in infants.Methods Forty patients 
who underwent ventricular septal defect within 3 years old were randomly divided 
into 2 groups(20 cases in each group).Aminophylline group:aminophylline (5 mg/kg)
was injected slowly via the vein after anesthesia and maintained at a dose of 0.5
mg/(kg.h) until the end of CPB. Control group:aminophylline was replaced by
Ringer's lactated solution. Samples were obtained at the beginning of CPB
(T(1)),the end of CPB (T(2)),6 h (T(3)) and 24 h (T(4)) after the operation to
measure S-100 beta protein, NSE, tumor necrosis factor-alpha (TNF-alpha),
interleukin-8 (IL-8), and interleukin-10 (IL-10) concentration by ELISA in the 2 
groups.Results Compared with the time point immediately before CPB, the S-100beta
protein,NSE, TNF-alpha, and IL-8 concentration in the 2 groups began to increase 
with the start of CPB, reached a climax at the end of CPB (T(2)),decreased
gradually 6 h after the termination of CPB(T(3)) and could not restore to the
level before CPB at T(4)(24 h after the termination of CPB).IL-10 in the 2 groups
both increased after the CPB. At T(2) and T(3), S-100beta protein,NSE, TNF-alpha,
and IL-8 concentrations were significantly lower than those in the aminophylline 
group (P<0.05 or P<0.01), while IL-10 was just the opposite. Conclusion There is 
cerebral damage induced by CPB. Aminophylline may play a protective role in
cerebral injury by modulating the balance between the pro-inflammatory factor and
anti-inflammatory factor to reduce the level of S-100beta protein and NSE during 
CPB and open cardiac surgeries.

Int J Obstet Anesth. 2009 Nov 26. [Epub ahead of print]

Anesthetic management for resection of cor triatriatum during the second
trimester of pregnancy.

Bai W, Kaushal S, Malviya S, Griffith K, Ohye RG.

Department of Anesthesiology.

Hemodynamic changes during pregnancy can result in cardiovascular decompensation 
in women with pre-existing cardiac diseases. Despite optimized medical treatment,
some patients with severe structural cardiac abnormalities may need surgical
intervention during pregnancy. We describe a woman who presented at 20 weeks of
gestation with acute heart failure due to cor triatriatum, a rare form of
congenital heart disease. This condition is characterized by a perforated
fibromuscular membrane dividing the left atrium into two chambers. The clinical
presentation varies from asymptomatic to acute heart failure depending on the
size of the fenestrations in the membrane and the presence of associated cardiac 
malformations. In our patient, two severely restrictive orifices in a membrane
within the left atrium, moderate to severe pulmonary hypertension and good
biventricular function were demonstrated by transthoracic echocardiography.
Without surgical resection, the increased blood volume and cardiac output
associated with pregnancy could have resulted in cardiovascular decompensation.
She underwent urgent corrective open heart surgery with cardiopulmonary bypass.
Perioperative anesthetic management included prevention of tachycardia, atrial
dysrhythmias and pulmonary hypertension, close monitoring for and prompt
treatment of maternal hypotension, maintaining euvolemia and good cardiac
contractility and avoiding hemodilution and hypothermia. These approaches,
together with minimizing bypass time, resulted in successful maternal and fetal
outcome.

Perfusion.. [Epub ahead of print]

Safe time limits of aortic cross-clamping and cardiopulmonary bypass in adult
cardiac surgery.

Nissinen J, Biancari F, Wistbacka JO, Peltola T, Loponen P, Tarkiainen P,
Virkkilä M, Tarkka M.

Department of Thoracic and Vascular Surgery, Vaasa Central Hospital, Vaasa,
Finland.

Objectives: We evaluated the impact of aortic cross-clamping time (XCT) and
cardiopulmonary bypass time (CPBT) on the immediate and late outcome after adult 
cardiac surgery and attempted to identify their safe time limits. METHODS: This
study includes 3280 patients who underwent adult cardiac surgery of various
complexities. Myocardial protection was achieved with tepid continuous
antegrade/retrograde blood cardioplegia. RESULTS: Receiver operating
characteristics (ROC) curve analysis showed that XCT (area under the curve, AUC: 
0.66), CPBT (AUC: 0.73) and CPBT with unclamped aorta (AUC: 0.77) were
significantly associated with 30-day postoperative mortality. XCT of increasing
30-minute intervals (Odds Ratio (OR) 1.21, 95%%C.I. 1.01-1.52) and CPBT of
increasing 30-minute intervals (OR 1.47, 95%C.I. 1.27-1.71) were independent
predictors of 30-day mortality. The best cutoff value for XCT was 150 min (30-day
death: 1.8% vs. 12.2%, adjusted OR 3.07, 95%C.I. 1.48-6.39, accuracy 91.5%) and
for CPBT 240 min (30-day death: 1.9% vs. 31.5%, adjusted OR 8.78, 95%C.I.
4.64-16.61, accuracy 96.0%). These parameters were significantly associated also 
with postoperative morbidity, particularly with postoperative stroke.
CONCLUSIONS: XCT and CPBT are predictors of immediate postoperative morbidity and
mortality. In our experience, cardiac procedures with CPBT<240 min and XCT<150
min were associated with a rather low risk of immediate postoperative adverse
events independently of the complexity of surgery patient's operative risk.