TOP TEN SELECTED PAPERS - December 2008

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J Thorac Cardiovasc Surg. 2008 Dec;136(6):1541-8. Epub 2008 Aug 15.

Effect of rosuvastatin pretreatment on myocardial damage after coronary surgery: 
A randomized trial.

Mannacio VA, Iorio D, De Amicis V, Di Lello F, Musumeci F.

Department of Cardiac Surgery, University of Naples Federico II, Naples, Italy.

OBJECTIVE: Myocardial disease without evidence of myocardial infarction is a
frequent complication after cardiac surgery during cardiopulmonary bypass.
Statins might be protective, but their efficacy has not been established in
randomized trials. METHODS: Two hundred patients undergoing coronary surgery were
enrolled. They were randomized to rosuvastatin (20 mg/d, n = 100) or placebo (n =
100) starting 1 week before the operation. Troponin I, myoglobin, creatine
kinase-MB mass, and high-sensitivity C-reactive protein were used as markers of
myocardial injury, and their values were determined at baseline and at regular
intervals after the operation. Electrocardiography and echocardiography were
performed before and after the operation. RESULTS: Myocardial disease was
diagnosed when troponin I, myoglobin, and creatine kinase-MB mass values were
above the upper normal limit without evidence of electrocardiographic changes,
echocardiographic changes, or both. The percentages of marker level increase
indicative of myocardial disease were determined in the placebo versus statin
groups and were as follows: troponin I, 35% versus 65% (P < .0001); myoglobin,
39% versus 72% (P < .0001); creatine kinase-MB mass, 22% versus 40% (P = .0002). 
Peak postoperative values of troponin I (0.16 +/- 0.15 vs 0.32 +/- 0.26 ng/mL, P 
= .0008), myoglobin (72.25 +/- 25 vs 98.31 +/- 31 ng/mL, P < .0001), and creatine
kinase-MB mass (3.9 +/- 3.3 vs 9.3 +/- 8.1 ng/mL, P < .0001) were significantly
higher in the placebo group. High-sensitivity C-reactive protein values were
increased in 58% of pretreated versus 88% of the control patients (15.4 +/- 2.5
vs 17.2 +/- 3.4 mg/L, P < .0001). In high-risk patients myocardial disease was
observed more frequently but significantly less in statin-pretreated patients.
CONCLUSIONS: Statin pretreatment reduces myocardial damage after coronary surgery
and could improve both short- and long-term results.

J Thorac Cardiovasc Surg. 2008 Dec;136(6):1450-5. Epub 2008 May 19.

The myocardial protective effects of a moderate-potassium adenosine-lidocaine
cardioplegia in pediatric cardiac surgery.

Jin ZX, Zhang SL, Wang XM, Bi SH, Xin M, Zhou JJ, Cui Q, Duan WX, Wang HB, Yi DH.

Institute of Cardiovascular Surgery, Xijing Hospital, the Fourth Military Medical
University, Xi'an, China.

OBJECTIVES: We sought to evaluate a moderate-potassium cardioplegic solution
using adenosine and lidocaine as the arresting and protecting cardioprotective
combination in pediatric cardiac surgery. METHODS: One hundred thirty-four
patients with congenital heart disease were randomly allocated to one of 3 groups
according to the cardioplegia formula used: the high-potassium (HP) group (K(+), 
20 mmol/L), 46 patients; the high-potassium adenosine-lidocaine (HPAL) group
(K(+), 20 mmol/L; adenosine, 0.7 mmol/L; and lidocaine, 0.7 mmol/L), 44 patients;
and the moderate-potassium adenosine-lidocaine (MPAL) group (K(+), 10 mmol/L;
adenosine, 0.7 mmol/L; and lidocaine, 0.7 mmol/L), 44 patients. Hemodynamic data 
during the operation and postoperative data were recorded. Serum cardiac troponin
I concentrations were examined at the time points of before cardiopulmonary
bypass and 1, 3, 6, 12, and 24 hours after aortic crossclamp removal. RESULTS: At
the end of cardiopulmonary bypass and modified ultrafiltration, the systolic and 
pulse pressures of the MPAL group were significantly increased compared with the 
respective values of the HP group. At the time points of 1 to 12 hours after
reperfusion, the levels of serum cardiac troponin I were significantly decreased 
in the MPAL group compared with those in the HP and HPAL groups. CONCLUSIONS: The
MPAL cardioplegia formula was associated with better myocardial protective
effects.

Crit Care Med. 2009 Jan;37(1):39-47.

Sodium bicarbonate to prevent increases in serum creatinine after cardiac
surgery: a pilot double-blind, randomized controlled trial.

Haase M, Haase-Fielitz A, Bellomo R, Devarajan P, Story D, Matalanis G, Reade MC,
Bagshaw SM, Seevanayagam N, Seevanayagam S, Doolan L, Buxton B, Dragun D.

Department of Nephrology and Intensive Care, Charité University Medicine,
Potsdam, Germany.

OBJECTIVE: To test whether perioperative sodium bicarbonate infusion can
attenuate postoperative increases in serum creatinine in cardiac surgical
patients. DESIGN: Double-blind, randomized controlled trial. SETTING: Operating
rooms and intensive care unit at a tertiary hospital. PATIENTS: Cohort of 100
cardiac surgical patients at increased risk of postoperative acute renal
dysfunction. INTERVENTION: Patients were randomized to either 24 hrs of
intravenous infusion of sodium bicarbonate (4 mmol/kg) or sodium chloride (4
mmol/kg). MEASUREMENTS AND MAIN RESULTS: The primary outcome measure was the
proportion of patients developing acute renal dysfunction defined as a
postoperative increase in plasma creatinine concentration >25% of baseline within
the first five postoperative days. Secondary outcomes included changes in plasma 
creatinine, plasma urea, urinary neutrophil gelatinase-associated lipocalin, and 
urinary neutrophil gelatinase-associated lipocalin/urinary creatinine ratio.
Patients were well balanced for baseline characteristics. Sodium bicarbonate
infusion increased plasma bicarbonate concentration (p < 0.001), base excess (p <
0.001), plasma pH (p < 0.001), and urine pH (p < 0.001). Fewer patients in the
sodium bicarbonate group (16 of 50) developed a postoperative increase in serum
creatinine compared with control (26 of 50) (odds ratio 0.43 [95% confidence
interval 0.19-0.98]), (p = 0.043). The increase in plasma creatinine, plasma
urea, urinary neutrophil gelatinase-associated lipocalin, and urinary neutrophil 
gelatinase-associated lipocalin/urinary creatinine ratio was less in patients
receiving sodium bicarbonate, (p = 0.014; p = 0.047; p = 0.009; p = 0.004). There
were no significant side effects. CONCLUSIONS: Sodium bicarbonate loading and
continuous infusion was associated with a lower incidence of acute renal
dysfunction in cardiac surgical patients undergoing cardiopulmonary bypass. The
findings of this pilot study justify further investigation. (ClinicalTrials.gov, 
NCT00334191).

Inflamm Res. 2008 Dec;57(12):577-85.

Leukocyte depletion during cardiac surgery with extracorporeal circulation in
high risk patients.

Bakhtiary F, Moritz A, Kleine P, Dzemali O, Simon A, Ackermann H, Martens S.

Department of Thoracic & Cardiovascular Surgery, Johann Wolfgang Goethe
University Hospital, 60596, Frankfurt/Main, Germany, farhad@bakhtiary.de.

BACKGROUND: Cardiopulmonary bypass is associated with systemic inflammation that 
may contribute to increased perioperative mortality. Depletion of circulating
leukocytes may reduce the inflammatory response. We studied the effect of a
leukocyte depleting filter on leukocyte activation during cardiopulmonary bypass 
in high risk patients.METHODS: Fifty patients undergoing coronary artery bypass
grafting with a preoperative high risk were randomly placed in an arterial line
leukocyte filter group (n = 25) with a leukocyte depleting filter. Blood sampling
took place from the arterial line to analyze polymorphnuclear elastase and
myeloperoxidase at six time points, including: A) before the induction of
anesthesia, B) before the induction of the cardiopulmonary bypass C) 1 min after 
the release of the aorta clamp, D) the end of the operation, E) 1 h
postoperative, and F) 24 h postoperative.RESULTS: Levels of polymorphonuclear
elastase, (PMNE), and myeloperoxidase (MPO) were found to be higher after the
release of the aortic cross clamp in the leukocyte filter group; these levels
remained elevated until 24 hours after surgery and were high in comparison to
preoperative baseline levels. The differences in PMNE between both groups at time
points C and D (p < 0.005) and E (p < 0.05) were statistically significant. The
serum levels of the S-100B and neuron specific enolase (NSE) were found to be
elevated between time points C and E in both groups without statistical
significance. The in-hospital mortality was 16% (4 patients) in leukocyte filter 
group and 4% in control group (1 patient).CONCLUSIONS: Interestingly, the
activation of neutrophils was more pronounced in the LF group. The use of a
leucocyte depleting filter was not advantageous for this patient cohort for
clinical or biomedical endpoints.

Anadolu Kardiyol Derg. 2008 Dec;8(6):437-43.

The effects of low dose N-acetylcysteine (NAC) as an adjunct to cardioplegia in
coronary artery bypass surgery.

Köksal H, Rahman A, Burma O, Halifeoglu I, Bayar MK.

Clinic of Cardiovascular Surgery, Sivas Numune Hospital, Sivas, Turkey.
hkoksalgkdc@yahoo.com

OBJECTIVE: We aimed to evaluate the efficacy of low dose N-acetylcysteine (NAC)
against myocardial ischemia-reperfusion damage in coronary artery bypass surgery 
accompanied by cardiopulmonary bypass (CPB). METHODS: Thirty patients operated
due to triple coronary artery disease were enrolled into this prospective
randomized study (control group -n=15 and NAC group - n=15). N-acetylcysteine was
added to induction cardioplegia solution in dose of 4 mmol/l and in dose of 2
mmol/l to maintenance cardioplegia solution in the NAC group. Hemodynamic
measurements were performed before and after anesthesia with different intervals.
Creatine kinase-MB (CK-MB) levels were analyzed during 24 hours postoperatively. 
Blood samples were obtained from coronary sinus before CPB (T1), just before the 
cross-clamp removed (T2) and 30 minutes later (T3). Malondialdehyde (MDA),
glutathione peroxidase (GSH-Px), nitric oxide (NO) levels and neutrophil
percentage were determined. Statistical analysis was performed using student's t 
test, Chi-square and two-way ANOVA tests. RESULTS: There were no significant
differences between the two groups with regard to the hemodynamic parameters, and
CK-MB levels. The MDA levels were significantly lower in NAC group than in
control group during reperfusion period (0.75 nmol/l vs 0.88 nmol/l, p<0.05).
Neutrophil percentage in coronary sinus blood was significantly lower in NAC
group than in control group during the reperfusion period (77.6% vs 82.7%,
p<0.05). The GSH-Px and NO levels were also not statistically different between
groups. CONCLUSION: Low dose NAC as an adjunct to cardioplegic solutions
effectively reduces myocardial oxidative stress in coronary bypass surgery with
cardiopulmonary bypass, but may not restore the myocardial injury.

Chin Med J (Engl). 2008 Dec 5;121(23):2397-402.

Is the use of cardiopulmonary bypass for isolated coronary artery bypass an
independent predictor of mortality and morbidity in patients with severe left
ventricular dysfunction?

Qiu ZB, Chen X, Xu M, Shi KH, Jiang YS, Xiao LQ.

Department of Cardiothoracic Surgery, Nanjing First Hospital Affiliated to
Nanjing Medical University, Nanjing Heart Institute, Nanjing, Jiangsu 210006,
China. qiuzhibingjs@yahoo.com.cn

BACKGROUND: Patients presenting with severe left ventricular dysfunction (SLVD)
undergoing conventional coronary artery bypass grafting (CCABG) are at an
increased risk of perioperative mortality and morbidity. The aim of this study
was to assess the risk factors responsible for mortality and morbidity among
patients with SLVD by comparing CCABG and off-pump coronary artery bypass surgery
(OPCAB). METHODS: We retrospectively evaluated 186 consecutive patients with SLVD
who underwent coronary artery bypass grafting (CABG), including 102 by CCABG and 
84 by OPCAB. Registry database, medical notes, and charts were studied for
preoperative and postoperative data of the patients. Different variables and risk
factors (preoperative, intraoperative, and postoperative) were evaluated and
compared. The morbidity and mortality outcomes were compared in the two groups.
The follow-up results and quality of life were assessed after surgery. RESULTS:
The two groups had similar percentage of patients with preoperative high-risk
profiles and no significant differences were found between groups in baseline
variables such as age or comorbidities. There was a significant difference in the
number of grafts used between the two groups. CCABG patients received (3.6 +/-
0.5) grafts per patient, while OPCAB patients had (2.7 +/- 0.6) grafts (P <
0.05). Completeness of revascularization was also significantly different between
the two groups (CCABG 91.1% vs OPCAB 73.8%, P < 0.05). The hospital mortality was
similar in the two groups (4.8% in OPCAB vs 5.9% in CCABG). The risk-adjusted
mortality, according to the calculated propensity score, did not reach
statistical significance in the two groups. In this study, OPCAB seemed to have a
beneficial effect on reducing reoperation for bleeding, blood transfusion
requirement, and the length of stay at ICU. But the incidence of perioperative
myocardial infarction was more common in the off-pump group (P < 0.05). The
degree of improvement in angina and quality of life did not differ significantly 
between the two groups. CONCLUSIONS: Using cardiopulmonary bypass is not an
independent predictor of mortality and morbidity in patients with SLVD. Isolated 
CABG can be safely performed in SLVD patients with acceptable postoperative
morbidity and mortality in addition to encouraging home discharge rates and
higher quality of life. Therefore, CCABG remains a viable option in selected
patients with SLVD.

Physiol Res. 2008 Dec 17. [Epub ahead of print]

Plasma prohepcidin as a negative acute phase reactant after large cardiac surgery
with a deep hypothermic circulatory arrest.

Maruna P, Lindner J, Kunštýr J, Kubzová K, Hubácek J.

Institute of Pathological Physiology of the First Faculty of Medicine UK, Prague,
Czech Republic. maruna@lf1.cuni.cz.

Hepcidin is a key regulator of iron metabolism and a mediator of anemia of
inflammation. Recent studies in vitro recognized prohepcidin as a type II acute
phase protein regulating via interleukin-6. The aim of the present study was to
investigate the time course of plasma prohepcidin after a large cardiac surgery
in relation to IL-6 and other inflammatory parameters. Patients with chronic
thromboembolic hypertension (n=22, males/females 14/8, age 51.9 +/- 10.2 yr.)
underwent pulmonary endarterectomy using cardiopulmonary bypass and deep
hypothermic circulatory arrest were included into study. Prohepcidin, IL-1beta,
IL-6, IL-8, tumor necrosis factor-alpha, and C-reactive protein arterial
concentrations were measured before/after sternotomy, last circulatory arrest,
separation from bypass, then 12, 18, 24, 36, 48 h and 72 h after the separation
from bypass. Hemodynamic parameters, hematocrit and markers of iron metabolism
were followed up. Pulmonary endarterectomy induced a 48 % fall in plasma
prohepcidin; minimal concentrations were detected after separation from
cardiopulmonary bypass. Prohepcidin decline correlated with an extracorporeal
circulation time (p < 0.01), while elevated IL-6 levels were inversely associated
with duration of prohepcidin decline. Postoperative prohepcidin did not correlate
with markers of iron metabolism or hemoglobin concentrations within a 72-hour
period after separation from CPB. Prohepcidin showed itself as a negative acute
phase reactant during systemic inflammatory response syndrome associated with a
cardiac surgery. Results indicate that the evolution of prohepcidin in
postoperative period implies the antagonism of stimulatory effect of IL-6 and
contraregulatory factors inhibiting prohepcidin synthesis or increasing
prohepcidin clearance.

J Endovasc Ther. 2008 Dec;15(6):639-42.

Bailout percutaneous external shunt to restore carotid flow in a patient with
acute type a aortic dissection and carotid occlusion.

Schönholz C, Ikonomidis JS, Hannegan C, Mendaro E.

Purpose: diamond To report the use of an external common femoral to carotid
artery shunt in the setting of acute type A aortic dissection associated with
carotid occlusion and stroke. Technique: diamond The procedure is illustrated in 
a 52-year-old man who presented with a type A dissection extending into the
innominate trunk, with associated occlusion of the right common carotid artery
(CCA). Angiography showed no collateral circulation to the right cerebral
hemisphere. To re-establish brain perfusion in this setting, a percutaneous
external shunt was installed from the common femoral artery to the right CCA. The
5-F femoral sheath used during diagnostic angiography was replaced by an 8-F
femoral introducer securely fixed to the skin with silk sutures.
Ultrasound-guided percutaneous CCA access was obtained using an 18-G needle and a
6-F introducer, also sutured to the skin. The ICA and intracranial branches
showed no evidence of thrombosis at this level. A plastic tube was used to
connect the femoral and carotid sheath side arms to restore ICA flow.
Transcranial Doppler showed normal flow at the right middle cerebral artery after
shunt placement. The patient was immediately transferred to the operating room
for aortic surgery, during which an intrapericardially ruptured aorta was found. 
The ascending aorta and proximal arch were replaced under cardiopulmonary bypass 
and circulatory arrest, but the patient died during the procedure due to
uncontrolled bleeding. Conclusion: diamond A temporary percutaneous external
femoral-carotid shunt can restore blood flow to the brain whenever the carotid
artery is occluded by the dissection flap and adequate collateral flow is absent.

Pediatr Cardiol. 2008 Dec 16. [Epub ahead of print]

Inflammatory Response and Neurodevelopmental Outcome After Open-Heart Surgery in 
Children.

Gessler P, Schmitt B, Prètre R, Latal B.

Division of Pediatric Intensive Care Medicine, University Children's Hospital of 
Zurich, 8032, Zurich, Switzerland, peter.gessler@klinikum-konstanz.de.

Long-term neurodevelopmental sequelae are commonly detectable in children after
open-heart surgery with cardiopulmonary bypass (CPB). The objective of the study 
was to determine the neurodevelopmental outcome in these children in relation to 
postoperative inflammatory reaction. This is a prospective, observational study
on children with congenital heart defects (n = 32) undergoing elective open-heart
surgery in a tertiary pediatric cardiac center. Neurodevelopmental outcome was
assessed in the median 6 months after CPB. Neurological examination was done in
all children before the operation and, additionally, complete neurodevelopmental 
status was assessed preoperatively in 14 children. Three hours after the end of
CPB, plasma concentrations of interleukin (IL)-6 and IL-8 were strongly elevated 
(p < 0.001). Moreover, there was a rise of neutrophils and C-reactive protein at 
24 h postoperatively (p < 0.001). Intellectual performance after surgery was
correlated with preoperative performance, r ( S ) = 0.83, p < 0.001 (mean IQ
scores after CPB = 90.4 +/- 18.4 and before CPB = 87.5 +/- 14.5, p = 0.20).
Multiple regression analysis demonstrated that preoperative IQ scores accounted
for 83.8% of the variance of postoperative IQ scores (p < 0.0001). Inflammatory
variables were not significant predictors of postoperative IQ scores. The
frequency of neuromotor abnormalities at 6 months after CPB was influenced by the
presence of a cyanotic heart defect, duration of CPB and aortic clamp time, and
plasma levels of IL-6 shortly after CPB (R (2) = 67.8%, p = 0.002). In
conclusion, in the examined population, preexisting neurodevelopmental impairment
is frequent and predicts postoperative outcome. The high frequency of
postoperative neuromotor disabilities seems to be associated with the type of
congenital heart defect but also with the procedure and possible complications of
CPB.

Pediatr Cardiol. 2008 Dec 16. [Epub ahead of print]

Prostaglandin E2 After Septostomy for Simple Transposition.

Beattie LM, McLeod KA.

Department of Cardiology, The Royal Hospital for Sick Children, Dalnair Street,
Yorkhill, Glasgow, G3 8SJ, UK, lynne_beattie@hotmail.com.

In simple transposition of the great arteries (sTGA), balloon atrial septostomy
is performed prior to arterial switch to improve mixing of systemic and pulmonary
circulations. Following septostomy, some patients are also given prostaglandin E2
(PGE2) until surgical repair. The aims of our study were to identify how often
PGE2 is given after septostomy, the indications for starting PGE2, and the effect
this has on postoperative outcome. The study was a retrospective review of
infants born with sTGA between 2000 and 2005, who underwent arterial switch at
Yorkhill Children's Hospital, Glasgow. Over a 5-year period, 26 infants (16 male)
with sTGA underwent septostomy. There was a significant rise in mean oxygen
saturation following septostomy (mean, 61.4 +/- 11.5% before, 81.5 +/- 9.4%
after; p < 0.05). Four of 26 (15%) did not receive PGE2 at all (group 1) and 8 of
26 (30%) received PGE2 before but not after septostomy (group 2). A total of 14
of 26 infants (54%) were given PGE2 following septostomy. This comprised 11 who
received PGE2 before and after septostomy (group 3) and 3 who did not receive
PGE2 prior to septostomy but did after (group 4). Groups 2 and 3 were compared
directly, as they both received PGE2 before septostomy. In group 3, oxygen
saturations were lower when PGE2 was started compared with saturations
immediately after septostomy (45 +/- 23.6% vs. 80 +/- 10.3%; p < 0.05). Groups 2 
and 3 showed no difference in atrial gap after septostomy (9.4 +/- 3 vs. 8 +/- 1 
mm; p > 0.05). Fifty percent of infants in group 3 underwent echocardiography
prior to restarting PGE2, which revealed a patent arterial duct in all but one
patient. Despite PGE2, Group 3 had lower saturations at arterial switch compared 
with Group 2 (71 +/- 14% vs. 82 +/- 8%; p < 0.05). No difference was observed
between group 2 and group 3 with regard to length of cardiopulmonary bypass
(group 2, 173 +/- 101.4 min, vs. group 3, 157.9 +/- 42.1 min; p > 0.05). However,
the Intensive Care Unit stay was longer for patients who received PGE2 following 
septostomy (8.5 +/- 10.3 vs. 5 +/- 0.93 days; p < 0.05). Total postoperative stay
was also longer for infants who received PGE2 after septostomy (26.8 +/- 14.3 vs.
16.8 +/- 6.3 days; p < 0.05). In conclusion, the use of pulse oximetry has led to
an increase in the administration of PGE2 after septostomy. PGE2 administration
was associated with a longer ICU stay. The association between administration of 
PGE2 and longer postoperative stay supports the approach of early surgical repair
with minimal preoperative medical intervention.