Perfusion Literature - December 2009

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TOP TEN SELECTED PAPERS
- December 2009

1

J Korean Med Sci. 2010 Jan;25(1):104-9. Epub 2009 Dec 26.

Surgical treatment of inferior vena cava tumor thrombus in patients with renal
cell carcinoma.

Kwon TW, Kim H, Moon KM, Cho YP, Song C, Kim CS, Ahn H.

Department of Surgery, University of Ulsan College of Medicine, Seoul, Korea.
twkwon2@amc.seoul.kr

Radical nephrectomy with inferior vena cava (IVC) thrombectomy remains the most
effective therapeutic option in patients with renal cell carcinoma and IVC tumor 
thrombus. Cephalic extension of the thrombus is closely related to perioperative 
morbidity. We purposed to design a safe and successful surgical strategy through 
a review of our surgical experience and treatment results in 35 patients
(male:female=28:7, mean age=56 yr [32-77]) who underwent IVC thrombectomy with
radical nephrectomy between January 1997 and December 2006. The limit of tumor
extension was level I in 10 patients (28.6%), level II in 17 (48.6%), and level
III and IV in 4 patients each (11.4%). Liver mobilization with hepatic vascular
exclusion was performed in 12 patients and cardiopulmonary bypass in 7.
Thirty-two primary closures, 2 patch closures, and 1 graft interposition were
performed. One patient underwent simultaneous pulmonary embolectomy because of an
operative pulmonary embolism. There was no operative mortality, and the overall
survival at 5-yr was 50.8%. Complete thrombus removal without tumor fragmentation
under long venotomy on fully exposed involved IVC is recommended for successful
result in a bloodless operative field. The applicability of liver mobilization,
hepatic vascular exclusion, and cardiopulmonary bypass, can be determined by the 
level of thrombus.

Interact Cardiovasc Thorac Surg. 2010 Jan 5. [Epub ahead of print]

Despite modern off-pump coronary artery bypass grafting women fare worse than
men.

Emmert MY, Salzberg SP, Seifert B, Schurr UP, Odavic D, Reuthebuch O, Genoni M.

University Hospital Zurich, Zurich, Switzerland.

Female gender is an established risk factor for worse outcomes after cardiac
surgery. Avoiding cardiopulmonary bypass (CPB) for coronary bypass grafting has
an unknown effect on gender differences. Herein, we evaluate if gender has an
impact on outcomes after modern off-pump coronary artery bypass grafting (OPCAB).
From 2002 to 2007, we analyzed 983 patients (male: n=807/female: n=176) who
underwent OPCAB with symptomatic multi-vessel disease at our institution. The
link between gender and outcome was assessed by multivariate analysis and
logistic regression. A composite endpoint was constructed from: 30-day-mortality,
renal failure, prolonged intensive care unit (ICU) stay, neurological
complications, use of intra-aortic balloon pump (IABP) and conversion to CPB.
Mortality was 3.2% in women vs. 1.8% in men (P=0.15) and the EuroSCORE was
significantly correlated to gender (6.8 vs. 5.2; P<0.001), even after correction 
(P=0.036). Significant more occurrence of the composite endpoint was noted in
women (39.8% vs. 29.0%; P=0.007) whereas for men the risk was much lower [odds
ratio (OR) 0.65; 95% CI: 0.46-0.92; P=0.015]. For both genders the logistic
regression revealed a risk increase of 15% per one-point-increase of EuroSCORE
(corrected) (OR 1.15; 95% CI: 1.10-1.19; P<0.0001). Women had more frequently a
prolonged stay at ICU (P=0.006) and had a higher stroke rate (2.3% vs. 1.2%;
P=0.29). Complete revascularization was achieved similarly (95% vs. 94%; P=0.93).
OPCAB offers low mortality and excellent clinical outcome. Women are more likely 
to experience postoperative complications. Even if partially neutralized by
avoiding CPB, gender differences remain present with modern OPCAB strategies.
Keywords: Coronary heart disease; Gender differences; Off-pump surgery.

Interact Cardiovasc Thorac Surg. 2010 Jan 5. [Epub ahead of print]

Effect of hydrogen sulfide on myocardial protection in the setting of
cardioplegia and cardiopulmonary bypass.

Osipov RM, Robich M, Feng J, Chan V, Clements RT, Deyo RJ, Szabo C, Sellke FW.

Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, USA.

We investigated the impact of hydrogen sulfide (H2S) on myocardium in the setting
of cold crystalloid cardioplegia and cardiopulmonary bypass (CP/CPB). Eighteen
male Yorkshire pigs underwent 1 h CP/CPB followed by 2 h of reperfusion. Pigs
received either: placebo (control, n=9), or H2S (as NaHS) as a bolusyinfusion
(bolusyinfusion, n=6), or as an infusion (infusion, n=6). The expression pattern 
of various myocardial effector pathways was investigated. Coronary microvascular 
relaxation to endothelium-dependent and -independent agonists was assessed. No
differences in cardiac function were observed among groups. Endothelium-dependent
microvascular relaxation to adenosine diphosphate was improved in the H2S
bolusyinfusion group only (P<0.05). The expression of hemeoxygenase-1,
phospho-heat shock proteins27 and phospho-p44/42 MAPK extracellular
signal-regulated kinase were higher in H2S-treated groups (P<0.05).
Phospho-endothelial nitric oxide synthase (P=0.08), phospho-B-cell lymphoma 2
(P=0.09), and phospho-Bad (P=0.06) all displayed a trend to be higher with H2S
treatment. The expressions of apoptosis inducing factor and Bcl 2/adenovirus E1B 
19 kDa-interacting protein were lower in H2S treated groups (P<0.05). The
microtubule-associated protein 1 light chain 3 ratio was lower in the infusion
group vs. control animals (P<0.05). There was a trend for lower phospho-mammalian
target of rapamycin expression in the infusion group (P=0.07), whereas
phosphorylation of p70S6K1 was higher with H2S-treatment (P=0.09). This study
demonstrates that H2S-treatment may offer biochemical myocardial protection via
attenuation of caspase-independent apoptosis and autophagy in the setting of
CP/CPB. Keywords: Cardiopulmonary bypass; Myocardial protectionyCardioplegia;
Cardiac function; Apoptosis.

Interact Cardiovasc Thorac Surg. 2009 Dec 21. [Epub ahead of print]

Clinical performance and biocompatibility of hyaluronan-based heparin-bonded
extracoporeal circuits in different risk cohorts.

Gunaydin S, McCusker K, Sari T, Onur MA, Zorlutuna Y.

University of Kirikkale, Ankara, Turkey.

This prospective randomized study compares novel hyaluronan-based heparin-bonded 
circuits versus uncoated controls across EuroSCORE patient risk strata including 
biomaterial evaluation. Over a two-year period, 90 patients undergoing coronary
artery bypass grafting were prospectively randomized to one of the two perfusion 
protocols: Group 1 was treated with hyaluronan-based heparin-bonded preconnected 
circuits (Vision HFO-GBS(TM), Gish, CA, USA) and Group 2 with identical uncoated 
controls. Each group was composed of three subgroups (n=15) with respect to
preoperative evaluation of low (EuroSCORE 0-2), medium (3-5) and high (6+) risk
patients. Blood samples were collected after induction (T1) and heparinization
(T2), 15 min after cardiopulmonary bypass start (T3), before cessation of CPB
(T4), 15 min after reversal (T5), and the first postoperative day (T6). In
high-risk patients, platelet counts demonstrated significant preservation at T4, 
T5 and leukocyte counts were lower at T5 in hyaluronan group (p

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.

Med Sci Monit. 2009 Dec;15(12):CR612-7.

Transcatheter closure as an alternative and equivalent method to the surgical
treatment of atrial septal defect in adults: comparison of early and late
results.

Suchon E, Pieculewicz M, Tracz W, Przewlocki T, Sadowski J, Podolec P.

Department of Cardiac and Vascular Diseases, Jagiellonian University, The John
Paul II Hospital, Cracow, Poland. esuchon@szpitaljp2.krakow.pl

BACKGROUND: The clinical efficacy of transcatheter atrial septal defect (ASD)
closure with the Amplatzer Septal Occluder (ASO) can only be judged against the
results of contemporaneous surgery. The present study compared early and late
results of ASD closure using ASO versus open-heart surgery. METHODS: Forty-eight 
adult patients were found eligible for transcatheter closure in transesophageal
echocardiography. The surgical group consisted of 52 patients with isolated
ostium secundum ASD. All patients underwent standard ECG, 24-hour ECG recording, 
and transthoracic echocardiography pre-procedure at 1-month and at 1-year
follow-up. Physical fitness was assessed by cardiopulmonary exercise testing
(CPX) prior to ASD closure and at 1-year follow-up. RESULTS: ASD closure was
successful in all surgical patients and in 94% of the ASO group (0% mortality).
The total complication rate for surgical vs. device closure was not significantly
different (19.2% vs. 26.7%; p=0.383), despite more serious complications in the
surgical group. Hospital stay was significantly shorter in the ASO group
(5.4+/-2.2 vs. 9.1+/-1.2 days; p<0.001). Although echocardiographic parameters
did not differ significantly between the respective groups at 1-year follow-up,
CPX revealed a higher decrease in the VE/VCO2 slope in the ASO group (-3.7+/-3.4 
vs.-1.2+/-4.8; p=0.003). CONCLUSIONS: As surgical and device closure appear
similarly effective in adults with ASD, avoidance of thoracotomy and
cardiopulmonary bypass, in conjunction with a shorter hospital stay, argues in
favour of device closure in selected patients.

Circ J. 2010 Jan;74(1):86-92. Epub 2009 Nov 27.

Diagnosis-based differences in response of global ventricular performance to
modified ultrafiltration in children.

Honjo O, Osaki S, Kotani Y, Akagi T, Sano S.

Department of Cardiovascular Surgery, Okayama University Graduate School of
Medicine, Dentistry and Pharmaceutical Sciences, Okayama, Japan.
osami.honjo@sickkids.ca

BACKGROUND: To determine diagnosis-based differences in the response of global
ventricular performance to modified ultrafiltration (MUF) using transesophageal
echocardiography during congenital heart surgery. METHODS AND RESULTS: The study 
included 38 children with atrial septal defect (n=10), ventricular septal defect 
(VSD) (n=8), tetralogy of Fallot (TOF) (n=9), or a single ventricle (n=11).
Arteriovenous MUF was performed for 10-15 min after cardiopulmonary bypass (CPB).
The myocardial performance index (MPI) of the systemic ventricles and the %
change in MPI before and after MUF were assessed. Impairment of MPI was noted at 
termination of CPB compared with baseline values in the VSD and TOF groups
(P<0.05). MUF resulted in an improvement in MPI in all groups (P<0.01). There was
a weak correlation between aortic cross-clamping or CPB time, and the degree of
improvement in MPI (r= 0.385, P=0.019; r= 0.348, P=0.037, respectively). MUF
improved fractional shortening in all groups (P<0.05) and reversed abnormal
relaxation in the VSD and TOF groups. CONCLUSIONS: Modified ultrafiltration
ameliorated MPI in all groups, indicating improved systemic ventricular function 
with MUF. The MPI recovery rate differed among the groups. MUF may be
particularly useful for restoring the global ventricular performance of patients 
undergoing longer CPB and may have minimal advantages for simple open-heart
surgery. (Circ J 2010; 74: 86 - 92).

Circ J. 2010 Jan;74(1):77-85. Epub 2009 Nov 27.

Early induction of hypothermia during cardiac arrest improves neurological
outcomes in patients with out-of-hospital cardiac arrest who undergo emergency
cardiopulmonary bypass and percutaneous coronary intervention.

Nagao K, Kikushima K, Watanabe K, Tachibana E, Tominaga Y, Tada K, Ishii M, Chiba
N, Kasai A, Soga T, Matsuzaki M, Nishikawa K, Tateda Y, Ikeda H, Yagi T.

Department of Cardiology, Resuscitation and Emergency Cardiovascular Care,
Surugadai Nihon University Hospital, Japan. kennagao@med.nihon-u.ac.jp

BACKGROUND: Therapeutic hypothermia for comatose survivors of out-of-hospital
cardiac arrest has demonstrated neurological benefits. Although early cooling
during cardiac arrest enhances efficacy in animal studies, few clinical studies
are available. METHODS AND RESULTS: The 171 patients who failed to respond to
conventional cardiopulmonary resuscitation were studied prospectively. Patients
underwent emergency cardiopulmonary bypass (CPB) plus intra-aortic balloon
pumping, with subsequent percutaneous coronary intervention (PCI) if needed. Mild
hypothermia (34 degrees C for 3 days) was induced during cardiac arrest or after 
return of spontaneous circulation. Of the 171 patients, 21 (12.3%) had a
favorable neurological outcome at hospital discharge. An unadjusted rate of
favorable outcome decreased in a stepwise fashion for increasing quartiles of
collapse-to-34 degrees C interval (P=0.016). An adjusted odds ratio for favorable
outcome after collapse-to-CPB interval was 0.89 (95% confidence interval (CI)
0.82-0.97) and after CPB-to-34 degrees C interval, 0.99 (95%CI 0.98-0.99) when
collapse-to-34 degrees C interval was divided into 2 components. Favorable
neurological accuracy of a collapse-to-CPB interval at a cutoff of 55.5 min and
CPB-to-34 degrees C interval at a cutoff of 21.5 min was 85.4% and 89.5%,
respectively. CONCLUSIONS: Early attainment of a core temperature had
neurological benefits for patients with out-of-hospital cardiac arrest who
underwent CPB and PCI. (Circ J 2010; 74: 77 - 85).

Interact Cardiovasc Thorac Surg. 2009 Nov 4. [Epub ahead of print]

Impact of preoperative anemia on cardiac surgery in octogenarians.

Carrascal Y, Maroto L, Rey J, Arevalo A, Arroyo J, Echevarria JR, Arce N, Fulquet
E.

University Hospital Valladolid, Spain.

Objectives: Preoperative anemia has been related with adverse outcomes in
elective valve replacement and CABG surgery. Impact of preoperative anemia on
outcome in octogenarians submitted to cardiopulmonary bypass (CPB) has not yet
been precisely described. Methods: We analyzed association between preoperative
hemoglobin level, minimum intraoperative and immediate postoperative hematocrit
(HCT), and other co-morbidities and occurrence of adverse outcomes in 227
octogenarians who underwent cardiac surgery. Results: Frequency of preoperative
anemia was 41.9% (40.4% in male and 43.5% in female patients). Postoperative
mortality was 13.2% (9% in non-anemic patients vs. 18.9% in anemic). 44.5% of
patients suffered no postoperative adverse outcome (43.1% non-anemic vs. 46.3%
anemic). In multivariate analysis (after adjusting independent preoperative risk 
factors for operative mortality and EuroSCORE) preoperative creatinin level [odds
ratio (OR), 2.29; 95% confidence interval (CI), 1.06-4.98; P=0.035], immediate
postoperative HCT <24% (OR, 2.78; 95% CI, 1.04-7.38; P=0.039), perioperative red 
blood cell (RBC) transfusion (OR, 1.58; 95% CI, 1.24-2.00; P=0.0001), peripheral 
vascular disease (OR, 4.92; 95% CI, 1.45-16.69; P=0.012) and urgent surgery (OR, 
10.57; 95% CI, 2.54-43.91; P=0.0001) were identified as independent predictors
for in-hospital mortality. Conclusions: Mortality and adverse postoperative
outcome increase in anemic octogenarians undergoing cardiac surgery. Although
mortality is directly related to immediate postoperative anemia, adverse outcomes
mainly depend on associated co-morbidities. Keywords: Octogenarians; Anemia;
Cardiac surgery.

Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):18-20. Epub 2009 Oct 27.

Comprehensive approach for clamping severely calcified ascending aorta using
computed tomography.

Nishi H, Mitsuno M, Ryomoto M, Miyamoto Y.

Department of Cardiovascular Surgery, Hyogo College of Medicine, 1-1 Mukogawacho,
Nishinomiya, Hyogo, 661-8501, Japan.

Comment in:
    Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):20.
    Interact Cardiovasc Thorac Surg. 2010 Jan;10(1):20-1.

A severely calcified ascending aorta is generally considered unclampable. Many
surgeons have developed procedures to avoid manipulation such as cross-clamping
on such calcified aorta. However, these alternatives are sometimes complicated
and require a more invasive procedure than the conventional method. We assessed
our comprehensive strategy for clamping of a severely calcified aorta using
preoperative computed tomography (CT). We found that the extent of calcification 
just below the innominate artery was significantly less than that at the usual
ascending aorta clamp site. After confirming that the extent of calcification
just below the innominate artery was <75% of the entire circumference by
preoperative CT, ascending aorta was clamped with a soft cross-clamp placed on
the ascending aorta with particular care to orientate the clamp parallel to the
calcification. All operations were completed under usual cardiopulmonary bypass
with mild hypothermia. All patients survived surgery and no patients had a
postoperative neurological complication. Our results provide important
information for the management of these high-risk patients, with a comprehensive 
approach used to choose the appropriate option for an optimal outcome.

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