Thorac Cardiovasc Surg  2003 Feb;51(1):11-6 

Impact of diabetes mellitus on cardiac surgery outcome.

Bucerius J, Gummert JF, Walther T, Doll N, Falk V, Onnasch JF, Barten MJ, Mohr
FW.

Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig,
Germany.

BACKGROUND: Diabetes mellitus is an established independent risk factor related
to significant morbidity and mortality after cardiac surgical procedures.
METHODS: Data on 16,184 patients undergoing cardiac surgery with and without
cardiopulmonary bypass between April 1996 and August 2001 were prospectively
evaluated. Diabetes mellitus as a patient related risk factor was subjected to
univariate analysis to identify potential associations to 28 intra- and
postoperative outcome variables. Outcome variables having a significant
association with diabetes mellitus (p < 0.05) were then subjected to a stepwise
logistic regression model to identify the influence of diabetes mellitus as
compared to additional 30 different patient related risk factors and treatment
variables. Diabetes mellitus was defined as glucose intolerance treated either
dietary, with oral hypoglycemics or with insulin. RESULTS: Overall prevalence of
diabetes mellitus was 33.3 %. Compared to non-diabetic patients the group with
diabetes mellitus was older (p < 0.0001) and had a significantly lower ejection
fraction (p < 0.0001). 15 outcome variables having a significant association
with diabetes mellitus were identified. Furthermore, diabetes mellitus could be
identified as an independent predictor for 7 postoperative outcome variables
(prolonged ICU-stay, sternal instability and/or infection, sternal revision and
refixation respiratory insufficiency, postoperative delirium, perioperative
stroke, renal dysfunction, postoperative reintubation). CONCLUSION: Diabetes
mellitus is a significant independent predictor for several postoperative
outcome variables after cardiac surgery associated with higher postoperative
morbidity and prolonged hospital stay.

J Thorac Cardiovasc Surg  2003 Feb;125(2):378-384 

Effectiveness of the Cobra aortic catheter for dual-temperature management
during adult cardiac surgery.

Cook DJ, Orszulak TA, Zehr KJ, Nussmeier NA, Livesay JJ, Hammon JW, Chen X.

Departments of Anesthesiology and Divisions of Cardiothoracic Surgery, Mayo
Clinic and Foundation, Rochester, Minn; Texas Heart Institute at St Luke's
Episcopal Hospital, Houston, Tex; Wake Forest University School of Medicine,
Winston-Salem, NC; and the Harvard Clinical Research Institute, Boston, Mass.

OBJECTIVES: In animals the Cardeon Cobra catheter (Cardeon Corp, Cupertino,
Calif) allows independent control of aortic arch and descending aortic
temperatures and profoundly reduces cerebral embolization during bypass. This
investigation describes the first clinical use of the device during adult
cardiac surgery. The purpose of the study was to confirm that the Cobra catheter
delivers adequate cerebral and systemic perfusion while providing simultaneous
cerebral hypothermia and systemic normothermia during cardiopulmonary bypass.
METHODS: In a prospective multicenter study the Cobra aortic catheter was placed
in 20 adults undergoing cardiopulmonary bypass. Arch and corporeal temperatures,
bypass flows, and arterial blood pressures were recorded intraoperatively.
Jugular bulb and mixed venous oxygen saturation was used to assess the adequacy
of cerebral and systemic perfusion. RESULTS: Surgeons at 3 institutions placed
the Cobra catheter in patients undergoing coronary artery bypass grafting (n =
13), valve (n = 3), and combined valve-bypass (n = 4) operations. Mean total
bypass flows of 2.1 +/- 0.2 L. min(-1). (-2) maintained mean arterial pressures
in arch and descending aortic circulations of greater than 55 mm Hg. A mean
differential of 4.3 degrees C between arch and descending aortic temperatures
was established before crossclamp application, and a mean maximum temperature
differential of 7 degrees C was established during bypass. A 2.4 degrees C
temperature differential was maintained at crossclamp removal. Cerebral and
systemic venous oxygen saturation remained greater than 65% during bypass.
CONCLUSIONS: The Cobra device met all expectations for an arterial cannula with
adequate perfusion to the arch and corporeal circulations. Dual perfusion with
the Cobra catheter allows for independent temperature control during
cardiopulmonary bypass with simultaneous cerebral hypothermia and systemic
normothermia.

J Thorac Cardiovasc Surg  2003 Feb;125(2):344-52 

Intravenous magnesium sulfate prophylaxis for atrial fibrillation after coronary
artery bypass surgery.

Kaplan M, Kut MS, Icer UA, Demirtas MM.

Departments of Cardiovascular Surgery and Biochemistry, Siyami Ersek Thoracic
and Cardiovascular Surgery Center, Istanbul, Turkey.

OBJECTIVE: Atrial fibrillation is a rhythm disorder commonly seen early after
coronary artery bypass grafting, and it increases morbidity. METHODS: To
investigate the effectiveness of magnesium sulfate in the prophylaxis of atrial
fibrillation, we conducted a prospective, randomized, placebo-controlled
clinical study on 200 consecutive patients in whom we performed elective and
initial coronary artery bypass grafting operations. In each group 50% of
patients underwent beating-heart operations. In the treatment group 100 patients
(76 men and 24 women; mean age, 57.63 +/- 9.68 years) received 24.34 mEq (3 g)
of magnesium sulfate in 100 mL of saline solution that was administered over 2
hours (50 mL/h) preoperatively, perioperatively, and at postoperative days 0, 1,
2, and 3. In the control group 100 patients (74 men and 26 women; mean age,
59.96 +/- 9.29 years) received only 100 mL of saline solution according to the
same administration schedule as the treatment group. RESULTS: Atrial
fibrillation developed in 15 patients from the treatment group and in 16
patients from the control group. The arrhythmia developed after 37.87 +/- 12.76
and 45.26 +/- 15.27 hours in the treatment and control groups, respectively.
Although a significant relationship was found between low magnesium sulfate
levels and increased incidence of atrial fibrillation (P <.05), when the
incidence of postoperative atrial fibrillation is concerned, no significant
difference was found between the 2 groups (P >.05). Also, no significant
difference was found between operations with cardiopulmonary bypass and
beating-heart operations in terms of atrial fibrillation incidence (P >.05).
However, atrial fibrillation extended the duration of hospital stay in both
groups (P <.05). CONCLUSION: Our findings indicate that magnesium sulfate
infusion alone is not sufficient for the prophylaxis of atrial fibrillation.

Eur J Cardiothorac Surg  2003 Feb;23(2):165-9 

Vasoplegic syndrome after off-pump coronary artery bypass surgery.

Gomes WJ, Erlichman MR, Batista-Filho ML, Knobel M, Almeida DR, Carvalho AC,
Catani R, Buffolo E.

Cardiovascular Surgery Discipline, Escola Paulista de Medicina and Sao Paulo
Hospital, Federal University of Sao Paulo, Rua Botucatu, 740 -, Sao Paulo, SP
04023-900, Brazil

OBJECTIVE: The vasoplegic syndrome (VS) has been implicated in life-threatening
complications after open heart surgery, where the whole-body inflammatory
reaction is attributed to the cardiopulmonary bypass (CPB). Off-pump coronary
artery bypass grafting (OPCAB) has been recently achieving growing enthusiasm
mainly due avoiding the side effects of CPB. However herein the occurrence of VS
in OPCAB is reported. METHODS: The vasoplegic syndrome usual findings occurring
in the early postoperative period include severe hypotension, tachycardia,
normal or elevated cardiac output and low systemic vascular resistance. Four
patients underwent to OPCAB presented all the signs of VS intraoperatively or
within the first 6 postoperative h. RESULTS: The patients needed aggressive
vasoactive drug support for hemodynamic stabilization and all of them developed
complications. These patients also had tendency to require administration of
blood and blood derivatives due to diffuse and oozing type bleeding. Mean
intensive care unit stay of surviving patients was 70 h and mean period of
postoperative hospitalization was 9 days. Tumor necrosis factor-alpha blood
levels in one patient were elevated postoperatively though no signs of infection
were observed. One patient died. CONCLUSIONS: Although vasoplegic syndrome can
complicate OPCAB surgery, the rationale for avoiding CPB remains valid
considering the benefits provided by OPCAB.

Eur J Cardiothorac Surg  2003 Feb;23(2):149-55 

Aortic arch reconstruction using regional perfusion without circulatory arrest.

Lim C, Kim WH, Kim SC, Rhyu JW, Baek MJ, Oh SS, Na CY, Kim CW.

Department of Cardiovascular Surgery, Sejong General Hospital, Sejong Heart
Institute, Bucheon, Kyungki-do, South Korea

OBJECTIVES: Deep hypothermic circulatory arrest during repair of aortic arch
anomalies may induce neurological complications or myocardial injury. Regional
cerebral and myocardial perfusion may eliminate those potential side effects.
METHODS: From March 2000 to March 2002, 48 neonates or infants with complex arch
anomaly were operated on using the regional perfusion technique. Thirty-three
patients were male and the median age was 24 days (range 5-301 days).
Preoperative diagnosis consisted of coarctation or interruption of the aorta
associated with ventricular septal defect (group I, n=26) and arch anomaly with
complex intracardiac defects such as hypoplastic left heart syndrome or its
variants (group II, n=22). Arterial cannula was inserted through the innominate
artery and the flow rate was regulated to about 50-100 ml/kg per min during
regional perfusion. Simultaneous myocardial perfusion was maintained using a
Y-connected infusion line. Cardioplegia was applied during intracardiac repair.
RESULTS: Cardiopulmonary bypass and aortic cross-clamp times were 154+/-49 and
39+/-34 min, respectively. Temporary circulatory arrest for intracardiac
procedures was performed in eight patients. However, the mean arrest time was
minimized (range 1-18 min). The descending aorta clamping time was 33+/-16 min.
Operative mortality rates in each group were 0 and 18.2% (0/26 and 4/22). Late
mortality rates were 0 and 11.1% (0/26 and 2/18) during 9.1 months of follow-up.
Complications consisted of low cardiac output in eight cases, transient
neurological problems in two cases, and transient renal insufficiency in two
cases, respectively. CONCLUSIONS: Regional perfusion is feasible and can be used
with acceptable results. It may reduce potential complications following aortic
arch reconstruction using circulatory arrest. However, repair of aortic arch in
the patients with complex intracardiac defects still imposes a significant rate
of mortality and morbidity.

J Urol  2003 Feb;169(2):435-44 

Surgical techniques for treating a renal neoplasm invading the inferior vena
cava.

Vaidya A, Ciancio G, Soloway M.

Department of Urology, University of Miami School of Medicine, Miami, Florida,
USA.

PURPOSE: Historically inferior vena caval thrombus associated with renal cell
carcinoma was a deterrent to surgery. During the last 3 decades there has been
steady improvement in surgical techniques and perioperative care, which has
dramatically improved the ability to resect safely these tumors. We acknowledge
these improvements in chronological order. MATERIALS AND METHODS: A
comprehensive literature review of the different techniques used for resecting
renal cell carcinoma with inferior vena caval involvement was performed using
MEDLINE. Data focused on surgical techniques, including various incisions,
exposures, adjuncts to surgery and outcomes. RESULTS: Tumor thrombus associated
with renal cell carcinoma is no longer considered to have a detrimental impact
on survival. Patients who are acceptable surgical candidates have survival rates
as high as 68%. Although there is a great deal of emphasis on the importance of
an aggressive surgical approach, a uniform operative strategy based on the level
of the tumor thrombus has not been established. Surgical techniques derived from
liver transplant surgery and cardiac arrest with cardiopulmonary bypass have
drastically decreased operative complications associated with extensive
involvement of the inferior vena cava with tumor thrombus. CONCLUSIONS: The only
curative approach to renal cell carcinoma is surgery. An aggressive approach is
warranted when tumor involves the renal vein and inferior vena cava. Surgical
strategy depends on the level of the inferior vena caval thrombus. Patients with
extension of the thrombus above the diaphragm are a greater technical challenge.
Hypothermic circulatory arrest should be considered when treating vena
caval-atrial tumor thrombus. Surgeons familiar with liver mobilization can
greatly facilitate the exposure needed for safely operating in these cases.

Intensive Care Med  2003 Feb;29(2):257-61 

Base deficit in immediate postoperative period of coronary surgery with
cardiopulmonary bypass and length of stay in intensive care unit.

Hugot P, Sicsic JC, Schaffuser A, Sellin M, Corbineau H, Chaperon J, Ecoffey C.

Department of Anesthesiology and Intensive Care, CHU Pontchaillou, Universite
Rennes 1, 2 rue Henri Le Guilloux, 35033, Rennes Cedex 9, France.

OBJECTIVE. To assess the relationship between the base deficit value in the
immediate postoperative period of coronary surgery for cardiopulmonary bypass
and the length of stay in the ICU. DESIGN AND SETTING. Prospective descriptive
study in the department of anesthesia and cardiovascular surgery of a university
hospital. PATIENTS. 185 consecutive patients. INTERVENTIONS. Coronary artery
bypass graft with cardiopulmonary by pass. MEASUREMENTS AND RESULTS. Thirty
variables were determined during the pre-, intra-, and postoperative periods; a
statistical univariate analysis was performed differentiating patients whose
length of stay in the ICU was 2 days or less and those whose stay was more than
2 days. Secondly, a logistic regression model was performed on the variables
shown to have a statistically significant difference in univariate analysis,
with determination of the odd ratio. Fourteen variables had a statistically
significant difference in univariate analysis and three of them highlighted by
the logistic regression model: administration of catecholamines, base deficit
value in the 1st h postoperatively, and age with odd ratios, respectively, of
3.15, 1.51, and 1.07). CONCLUSIONS. The value of base deficit measured during
the 1st h after coronary surgery for cardiopulmonary bypass is correlated with
the length of stay in ICU.

Anesth Analg  2003 Feb;96(2):344-50, table of contents 

Patients with a history of type II heparin-induced thrombocytopenia with
thrombosis requiring cardiac surgery with cardiopulmonary bypass: a prospective
observational case series.

Nuttall GA, Oliver WC Jr, Santrach PJ, McBane RD, Erpelding DB, Marver CL, Zehr
KJ.

Department of Anesthesiology, Mayo Clinic, Rochester, Minnesota 55905, USA.
nuttall,gregory@mayo.edu

Heparin-induced thrombocytopenia with thrombosis (HITT) type II is a
life-threatening complication of heparin therapy that most often occurs after
5-10 days of exposure to heparin. Anticoagulation is a significant concern for
patients with HITT type II being prepared for cardiac surgery requiring
cardiopulmonary bypass (CPB). We report a case series of 12 patients with a
history HITT type II who underwent CPB and cardiac surgery. Six patients did not
express the antibody that mediates HITT type II immediately before surgery.
Heparin was used as the anticoagulant for the duration of CPB only, and all
these patients did well without thrombotic complications. Six patients expressed
the antibody that mediates HITT type II immediately before surgery. Hirudin was
used as the anticoagulant for CPB in these patients. The ecarin clotting time
was used to guide hirudin therapy during CPB. The patients receiving hirudin did
well, but they had a large amount of bleeding, required transfusions of multiple
allogeneic blood products, and had a frequent rate of reexploration of the
mediastinum after CPB.

Anesth Analg  2003 Feb;96(2):328-35 

Strict thermoregulation attenuates myocardial injury during coronary artery
bypass graft surgery as reflected by reduced levels of cardiac-specific troponin
I.

Nesher N, Zisman E, Wolf T, Sharony R, Bolotin G, David M, Uretzky G, Pizov R.

Department of Cardiothoracic Surgery, Tel Aviv Sourasky Medical Center, Sackler
Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel.
nnesher@netvision.net.il

We assessed the cardioprotective effects of perioperative maintenance of
normothermia by determining the perioperative profile of troponin I, a highly
cardiac-specific protein important in risk stratification of patients with acute
ischemic events. Candidates for their primary coronary artery bypass grafting
(CABG) were randomized into a new thermoregulation system group, Allon(
thermoregulation (AT; n = 30), and a routine thermal care (RTC; n = 30) group.
Anesthetic and operative techniques were similar in both groups. Intraoperative
warming was applied before and after cardiopulmonary bypass (CPB) and up to 4 h
after surgery. Perioperative temperature and hemodynamic data were recorded.
Blood samples for creatine kinase (CK) and its isoform, MB (CK-MB), and for
cardiac-specific troponin I (cTnI) were obtained at predetermined intervals
throughout the entire operation. Core and skin temperatures were higher in the
AT group at all time points. The systemic vascular resistance was lower and the
cardiac index higher in the AT group at all intra- and postoperative time
points. Increases in CK, CK-MB, and cTnI levels indicated intraoperative
ischemic insult in all patients. The respective CK levels for the AT and RTC
groups were 53.3 +/- 22.7 IU/L and 47.9 +/- 17.86 IU/L at the time of anesthesia
and 64.7 +/- 45.6 IU/L and 47.8 +/- 19.4 IU/L 30 min after the onset of surgery,
demonstrating thereafter a steep increase before the discontinuation of CPB.
CK-MB mass concentrations in both groups behaved almost identically. Pre-CPB
cTnI levels at anesthesia induction were 0.3 +/- 0 ng/mL in both groups,
followed by a distinctive profile observed after separation from CPB: 28.1 +/-
11.4 ng/mL, 26.05 +/- 9.20 ng/mL, and 22.3 +/- 8.9 ng/mL at discontinuation from
CPB, chest closure, and 2 h after surgery, respectively, in the RTC group,
versus 0.6 +/- 4.6 ng/mL, 6.6 +/- 5.5 ng/mL, and 7.9 +/- 4.76 ng/mL at these
three time points, respectively, in the AT group (P < 0.01 between groups at the
specified time points). Contrary to conventional thinking about the benefits of
hypothermia, maintenance of normothermia throughout the non-CPB phases during
CABG was demonstrated to be important in attenuating myocardial ischemic injury.
Insofar as troponin I was more sensitive than other tested markers, it may
provide important data on possible protection from myocardial insult and on
other cardioprotective measures.