J Cardiothorac Vasc Anesth. 2005 Feb;19(1):54-9. 

Comparison of phenoxybenzamine to sodium nitroprusside in infants undergoing
surgery.

Motta P, Mossad E, Toscana D, Zestos M, Mee R.

OBJECTIVES: The purpose of this study was to compare the effects of a
direct-acting arterial dilator, sodium nitroprusside, to an alpha-adrenergic
receptor blocker, phenoxybenzamine, in infants with congenital heart defects
undergoing cardiac repairs on cardiopulmonary bypass. 
Design: A prospective, multicenter, observational study. Setting: Tertiary care center. Participants:
Sixty infants scheduled for elective congenital cardiac surgery repair requiring
cardiopulmonary bypass. Interventions: Patients received either sodium
nitroprusside 2 to 5 mug/kg/min infusion intraoperatively and in the intensive
care unit (n = 30 patients) or received phenoxybenzamine 1 mg/kg slowly
intravenously at the onset of cardiopulmonary bypass (n = 30 patients).
Measurement and Main Results: Despite similar mean arterial pressures during
cardiopulmonary bypass in both groups, infants who received phenoxybenzamine had
a significantly higher flow compared with those who received sodium
nitroprusside (180 +/- 4.8 v 73 +/- 5.12 mL/kg/min, p < 0.0001). Base deficit
was significantly larger in the sodium nitroprusside group compared with the
phenoxybenzamine group intraoperatively and postoperatively (3.4 +/- 0.5 v 1.3
+/- 0.5 mEq/L, p < 0.05). The core-to-peripheral temperature gradient was
significantly larger in the sodium nitroprusside group compared with the
phenoxybenzamine group intra- and postoperatively at all points studied. In the
intensive care unit, the left atrial pressure was significantly higher in the
sodium nitroprusside group compared with the phenoxybenzamine group (9 +/- 0.4 v
7 +/- 0.4 mmHg, p 

Intensive Care Med. 2005 Feb 15; [Epub ahead of print] 

Clinical assessment of cardiac performance in infants and children following
cardiac surgery.

Egan JR, Festa M, Cole AD, Nunn GR, Gillis J, Winlaw DS.

Paediatric Intensive Care Unit, The Children's Hospital at Westmead, 2145,
Westmead, NSW, Australia, jonathoe@chw.edu.au.

OBJECTIVE: To compare clinical assessment of cardiac performance with an
invasive method of haemodynamic monitoring.DESIGN AND SETTING: Prospective
observational study in a 16-bed tertiary paediatric intensive care unit.PATIENTS
AND PARTICIPANTS: Infants and children undergoing cardiopulmonary bypass and
surgical repair of congenital heart lesions.INTERVENTIONS: Based on physical
examination and routinely available haemodynamic monitoring in the paediatric
intensive care unit, medical and nursing staff assessed cardiac index, systemic
vascular resistance index and volume status. Clinical assessment was compared
with cardiac index, systemic vascular resistance index and global end diastolic
volume index, obtained by femoral artery thermodilution.MEASUREMENTS AND
RESULTS: A total of 76 clinical estimations of the three parameters were made in
16 infants and children undergoing biventricular repair of congenital heart
lesions. Agreement was poor between clinical and invasive methods of determining
all three studied parameters of cardiac performance. Cardiac index was
significantly underestimated clinically; mean difference was 0.71 l min(-1)
m(-2) (95% range of agreement +/-2.7). Clinical estimates of systemic vascular
resistance (weighted kappa=0.15) and volume status (weighted kappa=0.04) showed
poor levels of agreement with measured values and were overestimated clinically.
There was one complication related to a femoral arterial catheter and one device
failure.CONCLUSIONS: Routine clinical assessment of parameters of cardiac
performance agreed poorly with invasive determinations of these indices.
Management decisions based on inaccurate clinical assessments may be detrimental
to patients. Invasive haemodynamic monitoring using femoral artery
thermodilution warrants cautious further evaluation as there is little agreement
with clinical assessment which is presently standard accepted care in this
patient population.

Crit Care Med. 2005 Feb;33(2):355-60. 

Postoperative antithrombin levels and outcome in cardiac operations.

Ranucci M, Frigiola A, Menicanti L, Ditta A, Boncilli A, Brozzi S.

Department of Cardiothoracic Anesthesia and Intensive Care, Istituto Policlinico
S. Donato, Milan, Italy.

OBJECTIVE: During cardiac operations with cardiopulmonary bypass surgery,
antithrombin is consumed and low levels of antithrombin activity are commonly
observed at admission to the intensive care unit (ICU). This study investigates
the association between antithrombin activity at admission to the ICU
(ICU-antithrombin activity) and various outcome variables. DESIGN: The authors
conducted a prospective, observational cohort study. SETTING: The study was
conducted at a university hospital. PATIENTS: The study consisted of 647
consecutive patients who had undergone cardiac surgery with cardiopulmonary
bypass. MEASUREMENTS AND MAIN RESULTS: ICU-antithrombin activity significantly
(p < .001) decreased with respect to preoperative values. As seen with
univariate analysis, low levels of ICU-antithrombin activity were significantly
associated with higher blood loss, prolonged mechanical ventilation time and ICU
stay, a higher incidence of allogeneic blood products use, surgical
reexploration, low cardiac output syndrome, adverse neurologic events,
thromboembolic events, renal dysfunction, and hospital mortality. When corrected
for the other explanatory variables, low levels of ICU-antithrombin activity
remained independently associated with a prolonged ICU stay (p = .003) and with
a higher incidence of surgical reexploration (p = .023), adverse neurologic
events (p = .001), and thromboembolic events (p = .036). An ICU-antithrombin
activity value of <58% was found to be predictive of prolonged ICU stay, with a
sensitivity of 67% and a specificity of 83%. CONCLUSIONS: Low levels of
ICU-antithrombin activity are associated with a poor outcome in cardiac surgery;
ICU-antithrombin activity is predictive of prolonged ICU stay.

Thorac Cardiovasc Surg. 2005 Feb;53(1):16-22. 

Immunoglobulin levels and lymphocyte subsets following cardiac operations:
further evidence for a T-helper cell shifting*.

Lante W, Franke A, Weinhold C, Markewitz A.

Department of Cardiovascular Surgery, Central Military Hospital, Koblenz,
Germany.

BACKGROUND: Recent data indicate that cardiac surgery with cardiopulmonary
bypass (CPB) results in an imbalance of T-helper cell subsets towards the
anti-inflammatory pathway mediating humoral immune response. However, little is
known about immunoglobulin levels as an important part of humoral immune
response after CPB. Therefore, the objectives of this study were 1) to elucidate
the effects of CPB on perioperative immunoglobulin levels, and 2) to find out if
alterations in lymphocyte subsets are related to these findings. METHODS: Blood
samples from 83 patients undergoing elective cardiac operation were taken
preoperatively (d0), on the first (d1), third (d3), and fifth day (d5) after
operation. Levels of immunoglobulin (Ig) E, IgM, and IgG, including the
subclasses IgG 1 - 4, were measured. IgG2/IgE-ratio was used as indicator for
TH1/TH2 shifting, and production of tetanus antibodies (AB) was investigated as
an in vivo parameter of humoral immune reaction. The number and percentage of T-
and B-lymphocyte subsets were assessed in a subgroup of 50 patients to answer
the second question. RESULTS: Clinically, no mortality or major morbidity were
observed. IgE levels did not change until d3 and increased significantly on d5.
In contrast, both IgG and IgM levels decreased significantly on d1. While IgM
returned to baseline (BL) on d5, IgG levels remained below BL until d5.
IgG2/IgE-ratio decreased significantly on d1, reached its nadir on d3 and
remained depressed until d5. The number of T-lymphocytes decreased on d1 as well
as the number of B-cells. T-cells returned to BL on d5, B-cells on d3. However,
while the percentage of T-cells decreased on d1, the percentage of B-cells
increased. The percentage of T-cells returned to BL on d3, and B-cell percentage
returned to BL on d5. Tetanus AB production did not change until d5 when it
increased significantly. CONCLUSIONS: 1) Increase of IgE and tetanus AB
production indicate that humoral immune response is not affected by CPB, but
possibly even enhanced. The relative increase of B-cells is in line with this
hypothesis. 2) Postoperative changes in immunoglobulin levels provide further
evidence for a TH1/TH2-shifting. 3) The transient deficit in IgM-and IgG levels
did not result in clinically adverse events. Thus, therapeutic intervention
appears not to be required.

Pediatr Cardiol. 2005 Feb 10; [Epub ahead of print] 

Administration of Steroids in Pediatric Cardiac Surgery: Impact on Clinical
Outcome and Systemic Inflammatory Response.

Gessler P, Hohl V, Carrel T, Pfenninger J, Schmid ER, Baenziger O, Pretre R.

University Children's Hospital, Steinwiesstrasse 75, CH 8032, Zurich,
Switzerland, peter.gessler@kispi.unizh.ch.

Cardiopulmonary bypass (CPB) is associated with a systemic inflammatory
response. Pre-bypass steroid administration may modulate the inflammatory
response, resulting in improved postoperative recovery. We performed a
prospective study in the departments of cardiovascular surgery and pediatric
intensive care medicine of two university hospitals that included 50 infants who
underwent heart surgery. Patients received either prednisolone (30 mg/kg) added
to the priming solution of the cardiopulmonary bypass circuit (steroid group) or
no steroids (nonsteroid group). Clinical outcome parameters include therapy with
inotropic drugs, oxygenation, blood lactate, glucose, and creatinine, and
laboratory parameters of inflammation include leukocytes, C-reactive protein,
and interleukin-8. Postoperative recovery (e.g., the number, dosage, and
duration of inotropic drugs as well as oxygenation) was similar in patients
treated with or without steroids when corrected for the type of cardiac surgery
performed. After CPB, there was an inflammatory reaction, especially in patients
with a long CPB time. Postoperative plasma levels of interleukin-8 were
correlated with the duration of CPB time (r = 0.62, p < 0.001). Administration
of steroids had no significant impact on the laboratory parameters of
inflammation. Administration of prednisolone into the priming solution of the
CPB circuit had no measurable influence on postoperative recovery and did not
suppress the inflammatory response.

Int J Cardiol. 2005 Feb 15;98(2):261-6. 

The risk of stroke following CABG: one possible strategy to reduce it?

De Feo M, Renzulli A, Onorati F, Marmo J, Galdieri N, De Santo LS, Della Corte
A, Cotrufo M.

Department of Cardiothoracic Sciences, Division of Cardiac Surgery, Second
University of Naples V. Monaldi Hospital, Italy.

OBJECTIVE: Stroke remains a devastating complication of coronary artery bypass
grafting (CABG): we evaluated whether a more aggressive diagnostic and
therapeutic approach can reduce its incidence. METHODS: Between January 1998 and
January 2002, 1388 consecutive patients underwent isolated on pump CABG with
blood cardioplegia. Among the first 627 patients (Group A), Echo-Doppler study
(DS) was performed only in selected patients (58) with history of
cerebrovascular disease (CVD) and/or carotid bruit; in 761 patients (Group B),
DS was performed routinely. Carotid endarterectomy (CEA) was performed in 45
patients in Group A associated to CABG during cardiopulmonary bypass (CPB) and
in 90 patients in Group B under local anaesthesia before CABG. Brain CT scan was
performed in all cases with postoperative neurological symptoms. RESULTS: The
two groups were homogeneous for age, sex, associated diseases, history of CVD,
number of graft and CPB time. There were no differences in terms of hospital
mortality between Group A (22/627: 3.5%) and Group B (21/761: 2.75%); p=0.5.
Postoperative stroke was observed in 24/627 (3.82%) patients of Group A and in
2/761 (0.26%) of Group B (p<0.001). Hospital mortality for stroke was higher in
Group A (12/627: 1.91%) than in Group B (0/761; p<0.001) as well as the
incidence of non-fatal stroke (Group A 12/627: 1.91% versus Group B 2/761: 0.26%
p=0.006). CONCLUSIONS: Preoperative DS, performed in all cases of CABG, followed
by CEA under local anaesthesia in patients with critical carotid stenosis
reduces the incidence of postoperative stroke.

Ann Thorac Surg. 2005 Feb;79(2):666-71. 

Comparison of hydroxyethyl starch and ringer lactate as a prime solution
regarding S-100beta protein levels and informative cognitive tests in cerebral
injury.

Iriz E, Kolbakir F, Akar H, Adam B, Keceligil HT.

Department of Cardiovascular Surgery, School of Medicine, Gazi University,
Ankara, Turkey. erkaniriz@hotmail.com

BACKGROUND: Cognitive dysfunction (as an indicator of cerebral dysfunction after
open heart surgery) was observed in as many as 70% of patients who underwent
cardiopulmonary bypass. S-100beta protein is a sensitive indicator of cerebral
injury. We aimed to compare the effects of hydroxyethyl starch and Ringer
lactate prime solutions in the protection of cerebral tissue in cardiopulmonary
bypass using serum S-100beta protein levels and informative cognitive tests.
METHODS: Patients were randomized into two groups. Open heart surgery was
performed by using hydroxyethyl starch solution in group 1 (n = 15) and Ringer
lactate solution in group 2 (n = 15). Preoperative, perioperative, and
postoperative S-100beta protein levels and informative cognitive test scores,
clinical and operational characteristics of the patients were compared. RESULTS:
A significant difference was found only between preoperative and postoperative
results of verbal accuracy (human) test in group 1, whereas differences between
preoperative and postoperative scores of continuous skill, verbal accuracy
(human), verbal accuracy (animal), verbal accuracy (human-animal), go-no-go
paradigm, calculation, and abstract thinking tests were significant in group 2
(p < or = 0.05). The S-100beta protein levels were not significantly different
between the groups (group p = 0.97). CONCLUSIONS: Because hydroxyethyl starch
prime solution used in extracorporeal circulation had significant positive
effects with informative-cognitive tests when compared to Ringer lactate
solution, it seems to be a better prime solution to prevent cerebral dysfunction
in these patients.

J Thorac Cardiovasc Surg. 2005 Feb;129(2):391-400. 

Hemodilution during cardiopulmonary bypass is an independent risk factor for
acute renal failure in adult cardiac surgery.

Karkouti K, Beattie WS, Wijeysundera DN, Rao V, Chan C, Dattilo KM, Djaiani G,
Ivanov J, Karski J, David TE.

Department of Anesthesia, University Health Network, University of Toronto,
Ontario, Canada. keyvan.Karkouti@uhn.on.ca 

BACKGROUND: This observational study sought to determine whether the degree of
hemodilution during cardiopulmonary bypass is independently related to
perioperative acute renal failure necessitating dialysis support. METHODS: Data
were prospectively collected on consecutive patients undergoing cardiac
operations with cardiopulmonary bypass from 1999 to 2003 at a tertiary care
hospital. The independent relationship was assessed between the degree of
hemodilution during cardiopulmonary bypass, as measured by nadir hematocrit
concentration, and acute renal failure necessitating dialysis support.
Multivariate logistic regression was used to control for variables known to be
associated with perioperative renal failure and anemia. RESULTS: Of the 9080
patients included in the analysis, 1.5% (n = 134) had acute renal failure
necessitating dialysis support. There was an independent, nonlinear relationship
between nadir hematocrit concentration during cardiopulmonary bypass and acute
renal failure necessitating dialysis support. Moderate hemodilution (nadir
hematocrit concentration, 21%-25%) was associated with the lowest risk of acute
renal failure necessitating dialysis support; the risk increased as nadir
hematocrit concentration deviated from this range in either direction (P =
.005). Compared with moderate hemodilution, the adjusted odds ratio for acute
renal failure necessitating dialysis support with severe hemodilution (nadir
hematocrit concentration <21%) was 2.34 (95% confidence interval, 1.47-3.71),
and for mild hemodilution (nadir hematocrit concentration >25%) it was 1.88 (95%
confidence interval, 1.02-3.46). CONCLUSIONS: Given that there is an independent
association between the degree of hemodilution during cardiopulmonary bypass and
perioperative acute renal failure necessitating dialysis support, patient
outcomes may be improved if the nadir hematocrit concentration during
cardiopulmonary bypass is kept within the identified optimal range. Randomized
clinical trials, however, are needed to determine whether this is a cause-effect
relationship or simply an association.

Cytokine. 2005 Feb 7;29(3):95-104. Epub 2004 Dec 02. 

Relationship between cerebral injury and inflammatory responses in patients
undergoing cardiac surgery with cardiopulmonary bypass.

Nakamura K, Ueno T, Yamamoto H, Iguro Y, Yamada K, Sakata R.

Department of Clinical Pharmacy and Pharmacology, Graduate School of Medical and
Dental Sciences, Kagoshima University, Kagoshima, Japan.
nakamura@m3.kufm.kagoshima-u.ac.jp

This study was performed to evaluate whether cytokines, adhesion molecules,
ghrelin and S-100B are useful markers in predicting the cerebral infarction
after cardiac surgery with cardioplumomary bypass (CPB). The patients (n=20)
were classified into two groups; group A (n=4) showed postoperative organized
cerebral damage, while group B (n=16) consisted of patients without occurrence
of postoperative strokes. Before CPB, serum levels of S-100B in both groups A
and B were low (<0.5 ng/mL), while ghrelin concentrations in group A (all
patients had history of strokes) were much higher than those in group B. After
CPB, when serum levels of S-100B in group A at 24h were higher than those in
group B, ghrelin in group A at same time point showed high levels in comparison
to group B. At 12 and 24h after CPB, levels of tumor necrosis factor
(TNF)-alpha, interleukin-10 and soluble TNF-receptor I in group A were
significantly higher than those in group B. In conclusion, it is considered that
ghrelin as well as S-100B can be a useful marker for the prediction of stoke
after CPB. Increase of TNF-alpha, interleukin-10 and soluble TNF-receptor I
after CPB may be involved in the pathogenesis of stroke after CPB.

Br J Anaesth. 2005 Feb;94(2):174-80. Epub 2004 Nov 12. 

Exhaled nitric oxide before and after cardiac surgery with cardiopulmonary
bypass--response to acetylcholine and nitroglycerin.

Tornberg DC, Angdin M, Settergen G, Liska J, Lundberg JO, Weitzberg E.

Department of Surgical Sciences, Anaesthesiology and Intensive Care, Karolinska
Institute and Karolinska University Hospital Solna, S-171 76 Stockholm, Sweden.
danieltornberg@hotmail.com

BACKGROUND: Pulmonary endothelial dysfunction may occur after
ischaemia-reperfusion injury and can be revealed as a reduced vasodilatory
response upon administration of acetylcholine (ACh). ACh also releases the
endothelium-derived vasodilator nitric oxide but direct measurements of this gas
are difficult to perform in vivo. We wanted to study the effects of i.v.
administration of ACh and the endothelium-independent vasodilator nitroglycerin
on exhaled nitric oxide in relation to pulmonary endothelial dysfunction after
open-heart surgery and cardiopulmonary bypass (CPB). METHODS: Basal exhaled
nitric oxide and the response in exhaled nitric oxide to i.v. injections of ACh
and nitroglycerin were measured with chemiluminescence in 10 patients before and
after open-heart surgery. RESULTS: Exhaled nitric oxide decreased significantly
after CPB. I.V. bolus injections of ACh induced a reproducible and
dose-dependent increase in exhaled nitric oxide that was unaltered after CPB. In
contrast, the increase in exhaled nitric oxide evoked by nitroglycerin was
attenuated after CPB. The response in pulmonary vascular resistance index (PVRI)
to an infusion of ACh decreased after CPB, indicating endothelial dysfunction.
The decrease in PVRI response to ACh correlated to the duration of CPB.
CONCLUSIONS: Interestingly, pulmonary vascular dysfunction after CPB was
accompanied by a reduction in the exhaled nitric oxide response to nitroglycerin
and lower levels of basal exhaled nitric oxide. The ACh-induced responses in
exhaled nitric oxide were unchanged, which could indicate nitric
oxide-independent mechanisms behind the endothelial dysfunction in this study.
The possibility of using exhaled nitric oxide dynamics to investigate pulmonary
endothelial dysfunction merits further studies.