TITLE:   Individualized heparin and protamine management in infants and
         children undergoing cardiac operations.
AUTHORS: Codispoti M; Ludlam CA; Simpson D; Mankad PS
AUTHOR AFFILIATION:
      Department of Cardiac Surgery, Royal Hospital For Sick Children,
      Edinburgh, Scotland.
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      BACKGROUND: Measurements of activated coagulation time do not
      correlate with plasma concentration of heparin. This study
      investigated the effects of a patient-specific method to manage
      anticoagulation and its reversal in pediatric patients undergoing
      cardiopulmonary bypass. METHODS: Infants and children were randomly
      assigned to receive either a standard dose of heparin (300 IU/kg;
      group C, n = 13) or an individualized dose, calculated by an in vitro
      heparin dose-response test (group HC, n = 13). Protamine dose was
      based on a 1 mg/l mg ratio of total administered heparin for patients
      in group C and of the residual heparin concentration in group HC.
      RESULTS: Administered heparin was significantly higher and total
      protamine dose was significantly reduced in the HC group (both p <
      or = 0.001). There was less thrombin generation (p = 0.02) and
      fibrinolysis (p = 0.05) in group HC. Blood loss and requirement for
      transfusion of blood and fresh frozen plasma were also lower in group
      HC (all p < or =0.05). CONCLUSIONS: An individualized management
      of anticoagulation and its reversal results in less activation of the
      coagulation cascade, less fibrinolysis, and reduced blood loss and
      need for transfusions. Further studies are warranted to better define
      the clinical impact of these findings.
NLM PUBMED CIT. ID:
      11269475
SOURCE:  Ann Thorac Surg 2001 Mar;71(3):922-7; discussion 927-8.

TITLE:   Neurodevelopmental outcome related to cerebral risk factors in
         children after neonatal arterial switch operation.
AUTHORS: Hovels-Gurich HH; Seghaye MC; Sigler M; Kotlarek F
      Bartl A; Neuser J; Minkenberg R; Messmer BJ; von Bernuth G
AUTHOR AFFILIATION:
      Department of Pediatric Cardiology, Aachen University of Technology,
      Germany. hhoevels-guerich@post.klinikum.rwth-aachen.de
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      BACKGROUND: Neurodevelopmental outcome after neonatal arterial switch
      operation for complete transposition of the great arteries is an
      important topic needing prospective assessment. METHODS: A group of
      33 unselected children (3.0 to 4.6 years) operated on as neonates
      with combined deep hypothermic circulatory arrest and low flow
      cardiopulmonary bypass and a control group of 32 age-matched healthy
      children (3.0 to 4.8 years) underwent evaluation of socioeconomic and
      clinical neurological status and a standardized test comprising all
      areas of child development. Results of patients were related to those
      of the control group, to population norms, and to preoperative,
      perioperative, and postoperative cerebral risk factors. RESULTS:
      Clinical neurological status was normal in 26 patients (78.8%) and
      reduced in 7 (21.2%). Complete developmental score and the subscores
      for motor function, visual perception, learning and memory, cognitive
      function, language, and socioemotional functions were not different
      compared to population norms. Compared to the patients, the children
      of the control group scored higher on tests of complete development,
      cognition, and language, but also on socioeconomic status. Complete
      developmental score and the scores for motor, cognitive, and language
      functions were weakly inversely related to the duration of
      circulatory arrest, but not to the duration of bypass. Cerebral risk
      factors such as serum levels of the neuron-specific enolase,
      perinatal acidosis, perinatal asphyxia, peri- and postoperative
      cardiocirculatory insufficiency, or clinical seizures were not
      correlated to the test results. CONCLUSIONS: Neonatal arterial switch
      operation with combined circulatory arrest and low flow bypass is
      associated with neurological impairment, but not with reduced
      development as assessed by formal testing of motor, cognitive,
      language, and behavioral functions. Perioperative serum level of the
      neuron-specific enolase is not a valid marker for later developmental
      impairment.
NLM PUBMED CIT. ID:
      11269469
SOURCE:  Ann Thorac Surg 2001 Mar;71(3):881-8.

TITLE:   Postischemic reperfusion injury can be attenuated by oxygen tension
         control.
AUTHORS: Kaneda T; Ku K; Inoue T; Onoe M; Oku H
AUTHOR AFFILIATION:
      Department of Cardiovascular Surgery, Kinki University School of
      Medicine, Osaka-Sayama, Osaka, Japan. toshio_kaneda@hotmail.com
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      Oxygen-derived free radicals cause cytotoxic damage during reperfusion
      after a period of ischemia and the production of these free radicals
      may be proportionate to oxygen tension (PO2). The present study
      tested the hypothesis that oxidative damage may be limited by
      maintaining a more physiologic PO2 following ischemia. An
      experimental study in Wistar rats were mounted on a Langendorff
      apparatus was conducted to estimate baseline aortic flow (AF),
      coronary flow (CF), cardiac output (CO), systolic pressure (SP),
      heart rate (HR), and the rate-pressure product (RPP: HRxSP). The
      hearts were divided into 3 groups (n=7, hearts/group): group 1,
      hypoxic (PO2=300+/-50 mmHg) reperfusion; group 2, middleoxic
      (PO2=500+/-50 mmHg) reperfusion; and group 3, hyperoxic (PO2=700+/-50
      mmHg) reperfusion. Following 30 min of warm ischemia, hearts in all
      groups were reperfused at each oxygen pressure. The recovery of
      cardiac function of each heart was measured at the end of
      reperfusion. Concentrations of lactate (LAC), lactate dehydrogenase
      (LDH), and creatine kinase (CK) in the coronary perfusate during
      reperfusion were measured. The recovery rate of CO, SP, and RPP in
      group 2 were all significantly better than in the other 2 groups. CK
      leakage in group 2 was significantly lower than in group 3. A
      clinical study was also conducted during elective coronary artery
      bypass grafts in 16 consecutive patients who underwent either
      hyperoxic (n=8, PO2=450-550 mmHg) or more physiologic (n=8,
      PO2=200-250 mmHg) cardiopulmonary bypass after aortic unclamping. The
      clinical study assessed CK-MB, LDH, LAC, and malondialdehyde (MDA) in
      patient blood prior to starting the surgical procedure and at 30 min
      and 3, 9, and 21 h after unclamping. Cardiac index (CI), central
      venous pressure, pulmonary capillary wedge pressure, systolic
      arterial pressure, and the dose of cathecholamines were also
      measured. Although no significant differences were present in the
      dose of cathecholamines, the CI in the more physiologic oxygen
      tension group was significantly higher than in the hyperoxic group at
      3 and 6 h after unclamping. The levels of MDA in the more physiologic
      PO2 group was significantly lower at 30 min after aortic unclamping
      than in the hyperoxic group. The present results suggest that in the
      experimental as well as in the clinical study, high PO2 leads to
      myocardial reperfusion damage; however, maintaining a more
      physiologic PO2 during reperfusion following ischemia may attenuate
      reperfusion injury.
NLM PUBMED CIT. ID:
      11266197
SOURCE:  Jpn Circ J 2001 Mar;65(3):213-8.

TITLE:   Healing the heart with ventricular assist device therapy: mechanisms
         of cardiac recovery.
AUTHORS: Young JB
AUTHOR AFFILIATION:
      Kaufman Center for Heart Failure, Section of Heart Failure and Cardiac
      Transplant Medicine, The Cleveland Clinic Foundation, Ohio 44195,
      USA. young@ccf.org
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      As experience has grown with the use of mechanical circulatory support
      systems in patients with cardiogenic shock, many anecdotes have been
      noted where myocardial recovery occurred and devices could be removed
      with reasonable residual cardiovascular performance and resolution of
      the shock syndrome. Indeed, when first used, ventricular assist
      devices were inserted to bridge patients unable to be separated from
      cardiopulmonary bypass to eventual recovery. Many successes with
      ventricular support systems have been recorded in individuals with
      postcardiotomy cardiogenic shock, acute myocarditis, and in the
      periinfarction period where stunning of potentially viable myocardial
      tissue contributed to severe heart failure. From an experimental
      standpoint, recovery of myocyte function and restoration of more
      normal myocardial geometry and constitution have been noted. There
      are many explanations for this, but principally, benefit is related
      to amelioration of circulatory insufficiency with attenuation of
      perturbed humoral networks and reduction of myocardial wall stress.
      It is important to understand how ventricular assist device
      implantation in select advanced heart failure patients might
      precipitate recovery of depressed myocardial function.
NLM PUBMED CIT. ID:
      11265865
SOURCE:  Ann Thorac Surg 2001 Mar;71(3 Suppl):S210-9.

TITLE:   Hemolysis and hematology profile during perfusion: inter-species
         comparison.
AUTHORS: Mueller XM; Tevaearai HT; Jegger D; Tucker O
      von Segesser LK
AUTHOR AFFILIATION:
      Clinic for Cardiovascular Surgery, CHUV (Centre Hospitalier
      Universitaire Vaudois) Lausanne, Switzerland.
      xavier.mueller@chuv.hospvd.ch
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      INTRODUCTION: Cardiopulmonary bypass components need to be tested on
      an animal model before their clinical application. Because their
      weight is similar to that of man, the calf and pig are often used.
      This study compares the impact of prolonged perfusion on hemolysis
      and hematology profile in both species. METHODS: Three calves (mean
      bodyweight: 77.2+/-4.4 kg) and three pigs (80+/-5.3 kg) were
      connected to an extracorporeal circulation circuit by jugular venous
      and carotid arterial cannulation, with a mean flow rate of 3.5L/min
      for 6h. After 7 days, the animals were sacrificed. A standard battery
      of blood samples was taken before, throughout, and 24h, 48h and 7
      days after bypass. ANOVA was used for repeated measurements. RESULTS:
      Absolute values of red cell count were higher in the calf
      (p<0.001), while normalized values were higher in the pig
      (p<0.001). Absolute values of white cell count were higher in the
      pig, while normalized values diverged toward the end of the perfusion
      with an increase in the calf and a decrease in the pig (p<0.001).
      Free plasma Hb and LDH exhibited similar profiles in both groups.
      CONCLUSIONS: In the setting of prolonged perfusion, species
      type--bovine or porcine--has an impact on hematology profile, but not
      on hemolytic parameters. These findings should be taken into account
      when cardiopulmonary bypass components are tested.
NLM PUBMED CIT. ID:
      11256514
SOURCE:  Int J Artif Organs 2001 Feb;24(2):89-94.

TITLE:   ABO-incompatible heart transplantation in infants.
AUTHORS: West LJ; Pollock-Barziv SM; Dipchand AI; Lee KJ
      Cardella CJ; Benson LN; Rebeyka IM; Coles JG
AUTHOR AFFILIATION:
      Department of Paediatrics, Hospital for Sick Children and University
      of Toronto, ON, Canada. lwest@sickkids.on.ca
PUBLICATION TYPES:
      Clinical Trial
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      BACKGROUND: Transplantation of hearts from ABO-incompatible donors is
      contraindicated because of the risk of hyperacute rejection mediated
      by preformed antibodies in the recipient to blood-group antigens of
      the donor. This contraindication may not apply to newborn infants,
      who do not yet produce antibodies to T-cell-independent antigens,
      including the major blood-group antigens. METHODS: We studied 10
      infants 4 hours to 14 months old (median, 2 months) who had
      congenital heart disease or cardiomyopathy and who received heart
      transplants from donors of incompatible blood type between 1996 and
      2000. Serum isohemagglutinin titers were measured before and after
      transplantation. Plasma exchange was performed during cardiopulmonary
      bypass; no other procedures for the removal of antibodies were used.
      Standard immunosuppressive therapy was given, and rejection was
      monitored by means of endomyocardial biopsy. The results were
      compared with those in 10 infants who received heart transplants from
      ABO-compatible donors. RESULTS: The overall survival rate among the
      10 recipients with ABO-incompatible donors was 80 percent, with 2
      early deaths due to causes presumed to be unrelated to ABO
      incompatibility. The duration of follow-up ranged from 11 months to
      4.6 years. Two infants had serum antibodies to antigens of the
      donor's blood group before transplantation. No hyperacute rejection
      occurred; mild humoral rejection was noted at autopsy in one of the
      infants with antibodies. No morbidity attributable to ABO
      incompatibility has been observed. Despite the eventual development
      of antibodies to antigens of the donor's blood group in two infants,
      no damage to the graft has occurred. Because of the use of
      ABO-incompatible donors, the mortality rate among infants on the
      waiting list declined from 58 percent to 7 percent. CONCLUSIONS:
      ABO-incompatible heart transplantation can be performed safely during
      infancy before the onset of isohemagglutinin production; this
      technique thus contributes to a marked reduction in mortality among
      infants on the waiting list.
NLM PUBMED CIT. ID:
      11248154
SOURCE:  N Engl J Med 2001 Mar 15;344(11):793-800.

TITLE:   [Preoperative autologous blood donation in elderly patients with
         cardiovascular surgery]
AUTHORS: Yoda M; Nonoyama M; Shimakura T; Morishita A
      Takasaki T
AUTHOR AFFILIATION:
      Department of Cardiovascular Surgery, Fukuyama Circulation Hospital,
      Fukuyama, Japan.
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      jpn
ABSTRACT:
      BACKGROUND: During the cardiovascular surgeries in elderly people,
      only a few cases can avoid the homologous blood transfusion, because
      of their preoperative anemic tendency and low hemopoietic abilities.
      We examined the capability to avoid the homologous blood transfusion
      in over 75 year old patients by the preoperative autologous blood
      collection. Sixty-six patients underwent scheduled cardiovascular
      surgery between January 1996 and December 1999. The groups were
      divided into three categories of preoperatively collected autologous
      blood amounts: high-amount (800-1,200 ml), medium-amount (200-800
      ml), and low-amount (0 ml). Each group was divided into two subgroups
      in according to the use of cardiopulmonary bypass (CPB). There were
      no differences among the each group in age, body weight, or
      preoperative and postoperative day-7 hematocrit values. RESULTS: Only
      21.2% of patients could donate the expected blood amounts
      preoperatively. Mean volume was 641 ml. In groups used CPB, no
      patient was transfused homologous blood in high-amount group. On the
      contrary, 100% patients were donated in medium and low amount groups.
      In groups operated without CPB, homologous blood transfusion was
      required 14.3% in high-amount group, 25.0% in medium-amount group,
      and 83.3% in low-amount group. CONCLUSION: It seems that predonation
      of more than 800 ml may be sufficient to avoid the homologous blood
      transfusion in using CPB operation and more than 400 ml in non using
      CPB operation.
NLM PUBMED CIT. ID:
      11244751
SOURCE:  Kyobu Geka 2001 Mar;54(3):203-6.

TITLE:   Incidence and predictors of ards after cardiac surgery.
AUTHORS: Milot J; Perron J; Lacasse Y; Letourneau L
      Cartier PC; Maltais F
AUTHOR AFFILIATION:
      Centre de Recherche, Hopital Laval, Institut Universitaire de
      Cardiologie et de Pneumologie de l'Universite Laval, Sainte-Foy,
      Quebec, Canada.
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
ABSTRACT:
      BACKGROUND: Severe pulmonary injury with the development of ARDS is a
      potential complication of cardiac surgery and cardiopulmonary bypass
      (CPB). Study objectives: This retrospective, case-control study was
      designed to determine the incidence and mortality of ARDS after
      cardiac surgery and CPB, as well as to identify preoperative and
      perioperative predisposing factors of this complication. METHODS: Of
      3,278 patients who underwent cardiac surgery and CPB between January
      1995 and December 1998, 13 patients developed ARDS during the
      postoperative period. Each patient was matched with four or five
      control subjects who had the same type of surgery on the same day but
      did not develop postoperative respiratory complications. RESULTS: The
      incidence of ARDS was 0.4%, with an ARDS mortality of 15%. In the
      ARDS group, 38% had previous cardiac surgery, as compared to 3.5% in
      the control group (p < 0.002). During the postoperative period,
      ARDS patients received more blood products (4 +/- 5 vs 2 +/- 3; p
      < 0.01) and developed shock more frequently (31% vs 5%; p <
      0.02) than patients in the control group. Multivariate regression
      analysis identified previous cardiac surgery, shock, and the number
      of transfused blood products as significant independent predictors
      for ARDS, with odds ratios of 31.5 (p = 0.015), 10.8 (p = 0.03), and
      1.6 (p = 0.03), respectively. CONCLUSIONS: ARDS following cardiac
      surgery and CPB was a rare complication that carried a 15% mortality
      rate. Previous cardiac surgery, shock, and number of blood products
      received are important predicting factors for this complication.
NLM PUBMED CIT. ID:
      11243972
SOURCE:  Chest 2001 Mar;119(3):884-8.

TITLE:   An investigation of a new activated clotting time "MAX-ACT"
         in patients undergoing extracorporeal circulation.
AUTHORS: Leyvi G; Shore-Lesserson L; Harrington D
      Vela-Cantos F; Hossain S
AUTHOR AFFILIATION:
      Department of Anesthesiology, Mount Sinai Medical Center, New York,
      New York, USA. galina743@pol.net
PUBLICATION TYPES:
      Journal Article
LANGUAGES:
      eng
REGISTRY NUMBERS:
      0 (Anticoagulants)
      9000-94-6 (Antithrombin III)
      9005-49-6 (Heparin)
ABSTRACT:
      Activated clotting time (ACT) is a test used in the operating room for
      monitoring heparin effect. However, ACT does not correlate with
      heparin levels because of its lack of specificity for heparin and its
      variability during hypothermia and hemodilution on cardiopulmonary
      bypass (CPB). A modified ACT using maximal activation of Factor XII,
      MAX-ACT (Actalyke MAX-ACT; Array Medical, Somerville, NJ), may be
      less variable and more closely related to heparin levels. We compared
      MAX-ACT with ACT in 27 patients undergoing CPB. We measured ACT,
      MAX-ACT, temperature, and hematocrit at six time points: baseline;
      postheparin; on CPB 30, 60, and 90 min; and postprotamine.
      Additionally, we assessed anti-Factor Xa heparin activity and
      antithrombin III activity at four of these six time points. With
      institution of CPB and hemodilution, MAX-ACT and ACT did not change
      significantly but had a tendency to increase, whereas concomitant
      heparin levels decreased (P = 0.065). Neither test correlated with
      heparin levels. ACT and MAX-ACT did not differ during normothermia
      but did during hypothermia, and ACT was significantly longer than
      MAX-ACT (P = 0.009). At the postheparin time point, ACT-heparin
      sensitivity (defined as [ACT postheparin - ACT baseline]/[heparin
      concentration postheparin - heparin concentration baseline]) was
      greater than MAX-ACT-heparin sensitivity (analogous calculation for
      MAX-ACT; 520 [266 - 9366] s. U(-1). mL(-1) vs 468 [203 - 8833] s.
      U(-1). mL(-1); P = 0.022). IMPLICATIONS: MAX-ACT (a new activated
      clotting time [ACT] test) uses more maximal clotting activation in
      vitro and, although it is less susceptible to increase because of
      hypothermia and hemodilution than ACT, lack of correlation with
      heparin levels remains a persistent limitation.
NLM PUBMED CIT. ID:
      11226081
SOURCE:  Anesth Analg 2001 Mar;92(3):578-83.