J Cardiovasc Surg (Torino). 2006 Apr;47(2):211-5. 

Is hypothermia a benefit? Von Willebrand factor in pediatric cardiopulmonary
bypass.

Bec L, Karolczak MA, Motylewicz B, Rogala E.

Department of Cardiac and General Pediatric Surgery, University Medical School
of Warsaw, Poland.

AIM: The use of cardiopulmonary bypass (CPB) is associated with the risk of
development of postpump syndrome. Thrombocyte activation leads to microembolism,
endothelial damage and necrosis with release of various substances, such as the
von Willebrand factor (vWf). High levels of vWf increase the risk of
postoperative complications and mortality. Our objective was to find a
correlation between CPB and plasma levels of vWf in pediatric patients operated
on for congenital heart defects. METHODS: Twenty patients with congenital heart
defects (ventricular septal defect, atrial septal defect/partial anomalous
pulmonary vein drainage, Bland White Garland syndrome) were operated on with the
use of CPB. The arterial blood was sampled after induction of anesthesia, 5
minutes after commencing CPB, 1 hour and 3 hours after surgery. The plasma
levels of vWf were measured and compared to selected clinical findings. RESULTS:
There was no early mortality. There were no significant differences in CPB and
aortic cross clamp times when compared in patients with various defects. vWf
plasma levels were significantly elevated in all patients 1 hour and 3 hours
after surgery. We found no correlation between vWf levels and type of defect,
CPB duration, aortic cross clamp as well as reperfusion time. However, we were
able to demonstrate that the observed elevation of vWf levels was almost 4-fold
higher in patients cooled down to lower temperatures (15 patients; mean rectal
value 27.64+/-0.7 degrees C) than in 5 patients (mean rectal temperature
30.74+/-1.56 degrees C) where only slight elevation was found. There were no
differences in the postoperative course of these patients. All patients were
discharged from hospital 10+/-3 days after operation (mean value 9 days).
CONCLUSIONS: vWf plasma levels are significantly elevated after pediatric
hypothermic CPB. It seems that the augmentation of vWf values could be
independently associated with rate of hypothermia.

J Surg Res. 2006 Mar 24; [Epub ahead of print] 

Pulse Low Dose Steroids Attenuate Post-Cardiopulmonary Bypass SIRS; SIRS I.

Whitlock RP, Young E, Noora J, Farrokhyar F, Blackall M, Teoh KH.

Department of Surgery, Division of Cardiovascular Surgery, McMaster University,
Hamilton, Canada.

BACKGROUND: Cardiopulmonary bypass (CPB) initiates inflammation that contributes
to multiorgan dysfunction (SIRS). Steroids have been demonstrated to attenuate
this response; however, resistance to use steroids remains because of potential
adverse effects of the high doses used. This study examines a lower dose steroid
protocol for safety and attenuation of SIRS. METHODS: Sixty patients undergoing
CPB were randomized to pulse low doses of methylprednisolone (250 mg given twice
IV) or placebo in this RCT. Outcomes pertaining to hemodynamics, ventilator
requirement, arrhythmia, and metabolic derangements were recorded.
Post-operative glucose control and gastrointestinal prohylaxis was instituted in
all patients. RESULTS: IL-6 concentrations were lower in the steroid group at 4
and 8 h post-operatively (P < 0.0001). The steroid group demonstrated more
normothermia (37.2 degrees C versus 37.6 degrees C, P = 0.002), better
hemodynamic stability with less requirement for inotropes or vasopressors (0%
versus 27.6%, P = 0.005), higher SVRIs (1840 versus 1340 DSm(2)/cm(5), P =
0.002), and higher mean arterial pressures (79 versus 74 mmHg, P = 0.03). The
steroid group had a shorter duration of intubation (7.7 versus 10.7 h, P =
0.02), a shorter length of ICU stay (1.0 versus 2.0 days, P = 0.03), and less
blood loss (505 versus 690 ml, P = 0.04) with no difference in post-operative
blood glucose levels or complications. CONCLUSIONS: Patients undergoing
cardiopulmonary bypass receiving low pulse dose steroids had better
hemodynamics, shorter mechanical ventilation times, less blood loss, and
required less time in the ICU compared to those receiving placebo. Therefore,
this study demonstrates that prophylactic low dose steroids attenuate the SIRS
response to CPB without resulting in any untoward side-effects.

Ann Thorac Surg. 2006 Apr;81(4):1396-400. 

Mini-cardiopulmonary bypass system: results of a prospective randomized study.

Beghi C, Nicolini F, Agostinelli A, Borrello B, Budillon AM, Bacciottini F,
Friggeri M, Costa A, Belli L, Battistelli L, Gherli T.

Department of Cardiac Surgery, University of Parma, Italy.

BACKGROUND: We studied postoperative mortality and morbidity after coronary
artery bypass graft surgery performed using the mini-extracorporeal circulation
(MECC) system. METHODS: From June 2001 to June 2002, we randomly enrolled 60
patients who underwent isolated elective coronary artery bypass graft surgery,
and were operated on with the MECC system (30 patients: group A) or standard
cardiopulmonary bypass (30 patients: group B). Serial blood samples were
collected to evaluate the main preoperative, intraoperative, and postoperative
clinical and biological variables; and to measure hemolysis, interleukin-6
cytokine, and plasma C-reactive protein release. RESULTS: A more stable
hemoglobin level was detected in group A. The platelet count did not show a
significant difference between the two groups. Interleukin-6 cytokine release
showed higher values in group B, although no difference between groups was
statistically significant. The time course of circulating plasma C-reactive
protein concentration exhibited the same increase in both groups. Plasma free
hemoglobin levels showed higher hemolysis peaks in group B, although a
statistical significant difference was detected only at 4 hours after surgery. A
higher cardiac index and reduced systemic and pulmonary vascular resistance
index in the early postoperative period were found in group A at postoperative
time 30 minutes. CONCLUSIONS: Our experience shows that MECC offers satisfactory
clinical benefits in terms of good hemodynamic support, safety, and low
morbidity, although the study failed to demonstrate a significant clear
superiority of MECC versus conventional cardiopulmonary bypass. The results need
to be confirmed by a larger prospective, randomized study comparing MECC and
standard cardiopulmonary bypass.

Ann Thorac Surg. 2006 Apr;81(4):1379-84. 

Cardiac surgery in renal transplant recipients: experience from Washington
Hospital Center.

Zhang L, Garcia JM, Hill PC, Haile E, Light JA, Corso PJ.

Department of Surgery, Washington Hospital Center, Washington, DC 20010-2975,
USA.

BACKGROUND: The number of renal transplant survivors requiring surgical
treatment for cardiovascular diseases is increasing. A retrospective study was
conducted to determine the outcomes of renal transplant recipients undergoing
cardiac surgery. METHODS: Fifty-seven renal transplant recipients whose cardiac
surgery was performed between 1987 and 2004, and whose allograft was functioning
at the time of cardiac surgery, were identified. We analyzed postoperative
mortality and morbidity as well as late mortality. RESULTS: Among 57 patients,
70.2% had hypertension, 54.4% diabetes, and 28.1% poor left ventricular function
(ejection fraction < 0.35). Preoperative renal insufficiency (serum creatinine
level > or = 3 mg/dL) was noted in 12.3% of the patients. Coronary artery
disease was the dominant indication for the surgery. The median interval from
renal transplant to cardiac surgery was 60 months. In-hospital mortality was
5.3%. All deaths were cardiac-related. Infectious complications occurred in
17.5% of the patients. Acute allograft failure requiring hemodialysis occurred
in 28.6% of the patients with preoperative renal insufficiency, more frequent
than those without preoperative renal insufficiency. Multivariable analysis
identified preoperative renal insufficiency, mitral valve disease, and left
ventricular dysfunction as independent predictors of in-hospital major adverse
events (including death, infection, and renal failure). The 3-year survival was
71% after a median follow-up of 34 months. CONCLUSIONS: Infection control and
renal protection should be stressed to ensure the safety of cardiac surgery in
this patient group, while preoperative renal insufficiency, mitral valve
disease, and left ventricular dysfunction are associated with early adverse
outcomes. In the renal transplant recipients undergoing an isolated CABG,
avoidance of cardiopulmonary bypass and use of arterial grafts might lead to
better outcomes.

Pharmacotherapy. 2006 Apr;26(4):576-7. 

Recombinant Factor VIIa for Refractory Bleeding After Cardiac Surgery Secondary
to Anticoagulation with the Direct Thrombin Inhibitor Lepirudin.

Oh JJ, Akers WS, Lewis D, Ramaiah C, Flynn JD.

1 Department of Pharmacy Practice and Science, College of Pharmacy, University
of Kentucky, Lexington, Kentucky.

A 56-year-old man with heparin-induced thrombocytopenia with thrombosis syndrome
(HITTS) received anticoagulation with recombinant hirudin (lepirudin) for
emergency coronary artery bypass graft (CABG) surgery and aortic valve
replacement. The patient experienced life-threatening refractory bleeding that
was successfully treated with recombinant factor VIIa. He had a history of
infective endocarditis that resulted in severe aortic insufficiency,
three-vessel coronary artery disease, and acute renal failure requiring
hemodialysis. The patient was transferred from another hospital for the
emergency surgery, but before his transfer, he developed HITTS secondary to
therapeutic heparin for a deep vein thrombosis of the lower extremity. The
presence of HITTS, the urgent nature of the case, and the availability of the
direct thrombin inhibitor led the surgical team to select lepirudin for
anticoagulation to facilitate cardiopulmonary bypass. After separation from
cardiopulmonary bypass, the patient was in a coagulopathic state due to the
inability to reverse the lepirudin and the slowed elimination of the drug
secondary to inadequate renal function. As a result, the patient experienced
excessive generalized oozing that was unresponsive to traditional therapies and
blood product transfusions. Recombinant factor VIIa 35 mug/kg was given as
rescue therapy. The bleeding slowed, which allowed placement of chest tubes and
closing of the sternum. The patient was transferred to the intensive care unit
in stable condition with no evidence of thrombosis in the freshly placed bypass
grafts or on the bioprosthetic valve. Recombinant factor VIIa appears to be a
suitable option as salvage therapy in patients with refractory bleeding
secondary to anticoagulation with a direct thrombin inhibitor during cardiac
surgery.

Anesth Analg. 2006 Apr;102(4):1062-9. 

Population pharmacokinetics of milrinone in neonates with hypoplastic left heart
syndrome undergoing stage I reconstruction.

Zuppa AF, Nicolson SC, Adamson PC, Wernovsky G, Mondick JT, Burnham N, Hoffman
TM, Gaynor JW, Davis LA, Greeley WJ, Spray TL, Barrett JS.

Division of Clinical Pharmacology and Therapeutics, Department of Pediatrics,
Abramson Research Center, Philadelphia, Pennsylvania 19104-4318, USA.
zuppa@email.chop.edu

We performed a blinded, randomized pharmacokinetic study of milrinone in 16
neonates with hypoplastic left heart undergoing stage I reconstruction to
determine the impact of cardiopulmonary bypass and modified ultrafiltration on
drug disposition and to define the drug exposure during a continuous IV infusion
of drug postoperatively. Neonates received an initial dose of either a 100 or
250 microg/kg of milrinone into the cardiopulmonary bypass circuit at the start
of rewarming. Postoperatively, milrinone was infused to clinical needs. A
mixed-effect modeling approach was used to characterize milrinone
pharmacokinetics during cardiopulmonary bypass, modified ultrafiltration, and
postoperatively using the NONMEM algorithm. All patients in this study
demonstrated a modified ultrafiltration concentrating effect that occurred
despite a modified ultrafiltration drug clearance of 3.3 mL x kg(-1) x min(-1).
The infants in this study demonstrated an impaired renal clearance during the
immediate postoperative period. A constant infusion of 0.5 microg x kg(-1) x
min(-1) resulted in drug accumulation during the initial 12 h of drug
administration. Postoperatively, milrinone clearance was significantly impaired
(0.4 mL x kg(-1) x min(-1)), improved by the 12th postoperative hour, and
approached steady-state clearance (2.6 mL x kg(-1) x min(-1)) by postoperative
day 4. In the postoperative setting of markedly impaired renal function, an
infusion rate of 0.2 microg x kg(-1) x min(-1) should be considered.

Anesth Analg. 2006 Apr;102(4):998-1006. 

Gelatin and hydroxyethyl starch, but not albumin, impair hemostasis after
cardiac surgery.

Niemi TT, Suojaranta-Ylinen RT, Kukkonen SI, Kuitunen AH.

Department of Anesthesiology and Intensive Care Medicine, Helsinki University
Hospital, Meilahti Hospital, Helsinki, Finland. tomi.niemi@hus.fi

We investigated the effect of postoperative administration of colloids on
hemostasis in 45 patients after cardiac surgery. Patients were randomized to
receive 15 mL kg(-1) of either 4% albumin, 4% succinylated gelatin, or 6%
hydroxyethyl starch (molecular weight of 200 kDa/degree of substitution 0.5) as
a short-term infusion. There was a comparable decrease in maximum clot firmness
of thromboelastometry tracings in gelatin and hydroxyethyl starch groups
immediately after completion of the infusion, whereas these values remained
unchanged in the albumin group. The impairment in clot strength persisted up to
2 h, although the values partly recovered. Postoperative bleeding correlated
inversely with the clot strength in pooled data of the artificial colloids.
Fibrin formation (clot formation time, alpha-angle) and fibrinogen-dependent
clot strength (maximum clot firmness and shear elastic modulus) were more
disturbed in the hydroxyethyl starch group than in the gelatin group. We
conclude that after cardiopulmonary bypass surgery, both gelatin and
hydroxyethyl starch impair clot strength and fibrin buildup, which may
predispose patients to increased blood loss. The greatest impairment in
hemostasis was seen after hydroxyethyl starch administration, whereas albumin
appeared to have the least effect on hemostatic variables.

Asian Cardiovasc Thorac Ann. 2006 Apr;14(2):109-13. 

Minimal Access Heart Surgery via Lower Ministernotomy: Experience in 460 Cases.

Sun HS, Ma WG, Xu JP, Sun LZ, Lu F, Zhu XD.

, Department of Cardiovascular Surgery, Fu Wai Hospital, 167 Northern Lishi
Road, Beijing 100037, China. shs1505@sina.com.

Minimally invasive cardiac surgery has captured the interest and attention of
cardiac surgeons throughout the world. We reviewed our experience of minimal
access cardiac operations performed through a lower median ministernotomy.
Between January 1997 and August 2003, 100 congenital, 178 valvular, 168
coronary, 12 aneurysmal, and 2 other operations were performed via a 6 to 9 cm
lower ministernotomy in 460 consecutive patients. No special instruments were
required. Four patients died, and 2 re-operations were necessary. Complications
occurred in 28 patients (6.1%). The mean cardiopulmonary bypass time was 88.50
+/- 65.16 min, crossclamp time was 55.81 +/- 31.89 min, time to extubation was
14.71 +/- 29.33 h, and total chest drainage was 7.28 +/- 5.07 mL.kg(-1). Blood
transfusions of 951.42 +/- 642.34 mL were needed in 282 patients. Postoperative
hospital stay was 11.6 +/- 6.0 days. Our experience shows that many types of
cardiac operations can be performed through a lower ministernotomy. This
technique results in less trauma, quick recovery, and reduces the risk of
infection and blood loss. It is a safe and easy procedure that can bring about
favorable early outcomes in a wide range of cardiac operations.

Acta Anaesthesiol Scand. 2006 Apr;50(4):461-8. 

Effects of heparin, haemodilution and aprotinin on kaolin-based activated
clotting time: in vitro comparison of two different point of care devices.

Dalbert S, Ganter MT, Furrer L, Klaghofer R, Zollinger A, Hofer CK.

Institute of Anaesthesiology and Intensive Care Medicine, Triemli City Hospital
Zurich, Zurich, Switzerland.

Background: During cardiopulmonary bypass (CPB), measurement of kaolin-based
activated clotting time (kACT) is a standard practice in monitoring
heparin-induced anticoagulation. Despite the fact that the kACT test from the
Sonoclot Analyzer (SkACT) has been commercially available for several years, no
published data on the performance of SkACT are available. Thus, the aim of this
in vitro study was to compare SkACT with an established kACT from Hemochron
(HkACT). Methods: Blood was withdrawn from 25 patients before elective cardiac
surgery. SkACT and HkACT were measured in duplicate after in vitro
administration of heparin (0, 1, 2 and 3 U/ml), calcium-free lactated Ringer's
solution (25% and 50% haemodilution) and aprotinin (200 kIU/ml). Results: A
total of 600 duplicate kACT measurements were obtained from 25 cardiac surgery
patients. Overall, mean bias +/- SD between SkACT and HkACT was 7 +/- 70 s (1.3%
+/- 14.1%). Administration of heparin, haemodilution and aprotinin induced a
comparable effect on both activated clotting time (ACT) tests. Mean bias ranged
from -4 +/- 39 s (-1.7% +/- 12.9%) to 4 +/- 78 s (3.2% +/- 15.6%) for heparinzed
blood samples after haemodilution or aprotinin application and increased after
combined aprotinin administration and haemodilution. After haemodilution and
administration of aprotinin, both ACT tests were less reliable for values >480 s
in heparinized blood samples. Conclusion: Accuracy and performance of SkACT and
HkACT were comparable after in vitro administration of heparin, aprotinin and
haemodilution. Both ACT tests were considerably affected by aprotinin and
haemodilution.

Crit Care. 2006 Mar 15;10(2):R46 [Epub ahead of print] 

Circulating inflammatory mediators and organ dysfunction after cardiovascular
surgery with cardiopulmonary bypass: a prospective observational study.

de Mendonca-Filho HT, Pereira KC, Fontes M, Vieira DA, de Mendonca ML, Campos
LA, Castro-Faria-Neto HC.

Nucleo de Pesquisa Translacional, Hospital Pro Cardiaco, Rua General Polidoro
192, Botafogo, Rio de Janeiro, RJ, 22280-000 Brazil. htannus@centroin.com.br.

ABSTRACT : INTRODUCTION : Cardiovascular surgery with cardiopulmonary bypass
(CPB) has improved in past decades, but inflammatory activation in this setting
is still unpredictable and is associated with several postoperative
complications. Perioperative levels of macrophage migration inhibitory factor
(MIF) and other inflammatory mediators could be implicated in adverse outcomes
in cardiac surgery. METHODS : Serum levels of MIF, monocyte chemoattractant
protein (MCP)-1, soluble CD40 ligand, IL-6 and IL-10 from 93 patients subjected
to CPB were measured by enzyme-linked immunosorbent assay and compared with
specific and global postoperative organ dysfunctions through multiple organ
dysfunction score (MODS) and sequential organ failure assessment (SOFA). RESULTS
: Most of the cytokines measured had a peak of production between 3 and 6 hours
after CPB, but maximum levels of MIF occurred earlier, at the cessation of CPB.
Among specific organ dysfunctions, the most frequent was hematological,
occurring in 82% of the patients. Circulatory impairment was observed in 73.1%
of the patients, and 51% of these needed inotropics or vasopressors within the
first 24 hours after surgery. The third most frequent dysfunction was pulmonary,
occurring in 48.4% of the patients. Preoperative levels of MIF showed a relevant
direct correlation with the intensity of global organ dysfunction measured by
SOFA (rho = 0.46, p < 0.001) and MODS (rho = 0.50, p < 0.001) on the third day
after surgery. MCP-1 production was associated with postoperative
thrombocytopenia, and MIF was related to the use of a high dose of vasopressors
in patients with cardiovascular impairment and also to lower values of the ratio
of partial arterial oxygen tension (PaO2) to fraction of inspired oxygen (FiO2)
registered in the first 24 hours after CPB. CONCLUSION : Despite the
multifactorial nature of specific or multiple organ dysfunctions, MIF should be
explored as a predicting factor of organ dysfunction, or even as a potential
therapeutic target in decreasing postoperative complications.