Med Sci Monit. 2008 Mar;14(3):CS17-21.

Combined heart surgery and lung tumor resection.

Prokakis C, Koletsis E, Apostolakis E, Panagopoulos N, Charoulis N, Velissaris D,
Filos K, Dougenis D.

Department of Cardiothoracic Surgery, Patras University School of Medicine,
Patras, Greece.

Background: Combined heart surgery and lung resection remains a controversial
issue. This method facilitates the treatment of two major problems with one
intervention, reducing hospitalization cost with acceptable outcomes. On the
other hand, skepticism exists related to the effects of cardiopulmonary bypass on
malignancy and to a possible greater risk for perioperative bleeding.
 Case 
Reports: A retrospective study is presented of five male patients who underwent
combined surgical treatment for heart and lung disease in a one-step procedure
between November 2004 and November 2006. Three patients underwent aortic valve
replacement with right upper lobectomy. The other two patients underwent
pulmonary wedge resection, one combined with coronary bypass and the other with
ascending aorta replacement. In all cases, pulmonary resection was performed
before cardiopulmonary bypass was established. There was no perioperative death. 
Three patients had uneventful postoperative recovery, one patient developed
atrial fibrillation, and the last one temporary neurological dysfunction. There
was no increase in postoperative bleeding or in hospital stay. All patients are
under follow-up observation with good performance status. In those patients with 
pulmonary malignancy, no sign of regional or distant recurrence of the disease is
observed.
 Conclusions: Combined heart surgery and lung resection can be
performed without increased mortality and/or morbidity. The synchronous treatment
avoids the necessity of a second intervention with economic benefits and
excellent results.

J Clin Anesth. 2008 Mar;20(2):94-8.

The hemodynamic effects of phenoxybenzamine in neonates, infants, and children.

Mossad E, Motta P, Sehmbey K, Toscana D.

Department of Pediatric Anesthesia, Cleveland Clinic Foundation, Cleveland, OH
44195, USA; Department of Congenital Heart Surgery, Cleveland Clinic Foundation, 
Cleveland, OH 44195, USA.

STUDY OBJECTIVES: To evaluate the hemodynamic effects of the long-acting,
alpha-adrenergic blocker, phenoxybenzamine, in children of different age groups. 
DESIGN: Retrospective chart review. SETTING: Tertiary-care, congenital cardiac
surgery center. MEASUREMENTS: The data of 75 pediatric patients who received
phenoxybenzamine while undergoing surgical repair of congenital heart defects on 
cardiopulmonary bypass (CPB) were studied. Patients were selected in three age
groups: younger than one month (n = 25), one to 12 months (n = 25), and one to 5 
years (n = 25). All patients received a full dose of phenoxybenzamine 1 mg/kg.
Demographics, CPB duration, mean arterial pressure on CPB, mean flow on CPB
(normalized to body surface area), and central-to-peripheral temperature
gradients were recorded. Systemic vascular resistance index (SVRI) was
calculated. MAIN RESULTS: Cardiopulmonary bypass duration was significantly
longer in the age group of younger than 1 mo than in the older groups. Mean CPB
flow/body surface area was similar in all children (3.45 +/- 0.9, 3.74 +/- 0.69, 
and 3.48 +/- 0.59 L/min/m(2), respectively; P < 0.28). However, mean SVRI was
significantly lower in children younger than 1 mo (997.3 +/- 233, 1196.9 +/- 394,
and 1168.83 +/- 227 dynes/cm(2)m(5); P < 0.04). Temperature gradient was
significantly narrower in patients younger than one month than those who were one
to 12 months and one to 5 years at the end of cooling (0.90 degrees C +/- 0.1
degrees C, 1.04 degrees C +/- 3.61 degrees C, 1.4 degrees C +/- 3.07 degrees C; P
< 0.001) at end-rewarming and termination of CPB (4.58 degrees C +/- 2.36 degrees
C, 6.23 degrees C +/- 4.17 degrees C, 7.32 degrees C +/- 3.46 degrees C; P <
0.02). Multivariate analysis showed that patient age was a significant variable
affecting response to phenoxybenzamine, after adjusting for duration of CPB (P = 
0.31), mean hematocrit on CPB (P = 0.86), and core cooling temperature (P =
0.34). CONCLUSION: The effect of phenoxybenzamine on SVRI, cooling, and rewarming
on CPB varies with age as shown by more profound vasodilatation and narrower
temperature gradients.

J Extra Corpor Technol. 2008 Mar;40(1):74-6.

Rupture of extra-corporeal circuit tubing during cardiopulmonary bypass.

Krishna CS, Kumar PV, Satpathy SK, Mohan KR, Babu VR.

Department of Cardio-Thoracic Surgery, Apollo Heart Institute, Visakhapatnam,
Andhra Pradesh, India. csaikrishna@yahoo.com

Roller pumps are widely used for cardiopulmonary bypass in developing nations by 
virtue of proven safety during several years of institutional use and cost
effectiveness. However, careful adjustment of roller occlusion is needed because 
they are known to cause spallation, tubing wear, and the occasional incident of
rupture of tubing in the extracorporeal circuit. Rupture of polyvinylchloride
tubing in the pump raceway during repair of a ventricular septal defect in a
4-year-old child is discussed. The event was managed by exclusion and replacement
of the defective tubing during a short period of arrest. Use of an inappropriate 
boot pump and failure to detect its inclusion in the bypass circuit was a
significant departure from protocol. However, because occlusion settings and
duration of perfusion were within acceptable limits, a manufacturing flaw could
also have contributed to tubing failure, and the event may or may not have been
averted by the use of larger tubing. In conclusion, this incident reiterates the 
need for adherence to established protocol during assembly of the pump and draws 
attention to the fact that tubing integrity is not a guarantee and vigilance is
warranted to handle its failure.

J Extra Corpor Technol. 2008 Mar;40(1):43-51.

Factors that influence the ability to perform autologous priming.

Trowbridge C, Stammers A, Klayman M, Brindisi N.

Geisinger Medical Center, Perfusion Services 20-15, 100 N. Academy Avenue,
Danville, PA 17821, USA. cctrowbridge@geisinger.edu

The purpose of this study was to determine which factors impact the ability to
perform autologous priming (AP) of the extracorporeal circuit. Second, the
effects of differential AP on transfusion and volume requirements were evaluated.
After institutional review board approval, demographic, operative, volumetric,
and transfusion data were prospectively collected on 100 adult patients
undergoing cardiopulmonary bypass (CPB). Two analyses were conducted: AP Taken
and percent AP Given. For each analysis, three groups were created based on
standard distribution. Group A included patients within less than mean--1 SD (<
or = 500 mL AP Taken or > or = 90% AP Given back), group B included patients
within mean +/- 1 SD (501-1299 mL AP Taken or 11%-89% AP Given back), and group C
included patients greater than mean + 1 SD (> or = 1300 mL AP Taken or < or = 10%
AP given back). Weight, pre-CPB hematocrit, clinical severity, and pre-CPB volume
balance did not differ between the groups. Significant differences existed in AP 
Taken and percent AP Given between individual perfusionists. More AP was given
back with higher urine output (group A: 846 +/- 700 mL, group B: 613 +/- 414 mL, 
group C: 384 +/- 272 mL; p = .004), more autotransfusion [group A: 0 (0,1300 mL),
group B: 0 (0,500 mL), group C: 0 (0,250 mL); p = .008], and less AP Taken [group
A: 800 (0,1300 mL), group B: 1000 (200,1600 mL), group C: 1000 (800,1600 mL); p =
.001]. When more AP was taken, CPB hematocrit was higher (group A: 22.3% +/-
4.8%, group B: 25.6% +/- 4.7%, group C: 26.6% +/- 4.3%; p = .032), and fewer
patients received red blood cells (group A: 64.3%, group B: 28.3%, group C:14.3%;
p = .017). Some perfusionists were able to remove more AP before CPB. When more
AP was taken, CPB hematocrit was higher, fewer patients received a transfusion,
and less AP was given back. More AP was also given back with higher urine output 
and higher blood loss to the autotransfusion device.

Zhong Nan Da Xue Xue Bao Yi Xue Ban. 2008 Mar;33(3):262-5.

[Indications and effect of the intra-aortic balloon pump in 38 patients during
the cardiac surgery.]

[Article in Chinese]

Zhao Y, Zhou XM, Tang H, Hu JG, Liu LM, Li JM, Song FL, Dai AP.

Department of Cardiothoracic Surgery, Second Xiangya Hospital, Central South
University, Changsha 410011, China. zhaoyuan937@yahoo.com.cn.

Objective To review the indications and effect of the intra-aortic balloon pump
(IABP) in 38 patients during the cardiac surgery.Methods From June 2004 to August
2007, 38 patients were performed IABP in the cardiac surgery, including 28
coronary artery bypass grafting (CABG) and 10 valve replacements. The
intra-operation prophylactic use of IABP was in 5 cases, the use of IABP for
weaning from cardiopulmonary bypass (CPB) during the cardiac surgery was in 22
cases, and the rest use of IABP was after the operation in the intensive care
unit. Low molecular weight heparin was used for IABP anticoagulation.Results
Thirteen died out of the 38 IABP patients. The total IABP success rate was
66%.The IABP success rate in CABG was 82%, and 20% in the valve replacement. The 
patients with intra-operation prophylactic use of IABP all recovered, and 16
recovered out of the 22 patients with IABP uses for weaning from CPB, and 6
recovered out of the 11 patients with post-operation IABP application. No severe 
complications related to IABP occurred.Conclusion IABP has better effect in CABG 
patients than in valve replacements. Effect of the prophylactic use of IABP is
better than both the IABP use for weaning from CPB or the post-operation IABP
application. For IABP anticoagulation, low molecular weight heparin is the better
alternative than routine heparin, and the proper ACT is controlled at 150~170 s.

Congenit Heart Dis. 2008 Mar;3(2):82-9.

Early surgical morbidity and mortality in adults with congenital heart disease:
the University of Michigan experience.

Abarbanell GL, Goldberg CS, Devaney EJ, Ohye RG, Bove EL, Charpie JR.

Pediatric Cardiology, University of Michigan, Ann Arbor, MI 48109-9470, USA.

OBJECTIVES: To review early surgical outcomes in a contemporary series of adults 
with congenital heart disease (CHD) undergoing cardiac operations at the
University of Michigan, and to investigate possible preoperative and
intraoperative risk factors for morbidity and mortality. METHODS: A retrospective
medical record review was performed for all patients > or =18 years of age who
underwent open heart operations by a pediatric cardiothoracic surgeon at the
University of Michigan Congenital Heart Center between January 1, 1998 and
December 31, 2004. Records from a cohort of pediatric patients ages 1-17 years
were matched to a subset of the adult patients by surgical procedure and date of 
operation. RESULTS: In total, 243 cardiac surgical operations were performed in
234 adult patients with CHD. Overall mortality was 4.7% (11/234). The incidence
of major postoperative complications was 10% (23/234) with a 19% (45/23) minor
complication rate. The most common postoperative complication was atrial
arrhythmias in 10.8% (25/234). The presence of preoperative lung or liver
disease, prolonged cardiopulmonary bypass and aortic cross clamp times, and
postoperative elevated inotropic score and serum lactates were significant
predictors of mortality in adults. There was no difference between the adult and 
pediatric cohorts in terms of mortality and morbidity. CONCLUSIONS: The
postoperative course in adults following surgery for CHD is generally
uncomplicated and early survival should be expected. Certain risk factors for
increased mortality in this patient population may include preoperative presence 
of chronic lung or liver dysfunction, prolonged cardiopulmonary bypass and aortic
cross-clamp times, and postoperative elevated inotropic score and serum lactate
levels.

J Intensive Care Med. 2008 Mar-Apr;23(2):136-42.

Measurement of central venous pressure from a peripheral intravenous catheter
following cardiopulmonary bypass in infants and children with congenital heart
disease.

Baty L, Russo P, Tobias JD.

School of Medicine, University of Missouri.

The current study evaluates the feasibility and accuracy of measuring central
venous pressure from a peripheral intravenous catheter following cardiopulmonary 
bypass in infants and children. Central venous pressure was simultaneously
measured from a right atrial catheter and from a peripheral intravenous cannula. 
The continuity of the peripheral intravenous cannula with the central venous
system was evaluated by noting the change in the pressure during a sustained
inspiratory effort and during occlusion of the vessel above (proximal to) the
catheter. The cohort for the study included 29 infants and children. In 5 of the 
29 patients (17%), there was no increase in the peripheral venous pressure in
response to a Valsalva maneuver or occlusion of the extremity proximal to the
intravenous site. The difference between peripheral venous pressure and central
venous pressure in these patients was 11 +/- 3 mm Hg versus 2 +/- 1 mm Hg in the 
patients in whom the peripheral venous pressure increased with these maneuvers (P
< .0001). No clinically significant variation in the accuracy of the technique
was noted based on the actual CVP value, size of the PIV, its location, or the
patient's weight. Provided that the peripheral venous pressure increases to a
sustained inspiratory breath and occlusion above the intravenous site, there is a
clinically useful correlation between the peripheral venous pressure and the
central venous pressure following cardiopulmonary bypass in infants and children 
with congenital heart disease.

Eur J Cardiothorac Surg. 2008 Mar 20 [Epub ahead of print]

Outcomes of delayed sternal closure after complex aortic surgery.

Estrera AL, Porat EE, Miller CC 3rd, Meada R, Achouh PE, Irani AD, Safi HJ.

Department of Cardiothoracic and Vascular Surgery, University of Texas Medical
School and Memorial Hermann Hospital, Houston, TX, United States.

Objective: Open chest management during complex proximal aortic surgery may
sometimes be necessary. Infectious complications such as mediastinitis and late
aortic graft infection remain a concern. The objective of this study was to
report our experience with open chest management and delayed sternal closure
after complex proximal aortic surgery. Methods: Between 1991 and 2007, 12
patients (1.2%, 12/1011) required open chest management and delayed sternal
closure. Eight patients were men (67%), with a mean age of 56 years (range 28-83 
years). Four cases involved redo-median sternotomy (33%) and seven cases (58%)
involved acute dissection. All procedures were performed using total
cardiopulmonary bypass with profound hypothermic circulatory arrest. Reasons for 
open chest management included hemodynamic instability, mediastinal edema,
bleeding, and respiratory compromise. Results: In-hospital mortality was 16.7%
(2/12). Delayed sternal closure was achieved in 92% of patients (11/12). Mean
time to closure was 3 days (range 1-9 days). Five patients (42%) required one or 
more mediastinal explorations prior to final closure. Mean length of stay was 51 
days (range 1-186 days). Significant predictors of open chest management were
pump time (p<0.0001) and intra-operative blood transfusions (p<0.002). Mean
follow-up was 60 months (range 8-106 months). No patients developed mediastinitis
or aortic graft infection during postoperative follow-up. Conclusions: Open chest
management with delayed sternal closure after complex aortic repairs may be
performed with acceptable mortality. Open chest management does not appear to
increase the risk of infectious complications (mediastinitis or graft infections)
during complex proximal aortic replacement.

ASAIO J. 2008 Mar-Apr;54(2):203-6.

Reducing the effects of the systemic inflammatory response to cardiopulmonary
bypass: can single dose steroids blunt systemic inflammatory response syndrome?

Sobieski MA 2nd, Graham JD, Pappas PS, Tatooles AJ, Slaughter MS.

Division of Cardiac Surgery, Advocate Christ Medical Center, Oak Lawn, Illinois, 
USA.

The use of cardiopulmonary bypass (CPB) is associated with the development of a
significant systemic inflammatory response syndrome (SIRS) which can affect
patient outcomes. Multiple pathways are involved in initiating and maintaining
SIRS. We studied whether a single dose of steroids (dexamethasone) after the
induction of anesthesia could blunt the SIRS from CPB. A prospective, randomized,
double-blinded, placebo control trial of 28 patients (13 study vs. 15 control).
The study group received 100 mg of dexamethasone whereas the control group
received sterile saline. Inclusion criteria were the following: elective coronary
artery bypass grafting, less than 80 years old, normal ejection fraction, no
acute myocardial infarction. Serum levels of C3a, interleukin (IL)-6, and plasma 
norepinephrine (PNE) were measured after intubation, 30 minutes after initiation 
of CPB, 24 and 72 hours after termination of bypass. The study group demonstrated
significantly lower levels of IL-6 (p = 0.0005) at 24 hours and PNE (p = 0.05) at
72 hours post-CPB. There were no differences in the C3a levels between the
groups. No infections occurred in either group. A single dose of dexamethasone
reduces IL-6 and PNE levels associated with CPB. Despite the significant
reductions in IL-6 and PNE, there was no effect on clinical outcomes. Additional 
studies are needed to demonstrate a clinically significant effect on patient
outcomes.

Eur J Cardiothorac Surg. 2008 Mar 18 [Epub ahead of print]

Survival analysis in heart transplantation: results from an analysis of 1290
cases in a single center.

Tjang YS, van der Heijden GJ, Tenderich G, Grobbee DE, Körfer R.

Department of Thoracic & Cardiovascular Surgery, Heart & Diabetes Center NRW, Bad
Oeynhausen, Germany; Julius Center for Health Sciences and Primary Care,
University Medical Center Utrecht, Utrecht, The Netherlands; Netherlands
Institutes for Health Sciences, The Netherlands.

Background: The clinical profiles of recipients and donors eligible for the
procedure as well as the procedure itself have changed over time. We determined
the impact of changes in baseline risk profiles at different transplant periods
on outcome, and the time-specific distribution of causes of death. Patients and
methods: Adult heart transplantations were performed consecutively on 1290
patients. Three transplant periods were defined: 1989-1993, 1994-1998, and
1999-2004. Results: Recipient age and body mass index, previous cardiac surgery, 
high urgency status, need of ventricular assist device, waiting time (to
transplantation and on ventricular assist device), donor age and body mass index,
donor-recipient body mass index mismatch, and ischemic and cardiopulmonary bypass
time were significantly different over the three transplant periods. There was,
however, no significant difference in mortality risk. The major causes of deaths 
were: acute rejection, multiorgan failure, and right heart failure (1-5 years); 
cardiac allograft vasculopathy and malignancy (>5-10 years); and malignancy and 
infection (>10 years). The overall 1-, 5-, 10- and 15-year survival was respectively 
77%, 67%, 53% and 42%. 
There was no difference in survival by different transplant periods (p=0.68).
Conclusion: Despite clearly increased baseline risk profiles over time, the
outcome of adult heart transplantation remains stable and encouraging. Cardiac
allograft vasculopathy, malignancy, and infection threaten the long-term
survival.