J Cardiothorac Vasc Anesth  2003 Apr;17(2):221-225 

Antibiotic prophylaxis with cefazolin and gentamicin in cardiac surgery for
children less than ten kilograms.

Haessler D, Reverdy ME, Neidecker J, Brule P, Ninet J, Lehot JJ.

Service d'Anesthesie-Reanimation and Equipe d'Accueil 1896, Hopital
Cardiovasculaire et Pneumologique Louis Pradel, Lyon, France; Laboratoire
Central de Microbiologie, Hopital Edouard Herriot, Lyon, France; and Service de
Chirurgie Cardiaque, Hopital Cardiovasculaire et Pneumologique, Lyon, France.

OBJECTIVE: Antibiotic prophylaxis is recommended in pediatric cardiac surgery,
but no data concerning the current antibiotic regimen were available. DESIGN:
Prospective study from April to June 2000. SETTING: University hospital
operating room and postoperative intensive care unit. PARTICIPANTS: Nineteen
consecutive infants less than 10 kg with normal renal function undergoing
cardiac surgery with cardiopulmonary bypass longer than 30 minutes.
INTERVENTIONS: Intravenous administration of cefazolin, 40 mg/kg, and
gentamicin, 5 mg/kg, at induction of anesthesia; followed by cefazolin, 35 mg/kg
every 8 hours, and gentamicin, 2 mg/kg every 12 hours, over 48 hours.
MEASUREMENTS AND MAIN RESULTS: Levels of serum antibiotics were measured:
cefazolin (microbiologic) and gentamicin (fluorescence immunoassay) with 8
intraoperative and 5 postoperative samplings. Intraoperatively, cefazolin levels
decreased from 166 +/- 44 (mean +/- standard deviation) down to 54 +/- 16
&mgr;g/mL and gentamicin from 20.8 +/- 9.5 down to 5.9 +/- 1.5 &mgr;g/mL. The
postoperative trough levels were 12 +/- 7, 15 +/- 10, and 19 +/- 22 &mgr;g/mL
for cefazolin and 1.1 +/- 0.5, 0.8 +/- 0.4, and 0.8 +/- 0.9 &mgr;g/mL for
gentamicin. CONCLUSIONS: Antibiotic serum levels are consistent with
satisfactory efficacy, but intraoperative gentamicin peak levels appeared too
high. 

J Cardiothorac Vasc Anesth  2003 Apr;17(2):171-5 

Management of heparin resistance during cardiopulmonary bypass: The effect of
five different anticoagulation strategies on hemostatic activation.

Koster A, Fischer T, Gruendel M, Mappes A, Kuebler WM, Bauer M, Kuppe H.

Department of Anesthesia, Deutsches Herzzentrum Berlin, Germany; Institute of
Physiology, Freie Universitat Berlin, Germany; and the Department of
Cardiothoracic and Vascular Surgery, Deutsches Herzzentrum Berlin, Germany.

OBJECTIVE: Attenuation of hemostatic activation is a central goal during CPB.
However, this poses a problem in patients insensitive to heparin. The present
investigation was performed to assess different strategies of managing patients
with heparin resistance during CPB. DESIGN: A randomized, prospective clinical
investigation. SETTING: A major European heart center. PARTICIPANTS: Five groups
with 20 patients each were investigated. INTERVENTIONS: The groups were handled
as follows: (1) maintenance of a target ACT, (2) maintenance of the target
unfractionated heparin (UFH) level and supplementation of a UFH level-based
strategy with (3) AT III, (4) the direct thrombin inhibitor r-hirudin, or (5)
the short-acting platelet glycoprotein (GP) IIb/IIIa antagonist tirofiban.
Platelet count and generation of contact factor XIIa, thrombin, and soluble
fibrin were assessed. Samples were obtained before CPB and after CPB before
protamine infusion. MEASUREMENTS AND MAIN RESULTS: There were no differences
observed in the generation of factor XIIa. The UFH-based strategy and
supplementation with AT III, r-hirudin, and tirofiban resulted in significantly
reduced (p < 0.05) thrombin generation compared with ACT management. A
significant reduction of fibrin formation was seen only in patients who received
AT III, r-hirudin, or tirofiban supplementation to the UFH. The administration
of tirofiban resulted in a significant preservation of the platelet count
compared with the other groups. There were no significant differences in the
postoperative blood loss. CONCLUSIONS: Activation of hemostasis during CPB in
heparin-resistant patients most likely has to be attributed to stimulation of
the tissue factor pathway. Even the sole use of high concentrations of UFH does
not effectively inhibit this activation. Therefore, in these patients
anticoagulation during CPB with UFH should be supplemented with either AT III, a
short-acting direct thrombin inhibitor, or a short-acting platelet glycoprotein
IIb/IIIa antagonist. 

Eur J Cardiothorac Surg  2003 Apr;23(4):633-6 

A prospective randomised comparison of cardiotomy suction and cell saver for
recycling shed blood during cardiac surgery.

Jewell AE, Akowuah EF, Suvarna SK, Braidley P, Hopkinson D, Cooper G.

Department of Cardiothoracic Surgery, The Northern General Hospital, Herries
Road, Sheffield S5 7AU, UK

OBJECTIVE: Post-operative neuropsychological complications correlate with
intra-operative microemboli in the middle cerebral artery. When severe
neurological complications follow cardiac surgery, diffuse cerebral fat emboli
are present at autopsy. Recycling shed blood with cardiotomy suction is an
important source of cerebral fat microemboli. A cell saver may reduce this.
METHODS: Twenty patients were prospectively randomised to assess the amount of
fat in blood salvaged from the pericardium and returned to the patient with
either cell saver or cardiotomy suction. Blood samples were taken before and
after filtration in the cardiotomy suction group or cell saver processing in the
cell saver group. After centrifuging samples, fat content was graded on a scale
of 0-3 by a blinded independent observer. Fat content was also quantified by
weight. RESULTS: Compared with cardiotomy suction, cell saver removed
significantly more fat from shed blood. Median fat grading after cell saver was
0 (0-1) compared with 1 (1-2) for cardiotomy suction (P=0.0001). Percentage
reduction in fat weight achieved by cell saver or cardiotomy suction was 87%
compared to 45% (P=0.007). There was no difference in the post-operative use of
blood or blood products, haemoglobin, or bleeding between the two groups.
CONCLUSION: Use of cell saver results in less fat being recycled during
cardiopulmonary bypass.

Crit Care Med  2003 Apr;31(4):1068-74 

Stress doses of hydrocortisone reduce severe systemic inflammatory response
syndrome and improve early outcome in a risk group of patients after cardiac
surgery.

Kilger E, Weis F, Briegel J, Frey L, Goetz AE, Reuter D, Nagy A, Schuetz A, Lamm
P, Knoll A, Peter K.

Department of Anesthesiology, University of Munich, Klinikum Grosshadern,
Munich, Germany.

OBJECTIVE: Severe systemic inflammation with a vasodilatory syndrome occurs in
about one third of all patients after cardiac surgery with cardiopulmonary
bypass. Hydrocortisone has been used successfully to reverse vasodilation in
septic patients. We evaluated if stress doses of hydrocortisone attenuate severe
systemic inflammatory response syndrome in a predefined risk group of patients
after cardiac surgery with cardiopulmonary bypass. DESIGN: Randomized,
nonblinded, controlled trial. SETTING: Anesthesiologic intensive care unit for
cardiac surgical patients of an university hospital. PATIENTS: After a risk
analysis, we enrolled 91 patients into a prospective randomized trial. Patients
were included according to the evaluated criteria (preoperative ejection
fraction, duration of cardiopulmonary bypass, type of surgery). INTERVENTIONS:
The treatment group received stress doses of hydrocortisone perioperatively: 100
mg before induction of anesthesia, then 10 mg/hr for 24 hrs, 5 mg/hr for 24 hrs,
3 x 20 mg/day, and 3 x 10 mg/day. MEASUREMENTS AND MAIN RESULTS: We measured
various laboratory (e.g., lactate) and clinical variables (e.g., duration of
ventilation and length of stay in the intensive care unit), characterizing the
patients' outcome. The two study groups did not differ regarding age,
preoperative medication, duration of the cardiopulmonary bypass, and type of
surgery. The patients in the treatment group had significantly lower
concentrations of IL-6 and lactate, higher antithrombin III concentration, lower
need for circulatory and ventilatory support and for transfusions, lower
Therapeutic Intervention Scoring System values, and shorter length of stay in
the intensive care unit and in the hospital. The mortality rate did not differ
significantly between the groups. CONCLUSIONS: Although we acknowledge the
limitations of a nonblinded interventional trial, stress doses of hydrocortisone
seem to attenuate systemic inflammation in a predefined risk group of patients
after cardiac surgery with cardiopulmonary bypass and improve early outcome.

Crit Care Med  2003 Apr;31(4):1053-9 

Comment in:
     Crit Care Med. 2003 Apr;31(4):1281-2.

Plasminogen activator inhibitor activity is associated with raised lactate levels
after cardiac surgery with cardiopulmonary bypass.

Dixon B, Santamaria JD, Campbell DJ.

Intensive Care Centre, St. Vincent's Hospital, St. Vincent's Institute of
Medical Research, Fitzroy, Australia.

OBJECTIVE: To investigate the pathophysiology underlying raised lactate levels
after cardiac surgery with cardiopulmonary bypass (CPB). DESIGN: Prospective
observational study. SETTING: Medical and surgical intensive care unit of a
tertiary hospital. PATIENTS: A total of 40 patients undergoing first-time
coronary artery bypass grafting with CPB. INTERVENTIONS: The prothrombotic
response to cardiac surgery with CPB was assessed by measuring plasma levels of
prothrombin fragment 1 + 2 and plasminogen activator inhibitor (PAI) activity.
The hemodynamic responses to cardiac surgery with CPB were also measured using
standard techniques. MEASUREMENTS AND MAIN RESULTS: After cardiac surgery,
prothrombin fragment 1 + 2 levels increased 6-fold and PAI activity increase 2-
to 3-fold (p <.0001). Lactate levels were not associated with prothrombin
fragment 1 + 2 and PAI activity levels after CPB. Lactate levels were associated
with baseline PAI activity (p =.006), a history of hypertension (p =.02), raised
baseline lactate levels (p =.02), an early increase in body temperature after
CPB (p =.05), a late increase in oxygen consumption after CPB (p =.03), and a
raised white cell count after CPB (p =.06). Lactate levels were inversely
associated with the maximum activated clotting time level reached during CPB (p
=.02). Multivariate linear regression demonstrated lactate levels were
independently associated with baseline PAI activity. CONCLUSION: We found
cardiac surgery with CPB was associated with a marked prothrombotic response.
Lactate levels were associated with elevated baseline PAI activity and evidence
of an amplified inflammatory response to cardiac surgery with CPB. Our findings
implicate aspects of the inflammatory response, including microvascular
thrombosis, in the development of raised lactate levels after cardiac surgery
with CPB.

Ann Thorac Surg  2003 Apr;75(4):1261-6 

Aprotinin reduces operative closure time and blood product use after pediatric
bypass.

Costello JM, Backer CL, de Hoyos A, Binns HJ, Mavroudis C.

Division of Cardiology and Critical Care Medicine, Children's Memorial Hospital,
Chicago, Illinois, USA.

BACKGROUND: The use of aprotinin in children undergoing cardiopulmonary bypass
is controversial. We hypothesized that aprotinin would reduce blood product use
and operative closure time in selected pediatric patients. METHODS: For a
6-month period starting in October 1999, consecutive cardiopulmonary bypass
patients 6 months of age or less (n = 18) or having a repeat sternotomy (n = 18)
received aprotinin. Similar consecutive patients from the preceding 6 months
served as controls (n = 35 and 41, respectively). Data extracted from medical
records included preoperative clinical characteristics, operative and
postoperative procedures, and total blood product use. RESULTS: Patients in the
aprotinin and control groups were well matched with regard to preoperative and
intraoperative variables. Patients 6 months of age or less who received
aprotinin required less operative closure time when compared with controls
(median, 93 vs 127 minutes, p = 0.004), and trended toward requiring fewer red
blood cell unit exposures (median, three vs five exposures, p = 0.07). Patients
undergoing repeat sternotomy who received aprotinin required less operative
closure time when compared with controls (mean, 126 vs 159 minutes, p = 0.007),
fewer red blood cell unit exposures (median three vs four exposures, p = 0.002),
and fewer fresh-frozen plasma unit exposures (median, zero vs one exposure, p =
0.007). CONCLUSIONS: Aprotinin reduced operative closure time and blood product
exposure in pediatric patients undergoing cardiopulmonary bypass who were 6
months of age or less or underwent a repeat sternotomy.

Ann Thorac Surg  2003 Apr;75(4):1215-20 

Outcomes of cardiac surgery in nonagenarians: a 10-year experience.

Bacchetta MD, Ko W, Girardi LN, Mack CA, Krieger KH, Isom OW, Lee LY.

Department of Cardiothoracic Surgery, New York Presbyterian Hospital-Cornell
University Medical College, New York, New York 10021, USA.

BACKGROUND: With an increasing awareness of health issues and greater emphasis
on preventive medicine, the general population is living longer and healthier
lives than ever before. Physicians are taking care of older patients, many of
whom may require cardiac surgical procedures. Improving cardiopulmonary bypass
technology allows for safer procedures with reduced morbidity and mortality even
in older patients. METHODS: We have performed a retrospective analysis of 42
consecutive nonagenarian patients who underwent open-heart procedures over a
10-year period (1993 to 2002) at our institution. Their demographic profiles,
operative data, perioperative results, and long-term outcomes were recorded and
analyzed. RESULTS: Twenty-two women and 20 men with an age range of 90 to 97
years (mean, 91.4 years) had open-heart surgery over the study period. The
complication rate was 67% overall, consisting of 7% respiratory (pneumonia,
respiratory failure, reintubation), 7% hemorrhagic or embolic (postoperative
bleeding, cerebral vascular accident), 12% infectious (wound infection, sepsis),
and 31% new arrhythmia (atrial fibrillation, atrial flutter, ventricular
tachycardia, ventricular fibrillation). Despite these complication rates,
average hospital stay was 17.5 days (median, 11 days), with an intensive care
unit stay of 12.0 days (median, 5 days). Thirty-day survival was 95% and
survival to discharge was 93% (three deaths total; one cardiac arrest at
hospital day 134 and two perioperative deaths; one ventricular arrhythmia, one
cerebral vascular accident). The only statistically significant risk factor of
mortality was emergency surgery. Currently, 81% are still alive an average of
2.53 years since surgery (range, 0.16 to 7.1 years). CONCLUSIONS: With improving
techniques and greater attention to detail, the select nonagenarian can safely
undergo cardiac surgery.

Ann Thorac Surg  2003 Apr;75(4):1132-9 

Perfusion-assisted direct coronary artery bypass provides early reperfusion of
ischemic myocardium and facilitates complete revascularization.

Cooper WA, Corvera JS, Thourani VH, Puskas JD, Craver JM, Lattouf OM, Guyton RA.

The Division of Cardiothoracic Surgery, Emory University School of Medicine,
Atlanta, Georgia, USA. william_cooper@emoryhealthcare.org

BACKGROUND: Perfusion-assisted direct coronary artery bypass (PADCAB) was
developed to initiate early reperfusion of grafted coronary artery segments
during off-pump operations to resolve episodes of myocardial ischemia and avoid
its sequelae. This case series outlines intraoperative findings and clinical
outcomes of our first year clinical experience with PADCAB. METHODS: From
November 1999 to November 2000, 169 PADCAB and 358 off-pump coronary artery
bypass procedures were performed at the Emory University Hospitals. The decision
to use PADCAB was predicated on surgeon preference. Perfusion pressure and flow,
amount of intracoronary nitroglycerin, and total perfusion time and volume were
recorded at the time of operation. RESULTS: One off-pump coronary artery bypass
patient required emergent conversion to cardiopulmonary bypass. Two PADCAB
patients had ischemic ventricular arrhythmias during target vessel occlusion
that resolved once active perfusion had begun. Perfusion pressure in PADCAB
grafts was on average 44% higher than mean arterial pressure (p < 0.001).
Nitroglycerin, infused locally by PADCAB, was used in 67 patients to resolve
ischemic episodes and increase initial coronary flows. The mean number of
diseased coronary territories and grafts placed was 2.8 +/- 0.5 and 3.4 +/- 0.7,
respectively, in the PADCAB group, and 2.3 +/- 0.8 and 2.7 +/- 1.0,
respectively, in the off-pump coronary artery bypass group (p < 0.001 for both
comparisons). More PADCAB patients received lateral wall grafts than off-pump
coronary artery bypass patients (83.4% vs 59.4%; p < 0.001). Hospital death and
postoperative myocardial infarction were not different between groups.
CONCLUSIONS: PADCAB can provide suprasystemic perfusion pressures and a means to
add vasoactive drugs to target coronary vessels. PADCAB provides early
reperfusion of ischemic myocardium and facilitates complete revascularization of
severe multivessel coronary artery disease.

Pre-operative balloon counterpulsation and off-pump coronary surgery for
high-risk patients.

Babatasi G, Massetti M, Bruno Pg P, Hamon M, Le Page O, Morello R, Khayat A.

Coronary artery bypass surgery (CABG) can be performed less invasively without
cardiopulmonary bypass (CPB). Multivessel off-pump CABG (OPCAB) is challenging
in patients with critical left main stenosis (> 70%) and/or severe ventricular
dysfunction (ejection fraction < 0.35) Our objective was the evaluation of
efficiency of intra aortic balloon pump (IABP) preoperatively in this high-risk
group in order to perform OPCABG safely.Material and method: In a consecutive
10-month period (out of 88 OPCABG patients) 23 high-risk patients were treated
and were compared with 15 on-pump patients (out of 69) with the same criteria.
RESULTS: Preoperative implantation of IABP was significantly higher in the
OPCABG group (70% vs 46%, p < 0.05). No conversion to CPB was required in the
OPCABG group. Post-operative angiography was systematically performed and
demonstrated 97.5% patency of anastomosis. No device-related complications
occured. No difference was found concerning age, risk factors, emergency
surgery, ejection fraction, mean number of grafts per patient (2.64 versus 2.75)
and average operating time. In contrast, OPCABG demonstrated a trend toward
reduced morbidity in terms of atrial fibrillation, reexploration for bleeding
and prolonged ventilator requirement > 12 h. Mortality was less in the OPCABG
group (p < 0.05). CONCLUSION: More randomized controlled trials are needed to
evaluate the true efficacy of elective IABP in OPCABG high-risk patients. Until
such studies are evaluated, and therefore because older and sicker patients now
constitute a greater percentage of candidates for OPCABG, the timing of
application of the IABP is warranted. These results may further justify
preoperative use of the IABP in a large proportion of this group of patients.