Thorac Cardiovasc Surg.  2004 Apr;52(2):70-6.  

Requirement for renal replacement therapy in patients undergoing cardiac
surgery1.

Gummert JF, Bucerius J, Walther T, Doll N, Falk V, Schmitt DV, Mohr FW.

Department of Cardiac Surgery, Heart Center, University of Leipzig, Leipzig,
Germany.

BACKGROUND: Despite refinements in perioperative patient management renal
insufficiency requiring renal replacement therapy (RRT) is still a common
complication after cardiac surgical procedures associated with impaired patient
outcome and increased costs. METHODS: Prospective data on 16 184 patients
undergoing different cardiac surgical procedures (CABG, n = 8917; beating heart
CABG, n = 1842 [OPCAB, n = 765; MIDCAB, n = 1077]; aortic valve surgery, n =
1830; mitral valve surgery, n = 708; double valve surgery, n = 381; CABG and
valve surgery, n = 2506) between April 1996 and August 2001 were subjected to
univariate and multivariate logistic regression analysis. Postoperative RRT was
defined as any postoperative renal insufficiency requiring first time
hemofiltration or dialysis during the postoperative stay. Patients with
preoperative dialysis dependent renal insufficiency were excluded from further
analysis. RESULTS: The overall prevalence of postoperative RRT was 4.7 % which
varied according to different surgical procedures. 45 out of 49 selected pre-
and intraoperative patient- and treatment-related variables had a significant
association with postoperative RRT. 10 of these (renal disease, myocardial
infarction, diabetes, cardiogenic shock, urgent operation, NYHA >/= 3,
intraoperative hemofiltration, perfusion time >/= 2 hours, intraoperative low
cardiac output, perioperative high transfusion requirement) were independent
predictors. OPCAB surgery and younger patient age were identified as having a
significantly lower predictive value for postoperative RRT. Patients with
postoperative RRT were found to have a significantly longer ICU- and total
postoperative hospital stay as well as a higher 30-day mortality. CONCLUSION:
Identifying perioperative risk factors associated with postoperative RRT will
help to reduce the incidence of this complication. Avoiding cardiopulmonary
bypass seem to be beneficial with regard to the prevalence of postoperative RRT.

Cardiology.  2004 Apr 19;102(2):82-88.  

Reversal of Glucose-Insulin-Potassium-Induced Hyperglycemia by Aggressive
Insulin Treatment in Postoperative Heart Failure. An Observational Study.

Woods AA, Taegtmeyer H.

Department of Internal Medicine, Division of Cardiology, The University of
Texas-Houston Medical School, Houston, Tex., USA.

Metabolic support with glucose-insulin-potassium (GIK) significantly reduces the
morbidity and mortality of patients in cardiogenic shock after hypothermic
ischemic arrest for aortocoronary bypass surgery. However, a small subset of
these patients develops postoperative insulin resistance regardless of their
preoperative diabetic status. Whether GIK directly contributes to higher
mortality in these patients is unknown. We reviewed the records of 322 patients
whose treatment for postoperative cardiogenic shock included GIK. Ten patients
(3%) had postoperative hyperglycemia (serum glucose >/=250 mg/dl or 13.9 mmol/l)
due to insulin resistance. These were compared to randomly selected GIK-treated,
insulin-responsive patients (n = 10) and non-GIK-treated patients (n = 10) for
comparison. The insulin-resistant patients required increasing amounts of
regular insulin up to 130 U/h until blood glucose levels fell below 250 mg/dl.
However, short-term outcomes (IABP support time, length of stay in ICU, 7-day
mortality) for insulin- resistant patients were indistinguishable from those for
insulin-responsive patients. These data indicate that postoperative iatrogenic
hyperglycemia in patients after cardiopulmonary bypass may not be detrimental
per se and is reversible when treated with supplemental insulin. Copyright 2004
S. Karger AG, Basel

Can J Cardiol.  2004 Apr;20(5):501-504.  

Effect of left ventricular assist device bridging to transplantation on donor
waiting time and outcomes in Canada.

Carrier M, Perrault LP, Bouchard D, Pellerin M, Racine N, White M, Pelletier G.

Montreal Heart Institute, Montreal, Canada.

BACKGROUND: The Thoratec left ventricular assist device (LVAD; Thoratec
Laboratories Corporation, USA) was used as a bridge to transplantation at the
Montreal Heart Institute. LVAD patients were activated on the waiting list as
soon as they were in suitable clinical status. OBJECTIVE: To analyze the effect
of introducing the Thoratec LVAD in the heart transplantation program at the
Montreal Heart Institute. METHODS: The results of 16 LVAD patients and 20
patients who underwent heart transplantation without LVAD support between
January 2000 and February 2002 were reviewed. RESULTS: Sixteen patients in
cardiogenic shock underwent emergency implantation of a Thoratec LVAD following
acute myocardial infarction (five patients), acute viral cardiomyopathy (five
patients), idiopathic cardiomyopathy (three patients), postpartum cardiomyopathy
(two patients) and failure to wean from cardiopulmonary bypass (one patient).
Thirteen of 16 (81%) LVAD patients underwent heart transplantation, and three
LVAD patients were not listed and died from multiorgan failure. The wait for
transplantation averaged 17+/-19 days in LVAD patients compared with 87+/-66
days for the 20 patients undergoing transplantation without LVAD support
(P=0.01). Survival 12 months following transplantation averaged 84+/-10% in LVAD
supported patients and 90+/-7% in those without LVAD support (P=0.6).
CONCLUSION: The use of Thoratec LVAD as a bridge to transplantation did not
prolong the wait for a donor of patients without LVAD support (United Network
Organ Sharing status II). Moreover, listing patients as soon as they appear
suitable for transplantation resulted in a short period of LVAD support and a
good rate of survival one year after transplantation.

Artif Organs.  2004 Apr;28(4):347-52.  

Comparison of pH-stat versus Alpha-stat during hypothermic cardiopulmonary
bypass in the prevention and control of acidosis in cardiac surgery.

Piccioni MA, Leirner AA, Auler JO Jr.

Department of Anesthesiology, University of Sao Paulo Medical School, Sao Paulo,
Brazil.

OBJECTIVES: To compare the effects of blood-gas management using either
alpha-stat (temperature-uncorrected blood-gas management) or pH-stat
(temperature-corrected blood-gas management) strategies, 30 patients undergoing
coronary artery bypass surgery allocated randomly to either one of the
approaches were studied. Acid-base balance, tissue oxygenation, and biochemical
parameters were measured at distinct times: before bypass, after 15 min of
hypothermia at 32 degrees C, after 45 min of hypothermia at 32 degrees C, after
15 min of rewarming at 37 degrees C, and 45 min after the end of bypass in
normothermic conditions. RESULTS: The groups were similar with regard to
physical characteristics, physiological parameters, and bypass time. In the
pH-stat group, CO2 administered with the aim of correcting pH for the patients
hypothermic temperature caused a significant increase in temperature-uncorrected
PaCO2 and a decrease in arterial temperature-uncorrected pH at 45 min. During
the rewarming period and following bypass, the pH was lower and PaCO2 higher in
the pH-stat group (P < 0.001). CONCLUSION: It was found that during the
rewarming period and following bypass, the resulting acidosis caused by the
procedure was less in the alpha-stat group. It was found that there were no
difference between the two groups, with regard to tissue perfusion, as is seen
by the tissue oxygenation parameters and lactic acid concentration.

Chest.  2004 Apr;125(4):1581-6.  

The use of cardiopulmonary bypass during resection of locally advanced thoracic
malignancies: a 10-year two-center experience.

Byrne JG, Leacche M, Agnihotri AK, Paul S, Bueno R, Mathisen DJ, Sugarbaker DJ.

The Division of Cardiac Surgery, Brigham & Women's Hospital, Boston, MA 02115,
USA. JBYRNE@PARTNERS.ORG

The use of cardiopulmonary bypass (CPB) for locally advanced thoracic
malignancies is highly controversial. The purpose of this study was to document
the techniques and results of CPB to facilitate the resection of complex
thoracic malignancies and to identify common themes that provided for successful
outcomes. This was a retrospective study that took place from January 1992 to
September 2002. Fourteen consecutive patients (median age, 59 years; age range,
18 to 69 years; seven men and seven women) underwent CPB during the resection of
locally advanced thoracic malignancies at two Boston hospitals. CPB was planned
in 8 of 14 patients (57%) with centrally located tumors, while 6 of 14 patients
(43%) required emergent institution of CPB due to injury of the superior vena
cava (2 patients), inferior vena cava (2 patients), or pulmonary artery (2
patients). Complete microscopic resection was achieved in 12 of 14 patients
(86%). The operative mortality rate was 1 of 14 patients (7%) due to pulmonary
embolism (ie, the elective group). The median ICU and hospital lengths of stay
were 5 and 9 days, respectively. The overall 1-year, 3-year, and 5-year survival
rates were 57%, 36%, and 21%, respectively. The planned use of CPB to facilitate
complete resection of thoracic malignancies should be considered only after
careful patient selection. The availability of CPB also provides a safety net in
the event of injury to vascular structures during tumor resection.

J Cardiothorac Vasc Anesth.  2004 Apr;18(2):185-9.  

Comparison of esophageal Doppler, pulse contour analysis, and real-time
pulmonary artery thermodilution for the continuous measurement of cardiac
output.

Bein B, Worthmann F, Tonner PH, Paris A, Steinfath M, Hedderich J, Scholz J.

OBJECTIVE: Continuous measurement of cardiac output (CCO) is of great importance
in the critically ill. However, pulmonary artery thermodilution has been
questioned for possible complications associated with right heart
catheterization. Furthermore, measurements are delayed in the continuous mode
during rapid hemodynamic changes. A new pulmonary artery catheter CCO device
(Aortech, Bellshill, Scotland) enabling real-time update of cardiac output was
compared with 2 different, less-invasive methods of CCO determination,
esophageal Doppler and pulse contour analysis. DESIGN: Prospective,
observational study. SETTING: University hospital, single institution.
PARTICIPANTS: Patients scheduled for elective coronary artery bypass grafting
(CABG). INTERVENTIONS: None. Measurements and Main Results: CCO measurements
wereanalyzed using a Bland-Altman plot. Bias between CCO and pulse contour
cardiac output (PCCO), and Doppler-derived cardiac output (UCCO) was (mean +/- 1
SD) -0.71 +/- 1 L/min versus -0.15 +/- 1.09 L/min, and between UCCO and PCCO
-0.58 +/- 1.06 L/min. Bias was not significantly different among methods, nor
were comparative values before and after cardiopulmonary bypass (p > 0.05).
CONCLUSIONS: Agreement between the CCO method and both less-invasive
measurements was clinically acceptable. There were no adverse events associated
with the use of either device.

J Cardiothorac Vasc Anesth.  2004 Apr;18(2):175-9.  

Deep hypothermic circulatory arrest and the femoral-to-radial arterial pressure
gradient.

Manecke GR Jr, Parimucha M, Stratmann G, Wilson WC, Roth DM, Auger WR, Kerr KM,
Jamieson SW, Kapelanski DP, Mitchell MM.

OBJECTIVES: To determine the femoral-to-radial arterial pressure gradient, as
well as the factors associated with them, in patients receiving cardiopulmonary
bypass (CPB) with profound hypothermia and circulatory arrest. DESIGN:
Retrospective automated hemodynamic record review. SETTING: University hospital.
PARTICIPANTS: Patients undergoing pulmonary thromboendarterectomy with deep
hypothermic circulatory arrest. Measurements and Main Results: The automated
hemodynamic records of 54 consecutive patients undergoing pulmonary
thromboendarterectomy with deep hypothermic circulatory arrest were reviewed,
comparing the femoral and radial arterial pressures throughout the
intraoperative period. In 20 of the patients, the hemodynamic data from the
first 16 postoperative hours were also studied. Forty-one of 54 (76%) of the
patients exhibited a mean arterial gradient of at least 10 mmHg either during or
after CPB, femoral being higher. Clinically significant gradients were noted
throughout the CPB period and the post-CPB period in these patients. In the 54
patients studied, the systolic blood pressure (SBP) gradient was 32 +/- 19 mmHg
after CPB (95% confidence limits 28.2 mmHg, 39.0 mmHg), and the mean arterial
pressure (MAP) gradient was 6.3 +/- 4.9 mmHg (95% confidence limits 5.5 mmHg,
8.6 mmHg). The duration of clinically significant SBP (>10 mmHg) and MAP (>5
mmHg) gradients in the postoperative period were 5.2 +/- 5.7 hours and 5.8 +/-
7.2 hours, respectively. Advanced age correlated with high post-CPB pressure
gradients in this population and was associated with prolonged postoperative
resolution of the gradients. CONCLUSIONS: The femoral-to-radial arterial
pressure gradients, particularly systolic, after CPB, were greater and of longer
duration in these patients undergoing deep hypothermic circulatory arrest than
gradients previously reported for routine CPB. Central arterial pressure
monitoring is recommended for patients undergoing deep hypothermic circulatory
arrest, being valuable both for intraoperative and postoperative care.

J Cardiothorac Vasc Anesth.  2004 Apr;18(2):148-51.  

Effectiveness of a circulating-water warming garment in rewarming after
pediatric cardiac surgery using hypothermic cardiopulmonary bypass.

Motta P, Mossad E, Toscana D, Lozano S, Insler S.

OBJECTIVE: To evaluate the effectiveness and safety of the ALLON 2001
microprocessor-based thermoregulation system in pediatric patients undergoing
cardiac surgery requiring hypothermic cardiopulmonary bypass compared with the
routine thermal care. DESIGN: Prospective randomized clinical study. SETTING:
Single tertiary academic medical center. PARTICIPANTS: Infants (0-1 year) who
underwent congenital heart surgery requiring hypothermic cardiopulmonary bypass
(n = 18). Patients with open wounds and/or patients treated with an
investigational drug or device within 30 days of surgery were excluded.
INTERVENTIONS: Randomized use of thermoregulation system (warming garment, n =
9) or routine thermal care (control, n = 9) after separating from
cardiopulmonary bypass until the arrival to the pediatric intensive care unit
(PICU). Measurements and Main Results: There were no statistically significant
differences in the demographic data, cardiopulmonary bypass time, operating room
time, incidence of deep hypothermic circulatory arrest, and cooling temperature
between the groups. The nasopharyngeal temperature was significantly higher in
the warming garment group after separation from cardiopulmonary bypass.
Nasopharyngeal temperature at 20 minutes was 36.5 degrees C versus 35.01 degrees
C (p = 0.0047), at 40 minutes was 36.98 degrees C versus 35.30 degrees C (p =
0.034), and at admission to the PICU was 36.09 degrees C versus 35.31 degrees C
(p = not significant). There was no difference in the core-to-peripheral
temperature gradient (nasopharyngeal-to-skin temperature) between the 2 study
groups at any time point. No adverse events related to the use of the warming
garment thermoregulation system were observed. CONCLUSION: The investigated
thermoregulation system was effective in preventing the after-drop of
temperature that occurs after cardiopulmonary bypass in small infants compared
with routine warming methods.

J Cardiothorac Vasc Anesth.  2004 Apr;18(2):131-5.  

Decreased concentration of antithrombin after preoperative therapeutic heparin
does not cause heparin resistance during cardiopulmonary bypass.

Linden MD, Schneider M, Baker S, Erber WN.

OBJECTIVE: To determine if preoperative heparin therapy causes an increase in
the incidence of intraoperative heparin resistance by reducing the concentration
of antithrombin in plasma. DESIGN: Prospective laboratory investigation of
clinical samples. SETTING: Public tertiary care hospital and public pathology
service. PARTICIPANTS: Forty-six patients undergoing cardiac surgery involving
cardiopulmonary bypass. INTERVENTIONS: Fourteen patients received preoperative
heparin therapy (POHI group) and 32 patients were controls (CONT group).
Measurements and Main Results: The concentration of antithrombin, activated
coagulation time (ACT), and clinical parameters were measured at intervals. More
POHI patients had on-bypass heparin resistance than CONT (43% and 3%,
respectively, p < 0.01). The POHI group had a lower concentration of
antithrombin than the CONT group before (80.9% and 92.6%, respectively, p <
0.01) and while on cardiopulmonary bypass (51.6% and 57.5%, respectively, p =
0.04). Comparison of heparin-resistant and heparin-responsive POHI patients
showed that the concentration of antithrombin did not differ before bypass
(82.4% and 79.8%, respectively, p = 0.53) or during bypass (51.8% and 51.4%,
respectively, p = 0.91). In fact, antithrombin concentrations were slightly
higher in the heparin-resistant POHI patients (not significant). POHI patients
received more heparin than CONT patients (medians 787 U/kg and 600 U/kg,
respectively, p = 0.01) and were transfused with more fresh frozen plasma on
bypass (p = 0.03). CONCLUSIONS: Preoperative heparin causes an increased
incidence of heparin resistance and reduced antithrombin concentrations.
However, heparin resistance was not causally related to reduced antithrombin
because antithrombin concentrations were not different between heparin-resistant
and heparin-responsive patients in the POHI group.