Scand Cardiovasc J. 2006 Apr;40(2):105-9. 

Tranexamic acid reduces postoperative bleeding in off-pump coronary artery
bypass grafting.

Wei M, Jian K, Guo Z, Wang L, Jiang D, Zhang L, Tarkka M.

Department of Cardiac Surgery, Tianjin Chest Hospital, Tianjin, P.R. China.

Objective. Tranexamic acid (TA) reduces blood loss in coronary artery surgery
with cardiopulmonary bypass. The present prospective study was designed to
investigate its hemostatic effect in off-pump coronary artery bypass (OPCAB).
Method. Seventy-six patients undergoing elective OPCAB were randomized into two
groups, received TA (0.75?g loading dose before surgery and 250?mg/h during
surgery, gross dose: 1.5?g, n?=?36) and saline solution (control, n?=?40),
respectively. Perioperative blood samples were collected. Hematochemical
parameters including platelet adhesion rate, D-dimer and fibrinopeptide-A (FPA)
were analysis. Volume of blood loss, blood transfusion and other clinical data
were recorded throughout the perioperative period. Results. Cumulative blood
loss was significantly reduced in the TA group as compared to the controls
postoperatively (6 hrs (median [25(th)-75(th)]): TA: 200.0 [140.0-230.0]?ml,
Control: 225.0 [200.0-347.5.0]?ml, p?=?0.009; 24 hrs: TA: 440.0
[270.0-605.0]?ml, Control: 655.0 [500.0-920.0]?ml, p?<?0.001). Number of
patients received blood transfusion in each group was similar. Levels of D-dimer
rose significantly after surgery, and were significantly lower in the TA group
than that in controls. Platelet adhesion rate and FPA levels remained at
baseline levels after the operation in two groups. Early clinical outcomes were
similar between groups. Conclusion. The results indicated that tranexamic acid
limits fibrinolysis and reduces blood loss after off-pump coronary artery bypass
surgery.

Jpn J Thorac Cardiovasc Surg. 2006 Apr;54(4):149-54. 

Prostaglandin E1 attenuates impairment of cellular immunity after
cardiopulmonary bypass.

Sano T, Masuda M, Morita S, Yasui H.

Department of Cardiovascular Surgery, Graduate School of Medical Sciences,
Kyushu University, Fukuoka, Japan.

OBJECTIVE: It is well documented that cardiopulmonary bypass (CPB) severely
impairs cellular immunity. The objective of this study was to investigate the
effect of prostaglandin E1 (PGE1) on cellular immunity after CPB. METHODS:
Patients who underwent elective cardiac surgery were randomly divided into the
PGE1 group (n=12) and the control group (n=12). In the PGE1 group, PGE1 was
administered at 20 ng/kg/min from just after the induction of anesthesia to the
end of surgery. Peripheral blood mononuclear cells (PBMCs) were taken before
anesthesia and on postoperative days 1, 3 and 7 (POD 1, POD 3 and POD 7).
Proliferation responses of T cells to phytohemagglutinin (PHA) and pure protein
derivative (PPD) antigen were measured as indicators of cellular immunity.
RESULTS: PGE1 significantly attenuated the impairment of both PHA and PPD
response after cardiac surgery on POD 1 (PHA response, 30 +/- 21% vs. 53 +/-
32%, control vs. PGE, p=0.048; PPD response, 18 +/- 21% vs. 39 +/- 27%, control
vs. PGE, p=0.046). The reduced glutathione content of PBMCs in the control group
was significantly decreased on POD 1. CONCLUSION: PGE1 attenuated the impairment
of cellular immunity after cardiac surgery with CPB by reducing oxidative stress
on PBMCs.

Pharmacotherapy. 2006 Apr;26(4):569-577. 

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.

Department of Pharmacy Practice and Science, College of Pharmacy, University of
Kentucky, Lexington, Kentucky 40536, USA.

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 microg/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):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.

Emerg Med J. 2006 Apr;23(4):246-50. 

Treatment of poisoning induced cardiac impairment using cardiopulmonary bypass:
a review.

Purkayastha S, Bhangoo P, Athanasiou T, Casula R, Glenville B, Darzi AW, Henry
JA.

Department of Biosurgery and Surgical Technology, Imperial College, St Mary's
Hospital, London, UK.

Severe poisoning can cause potentially fatal cardiac depression. Cardiopulmonary
bypass (CPB) can support the depressed myocardium, but there are no clear
indications or guidelines available on its use in severe poisoning. A review was
conducted of relevant papers in the available literature (seven single case
reports of both deliberate and accidental ingestion of cardiotoxic drugs and two
animal studies). Although CPB is rarely used in the management of poisoning, it
may have potential benefits for haemodynamic instability not responding to
conventional measures. At present there is insufficient evidence concerning the
use of CPB as a treatment for severe cardiac impairment due to poisoning (grade
C). This review suggests that in patients with severe and potentially prolonged
reversible cardiotoxicity there is potential for full survival with CPB,
provided that the patient has not already sustained hypoxic cerebral damage due
to resistant hypotension prior to its use.

J Neuroimaging. 2006 Apr;16(2):126-32. 

Sources of variability in the detection of cerebral emboli with transcranial
Doppler during cardiac surgery.

Rodriguez RA, Rubens F, Rodriguez CD, Nathan HJ.

Department of Surgery, Division of Cardiac Surgery, University of Ottawa Heart
Institute, 40 Ruskin Street, Ottawa, Ontario K1Y 4W7, Canada.
Rrodriguez@Ottawaheart.ca

OBJECTIVE: The application of intensity thresholds for embolus detection with
transcranial Doppler (TCD) can exclude from analysis an unrecognized proportion
of high-intensity transient signals (HITS))whose intensities are below the
threshold. The lack of consistent threshold criteria between clinical trials may
explain part of the discrepancy in the reported HITS counts. We investigated the
effect of choosing different thresholds on the sensitivity and specificity of
detecting HITS during cardiopulmonary bypass (CPB). METHODS: Two observers
independently analyzed TCD recordings from 8 patients under CPB. Doppler signals
were classified as true HITS, equivocal HITS, artifacts, and Doppler speckles
according to preestablished criteria. The relative intensity of Doppler signals
was measured by two different methods (TCD software vs manual). Receiver
Operating Characteristic curves determined the optimal threshold for each of the
two intensity methods. RESULTS: Reviewers achieved agreement in 96% of 2190
Doppler signals (kappa = 0.90). Relative intensities calculated with the
TCD-software method were 3 dB (95% CI: 3.0-3.4) higher than the manual method.
The optimal threshold was found at 10 dB (sensitivity: 99%; specificity: 90.8%)
with the software method and at 7 dB with the manual method (sensitivity: 96%;
specificity: 83%). The use of an intensity threshold 2 dB higher than the
optimal increased the rejection of true HITS by 8% and 14%, respectively.
CONCLUSIONS: Using intensity thresholds higher than the optimal for embolus
detection decreases HITS counts. Choosing a threshold depends on the type of
method used for measuring the signal intensity. Uniform threshold criteria and
comparative studies between different Doppler devices are necessary for making
clinical trials more comparable.

Stroke. 2006 Apr 20; [Epub ahead of print] 

NMDA Receptor Antibodies Predict Adverse Neurological Outcome After Cardiac
Surgery in High-Risk Patients.

Bokesch PM, Izykenova GA, Justice JB, Easley KA, Dambinova SA.

From the Department of Anesthesia, Emory University; the Department of
Chemistry, Emory University; the Emory Biostatistics Consulting Center, Emory
University School of Medicine, Atlanta, Ga; and the Department of Neurology and
Neurosurgery, St Petersburg's State Medical University, St Petersburg, Russia.

BACKGROUND AND PURPOSE: The goal of this study was to compare the predictive
ability of S100B, N-methyl-D-aspartate (NMDA) receptor antibodies (NR2Ab) and
C-reactive protein (CRP) for neurological deficits after cardiac surgery with
cardiopulmonary bypass (CPB). METHODS: We investigated 557 high-risk adult
patients who underwent coronary artery or valve replacement surgery using CPB as
a substudy of a prospective, blinded, multicenter clinical trial. Serum
concentrations of S100B (n=513 patients), NR2Ab (n=398) and CRP (n=510) were
measured preoperatively, 24 and 48 hours after CPB. Neurological adverse events
were assessed at baseline and postoperative days 1 and 2; neurocognitive
function (mini-mental status examination) was assessed at baseline and on
postoperative days 1, 7 and 28. RESULTS: Fifty-five (9.9%) patients had moderate
or severe neurological adverse events (confusion/delirium, transient ischemic
attack, or stroke) within 48 hours of CPB. Women had significantly more
neurological complications than men (15.5% versus 7.8%; P=0.007). Ninety-six
percent (24/25) of patients with NR2Ab concentrations >/=2.0 ng/mL
preoperatively had neurological complications within 48 hours post-CPB, versus
only 5.4% (20/373) of patients with NR2Ab concentrations <2.0 ng/mL, resulting
in a 17.9-fold increase (95% CI, 11.6 to 27.6) in postoperative neurological
complications for patients with high levels of NR2A antibodies. Preoperative
serum S100B and CRP did not predict neurological complications from CPB.
Decreased mini-mental status examination scores for orientation, attention and
recall were associated with neurological adverse events early after CPB.
CONCLUSIONS: Preoperative serum concentrations of NR2Ab, but not S100B or CRP,
are predictive of severe neurological adverse events after CPB. Patients with a
positive NR2Ab test (>/=2.0 ng/mL) preoperatively were nearly 18 times more
likely to experience a postoperative neurological event than patients with a
negative test (<2.0 ng/mL).

Paediatr Anaesth. 2006 Apr;16(4):429-35. 

A trial of fresh autologous whole blood to treat dilutional coagulopathy
following cardiopulmonary bypass in infants.

Friesen RH, Perryman KM, Weigers KR, Mitchell MB, Friesen RM.

Department of Anesthesiology, The Children's Hospital and the University of
Colorado School of Medcine, Denver, CO 80218, USA. friesen.robert@tchden.org

BACKGROUND: Transfusion of fresh whole blood is superior to blood component
therapy in correcting coagulopathies in children following cardiopulmonary
bypass (CPB); however, a supply of fresh homologous whole blood is difficult to
maintain. We hypothesized that transfusion of fresh autologous whole blood
obtained prior to heparinization for CPB and infused following CPB would be
associated with improved coagulation function when compared with standard
therapy. METHODS: A total of 32 infants 5-12 kg undergoing noncomplex open
cardiac surgery were randomly assigned to either the treatment or control group.
In the treatment group, 15 ml x kg(-1) of autologous whole blood was collected
into a CPDA bag prior to heparinization while 15 ml x kg(-1) of 5% albumin was
infused intravenously. After reversal of heparin, coagulation tests were drawn
in both groups, and the autologous whole blood was infused over 20 min in the
treatment group. RESULTS: The treatment group had greater (P < 0.05) improvement
in platelet count, prothrombin time, and fibrinogen than the control group.
CONCLUSIONS: We conclude that collection of fresh autologous whole blood prior
to heparinization and reinfusion following CPB is associated with greater
improvement of coagulation status after CPB in infants.

J Cardiothorac Vasc Anesth. 2006 Apr;20(2):217-22. Epub 2006 Mar 9. 

A randomized, double-blind, placebo-controlled study assessing the
anti-inflammatory effects of ketamine in cardiac surgical patients.

Bartoc C, Frumento RJ, Jalbout M, Bennett-Guerrero E, Du E, Nishanian E.

Department of Anesthesiology, Columbia University College of Physicians and
Surgeons, New York, NY 10032-3784, USA.

OBJECTIVE: To determine whether ketamine administration affects markers of
inflammation in cardiac surgery with cardiopulmonary bypass (CPB) and to
investigate differences between 2 low-dose ketamine regimens. DESIGN:
Prospective, randomized, placebo-controlled trial. SETTING: Single-center
university hospital. PARTICIPANTS: Patients undergoing cardiac surgery with CPB.
INTERVENTION: Patients (n = 50) were randomized to 1 of 3 groups: ketamine, 0.25
mg/kg (n = 15); ketamine, 0.5 mg/kg (n = 18);or placebo (n = 17) in a
double-blind manner at the time of induction of general anesthesia. MEASUREMENTS
AND MAIN RESULTS: Serum C-reactive protein (CRP) and interleukin (IL)-6, IL-8,
and IL-10 were measured at baseline, on intensive care unit (ICU) arrival, and
on the first postoperative day (POD 1). Both ketamine doses decreased the serum
IL-6 response at ICU arrival and POD 1 compared with placebo (p < 0.05). CRP was
lower in the 0.5-mg/kg group than placebo on POD 1 (p = 0.003). IL-10 was lower
in the ketamine groups (p = 0.01) at POD 1 compared with placebo; IL-8 levels
were not affected by ketamine. Mean arterial pressure and systemic vascular
resistance were higher at the end of surgery, arrival in the ICU, and POD 1 in
the ketamine groups (p < 0.05). CONCLUSION: Low-dose ketamine (0.5 mg/kg)
attenuates increases in CRP, IL-6, and IL-10 while decreasing vasodilatation
after CPB.

J Cardiothorac Vasc Anesth. 2006 Apr;20(2):156-61. Epub 2006 Jan 6. 

Retrograde autologous priming of the cardiopulmonary bypass circuit: safety and
impact on postoperative outcomes.

Murphy GS, Szokol JW, Nitsun M, Alspach DA, Avram MJ, Vender JS, DeMuro N, Hoff
WJ.

Department of Anesthesiology, Evanston Northwestern Healthcare, Evanston, IL
60201, USA. gmurphy@enh.org

OBJECTIVES: Retrograde autologous priming (RAP) is a blood conservation
technique used to limit the severity of hemodilution during cardiopulmonary
bypass and reduce perioperative transfusions. The aim of this investigation was
to examine the safety of RAP and to determine the effect of RAP on adverse
outcomes after cardiac surgery. DESIGN: Retrospective cohort study. SETTING:
University hospital. PARTICIPANTS: Five hundred fifty-nine undergoing
cardiopulmonary bypass. INTERVENTIONS: Data were retrospectively collected on 2
cohorts of adult cardiac surgical patients operated on by a single surgeon. In
the RAP group (n = 256), outcome data were analyzed on all subjects over a
2-year period during which RAP was used routinely. This group was compared with
a similar cohort of patients undergoing cardiopulmonary bypass over a 2-year
period immediately before the introduction of RAP into the clinical practice
(no-RAP group, n = 287). MEASUREMENTS AND MAIN RESULTS: In-hospital mortality
was not significantly different between the RAP group (2.7%) and the no-RAP
group (3.8%, p = 0.636). The incidence of postoperative cardiac arrest was
significantly less in the RAP group (1 patient) compared to the no-RAP group (9
patients, p = 0.040). There were no differences between the 2 groups in the
incidence of several other postoperative complications, including postoperative
delirium (1.6% RAP v 3.1% no RAP), heart block (1.6% RAP v 4.2% no RAP), atrial
fibrillation (19.1% RAP v 22.7% no RAP), and requiring postoperative ventilation
>24 hours (2.7% RAP v 5.2% no RAP). CONCLUSIONS: The authors observed no
evidence of any increase in adverse events in the RAP group of this
retrospective cohort study, but they did observe a decrease in the incidence of
postoperative cardiac arrest in the RAP group. These findings suggest that RAP
is a safe technique and may have a beneficial effect on postoperative outcomes.