Ann Vasc Surg. 2005 Jun 23; [Epub ahead of print] 

Renal Cell Carcinoma Associated with Tumor Thrombus in the Inferior Vena Cava:
Surgical Strategies.

Zini L, Haulon S, Decoene C, Amara N, Villers A, Biserte J, Leroy X, Koussa M.

Service d'Urologie, Lille, France.

The purpose of this study was to evaluate strategies used for surgical
management of renal cell carcinoma with a tumoral thrombus extension in the
inferior vena cava (IVC). From January 2000 to December 2001, urological and
vascular surgeons jointly undertook surgical treatment on 10 patients with renal
cell carcinoma and tumor thrombus in the IVC. There were five women and five
men, with a mean age of 60.2 years. The limit of thrombus extension, classified
according to the Neves and Zincke system, was level I (renal) in one patient,
level II (infrahepatic) in one, level III (retrohepatic) in three, and level IV
(atrial) in five. Exposure was achieved by chevron bilateral subcostal
laparotomy associated with sternotomy in three patients, bilateral subcostal
laparotomy in six, and median sternolaparotomy in one. Radical nephrectomy
associated with caval thrombectomy was performed in all patients.
Cardiopulmonary bypass was used in four of the five level IV patients. The fifth
patient was contraindicated for cardiopulmonary bypass. Transesophageal
echography (TEE)-guided endoluminal occlusion of the unobstructed
infradiaphragmatic IVC was performed in patients with level III thrombus.
Clamping of the IVC was performed in patients with levels I and II thrombus. All
procedures were assisted by continuous TEE surveillance. No intraoperative gas
or tumor emboli were detected by TEE. The mean number of red blood cell units
transfused during the course of hospitalization was 9.7 (range 2-22, median 9).
One patient died of multiple organ failure on the day 28 after the procedure.
The mean duration of hospitalization was 16 days. The mean duration of follow-up
was 9.7 months. During follow-up, two of the remaining nine patients died due to
tumor recurrence. Tumor recurrence was also detected in one of the seven
surviving patients. Surgery for renal cell carcinoma with tumor thrombus in the
IVC must be carried out in a specialized facility with the assistance of TEE
surveillance and, in some cases, cardiopulmonary bypass. Operative treatment
improves the prognosis of renal cell carcinoma with tumor thrombus in the IVC.
In patients with level III thrombus, TEE-guided endoluminal occlusion of the
unobstructed infradiaphragmatic IVC simplifies surgical management by obviating
the need for exposure of the retrohepatic and supradiaphragmatic IVC.

Thromb Haemost. 2005 Jun;93(6):1101-7. 

Relationship between factor XIII activity, fibrinogen, haemostasis screening
tests and postoperative bleeding in cardiopulmonary bypass surgery.

Blome M, Isgro F, Kiessling AH, Skuras J, Haubelt H, Hellstern P, Saggau W.

Clinic for Cardiac Surgery, Institute of Hemostaseology, Academic City Hospital,
D-67063 Ludwigshafen, Germany.

We investigated the relationship between factor XIII, fibrinogen, blood
coagulation screening tests and postoperative bleeding in 98 patients undergoing
cardiopulmonary bypass (CPB) surgery. All patients received aprotinin. Blood
samples were collected preoperatively (T1),after termination of CPB (T2),12 h
(T3) and 24 h (T4) after surgery to determine FXIII activity, fibrinogen,
platelet count, prothrombin time (PT), activated partial thromboplastin time
(APTT) and D-dimers (DD). Laboratory results were correlated with the chest tube
drainage 24 h after surgery and compared between patients with 24-hour chest
tube drain volumes in the lower (Group 1) with those in the upper tertile (Group
3). Median FXIII and fibrinogen levels dropped by 33.9% and 34.2%, respectively,
during CPB. No association between FXIII activity and the extent of
postoperative bleeding was found. However, chest tube bleeding was significantly
correlated with preoperative and postoperative fibrinogen. This was confirmed by
comparing Groups 1 and 3. Group 3 patients had significantly lower fibrinogen
levels than Group 1 at T1 - T4, although most fibrinogen values were within or
above the reference range (medians, g/l: 3.5 vs. 4.0, p = 0.043 at T1; 2.3 vs.
2.7, p = 0.015 at T2; 2.9 vs. 3.3, p = 0.008 at T3; 4.2 vs. 5.2, p = 0.002 at
T4). There was also a significant relationship of platelet count, PT and APTT,
as measured after CPB (T2), with postoperative chest tube drainage. In
conclusion, plasma FXIII activity does not influence postoperative bleeding in
patients undergoing CPB surgery. There is however an inverse association between
preoperative or postoperative plasma fibrinogen levels and postoperative
bleeding. These findings indicate a modulation of postoperative bleeding by
fibrinogen levels.

J Cardiovasc Surg (Torino). 2005 Jun;46(3):305-12. 

Myocardial protection in diabetics with left main stem disease: which is the
best strategy?

Onorati F, De Feo M, Cerasuolo F, Mastroroberto P, Bilotta ML, De Santo S,
Renzulli A, Cotrufo M.

Department of Cardiothoracic and Respiratory Sciences, Second University of
Naples, Naples, Italy.

AIM: Diabetes mellitus is a well known risk factor for extensive coronary
disease. The optimal route for cardioplegia administration in patients with
severe ischaemic heart disease undergone surgery, especially with left main stem
disease (LMSD) is still under debate. Aim of the study is to compare 2 different
strategies of myocardial protection in diabetics with LMSD. METHODS: Between
January 2000 and June 2003 90 consecutive patients with type II diabetes
mellitus and LMSD undergoing isolated myocardial revascularization were divided
into 2 groups according to the route of cardioplegia delivery: antegrade in 45
patients (group A), antegrade followed by intermittent retrograde in 45 (group
B). ECG, Troponin I, MB-CPK, MB-CPK mass were performed at 12, 24, 48, and 72
hours postoperatively. Echocardiography was performed preoperatively and before
hospital discharge. RESULTS: Groups were homogeneous in preoperative and
intraoperative variables, apart from higher incidence of unstable angina and
longer cardiopulmonary bypass time in Group B and hypertension in Group A.
Hospital deaths, in intensive care units (ITU) stay, perioperative acute
myocardial infarction, intra-aortic balloon pump support, postoperative recovery
of left ventricle ejection fraction and wall motion score index were similar in
both groups. In hospital stay proved shorter in group B (p=0.002), whereas
postoperative atrial fibrillation was higher in group A (p<0.001), as
postoperative inotropic support (p=0.006). Troponin I proved significantly
higher in group A from the 12 degrees to the 72 degrees postoperative hour
(p<0.0001). CONCLUSIONS: Despite major in hospital end-points did not differ
with strategy of cardioplegia administration, combined route of intermittent
blood cardioplegia allows better biochemical and perioperative results in
diabetics with LMSD.

Exp Biol Med (Maywood). 2005 Jun;230(6):413-20. 

Propofol is cardioprotective in a clinically relevant model of normothermic
blood cardioplegic arrest and cardiopulmonary bypass.

Lim KH, Halestrap AP, Angelini GD, Suleiman MS.

Bristol Heart Institute, University of Bristol, Bristol Royal Infirmary, Bristol
BS2 8HW, United Kingdom.

The general anesthetic propofol has been shown to be cardioprotective. However,
its benefits when used in cardioplegia during cardiac surgery have not been
demonstrated. In this study, we investigated the effects of propofol on
metabolic stress, cardiac function, and injury in a clinically relevant model of
normothermic cardioplegic arrest and cardiopulmonary bypass. Twenty anesthetized
pigs, randomized to propofol treatment (n = 8) and control (n = 12) groups, were
surgically prepared for cardiopulmonary bypass (CPB) and cardioplegic arrest.
Doses of warm blood cardioplegia were delivered at 15-min intervals during a
60-min aortic cross-clamped period. Propofol was continuously infused for the
duration of CPB and was therefore present in blood cardioplegia. Myocardial
biopsies were collected before, at the end of cardioplegic arrest, and 20 mins
after the release of the aortic cross-clamp. Hemodynamic parameters were
monitored and blood samples collected for cardiac troponin I measurements.
Propofol infusion during CPB and before ischemia did not alter cardiac function
or myocardial metabolism. Propofol treatment attenuated the changes in
myocardial tissue levels of adenine nucleotides, lactate, and amino acids during
ischemia and reduced cardiac troponin I release on reperfusion. Propofol
treatment reduced measurable hemodynamic dysfunction after cardioplegic arrest
when compared to untreated controls. In conclusion, propofol protects the heart
from ischemia-reperfusion injury in a clinically relevant experimental model.
Propofol may therefore be a useful adjunct to cardioplegic solutions as well as
being an appropriate anesthetic for cardiac surgery.

Ann Pharmacother. 2005 Jul;39(7):1275-85. Epub 2005 Jun 14. 

Anticoagulation monitoring part 2: unfractionated heparin and
low-molecular-weight heparin.

Spinler SA, Wittkowsky AK, Nutescu EA, Smythe MA.

Adjunct Associate Professor of Pharmacy in Medicine, Cardiovascular Division,
Department of Medicine, Philadelphia College of Pharmacy, University of
Pennsylvania, Philadelphia, PA.

OBJECTIVE: To review the availability, mechanisms, limitations, and clinical
application of point-of-care (POC) devices used in monitoring anticoagulation
with unfractionated heparin (UFH) and low-molecular-weight heparins (LMWHs).
DATA SOURCES: Articles were identified through a MEDLINE search (1966-August
2004), device manufacturer Web sites, additional references listed in articles
and Web sites, and abstracts from scientific meetings. STUDY SELECTION AND DATA
EXTRACTION: English-language literature from clinical trials was reviewed to
evaluate the accuracy, reliability, and clinical application of POC monitoring
devices. DATA SYNTHESIS: The activated partial thromboplastin time (aPTT) and
activated clotting time (ACT) are common tests for monitoring anticoagulation
with UFH. Multiple devices are available for POC aPTT, ACT, and heparin
concentration testing. The aPTT therapeutic range for UFH will vary depending
upon the reagent and instrument employed. Although recommended by the American
College of Chest Physicians Seventh Conference on Antithrombotic and
Thrombolytic Therapy, establishing a heparin concentration-derived therapeutic
range for UFH is rarely performed. Additional research evaluating anti-factor Xa
monitoring of LMWHs using POC testing is necessary. CONCLUSIONS: Multiple POC
devices are available to monitor anticoagulation with UFH. For each test, there
is some variability in results between devices and between reagents used in the
same device. Despite these limitations, POC anticoagulation monitoring of UFH
using aPTT and, more often, ACT is common in clinical practice, particularly
when evaluating anticoagulation associated with interventional cardiology
procedures and cardiopulmonary bypass surgery.

Eur J Cardiothorac Surg. 2005 Jun 10; [Epub ahead of print] 

Optimal pH strategy for selective cerebral perfusion.

Halstead JC, Spielvogel D, Meier DM, Weisz D, Bodian C, Zhang N, Griepp RB.

Department of Cardiothoracic Surgery, Mount Sinai School of Medicine, One
Gustave L. Levy Place, New York, NY 10029, USA.

Objective: Selective cerebral perfusion (SCP) affords brain protection superior
to hypothermic circulatory arrest (HCA) for prolonged aortic arch procedures.
Optimal pH strategy for HCA is controversial; for SCP it is unknown. We compared
pH strategies during SCP in a survival pig model. Methods: Twenty juvenile pigs
(26+/-2.4kg), randomized to alpha-stat (n=10) or pH-stat (n=10) management,
underwent cooling to 20 degrees C on cardiopulmonary bypass (CPB) followed by
90min of SCP at 20 degrees C. SCP was conducted with a mean pressure of 50mmHg
and hematocrit of 22.5%. Using fluorescent microspheres and sagittal sinus blood
sampling, cerebral blood flow (CBF) and oxygen metabolism (CMRO(2)) were
assessed at the following time points: baseline, after 30min cooling (20 degrees
C), 30min of SCP, 90min of SCP, 15min post-CPB and 2h post-CPB. Visual evoked
potentials (VEP) were assessed at baseline and monitored for 2h during recovery.
Neurobehavioral recovery (10=normal) was assessed in a blinded fashion for 7
postoperative days. Results: There were no significant differences between the
groups at baseline. CBF was significantly higher at the end of cooling, and
after 30 and 90min of SCP in the pH-stat group (P=0.02, 0.007, 0.03). CMRO(2)
was also higher with pH-stat (P=0.06, 0.04, 0.10). Both groups showed prompt
return to values close to baseline after rewarming (P=ns). VEP suggested a trend
towards improved recovery in the alpha-stat group at 2h post-CPB, P=0.15.
However, there were no significant differences in neurobehavioral score:
(alpha-stat versus pH-stat) median values 7 and 7.5 on day 1; 9 and 9 on day 4,
and 10 and 10 on day 7. Conclusions: These data suggest that alpha-stat
management for SCP provides more effective metabolic suppression than pH-stat,
with lower CBF. Clinically, the better preservation of cerebral autoregulation
during alpha-stat perfusion should reduce the risk of embolization.

J Thorac Cardiovasc Surg. 2005 Jun;129(6):1421-9. 

Primary graft dysfunction and other selected complications of lung
transplantation: A single-center experience of 983 patients.

Meyers BF, de la Morena M, Sweet SC, Trulock EP, Guthrie TJ, Mendeloff EN,
Huddleston C, Cooper JD, Patterson GA.

Division of Cardiothoracic Surgery, Department of Surgery, Washington University
School of Medicine, St Louis, MO, USA. meyersb@wustl.edu

OBJECTIVES: We sought to review the incidence and outcome of lung
transplantation complications observed over 15 years at a single center.
METHODS: We performed a retrospective review from our databases, tracking
outcomes after adult and pediatric lung transplantation. The 983 operations
between July 1988 and September 2003 included 277 pediatric and 706 adult
recipients. Bilateral (74%), unilateral (19%), and living lobar transplants (4%)
comprised the bulk of this experience. Retransplantations accounted for 44
(4.5%) of the operations. RESULTS: The groups differed by indication for
transplantation. The adults included 57% with emphysema and 17% with cystic
fibrosis, and the children included no patients with emphysema and 50% with
cystic fibrosis. Hospital mortality was 96 (9.8%) of 983, including 46 (17%) of
277 of the children and 50 (7%) of 706 of the adults. The overall survival
curves did not differ between adults and children ( P = .56). Freedom from
bronchiolitis obliterans syndrome at 5 and 10 years was 45% and 18% for adults
and 48% and 30% for children, respectively ( P = .53). The causes of death for
adults included bronchiolitis obliterans syndrome (40%), respiratory failure
(17%), and infection (14%), whereas the causes of death in children included
bronchiolitis obliterans syndrome (35%), infection (28%), and respiratory
failure (21%) ( P < .01). Posttransplantation lymphoproliferative disease
occurred in 12% of pediatric recipients and 6% of adults ( P < .01). The
frequency of treated airway complications did not differ between adults and
children (9% vs 11%, P = .48). The frequency of primary graft dysfunction did
not differ between children (22%) and adults (23%), despite disparity in the use
of cardiopulmonary bypass. CONCLUSION: These results highlight major
complications after lung transplantation. Despite differences in underlying
diagnoses and operative techniques, the 2 cohorts of patients experienced
remarkably similar outcomes.

Crit Care Med. 2005 Jun;33(6):1327-32. 

"Renal dose" dopamine is associated with the risk of new-onset atrial
fibrillation after cardiac surgery.

Argalious M, Motta P, Khandwala F, Samuel S, Koch CG, Gillinov AM, Yared JP,
Starr NJ, Bashour CA.

Department of General Anesthesiology, The Cleveland Clinic Foundation, Cleveland
OH 44195, USA.

OBJECTIVE: "Renal dose" dopamine (rDA; 1-3 microg/kg per min) is administered to
patients after cardiac surgery to preserve or improve renal function. Many of
these patients develop new-onset postoperative atrial fibrillation or atrial
flutter (pAF) that could be related to rDA administration. The objective of this
investigation was to determine whether there was an association between rDA and
new-onset pAF in patients undergoing coronary artery bypass grafting with
cardiopulmonary bypass (CABG). SETTING: Research hospital. SUBJECTS: The study
population consisted of 1,731 patients undergoing CABG. INTERVENTIONS: CABG with
and without rDA. DESIGN: After approval by the institutional review board, a
retrospective study using the Cardiothoracic Anesthesia Patient Registry was
undertaken to determine the association between rDA and pAF in patients
undergoing CABG. Patients with a documented history of atrial fibrillation,
those who required inotrope use during or after surgery, and those having valve
surgery were excluded. MEASUREMENTS AND MAIN RESULTS: One-thousand seven-hundred
thirty-one patients undergoing CABG during the period of January 1, 2000,
through June 30, 2002, were the study population; of these, 15.0% (260/1,731)
developed pAF. The incidence of pAF was 23.3 % (41/176) among patients who
received rDA and 14.1% (219/1,555) among those who did not receive rDA. In the
multivariable logistic regression model, patient age, gender, chronic
obstructive pulmonary disease or asthma, and rDA were associated with pAF (p <
.01). Receipt of rDA increased the odds of developing pAF by 74%, independent of
the effect of other variables. CONCLUSIONS: Renal-dose dopamine is associated
with a 1.74 odds ratio of pAF developing after CABG.

Exp Brain Res. 2005 Jun 7; [Epub ahead of print] 

Cerebral oxygen saturation and electrical brain activity before, during, and up
to 36 hours after arterial switch procedure in neonates without pre-existing
brain damage: its relationship to neurodevelopmental outcome.

Toet MC, Flinterman A, Laar IV, Vries JW, Bennink GB, Uiterwaal CS, Bel FV.

Department of Neonatology, KE 04.123.1, University Medical Center Utrecht/
Wilhelmina Children's Hospital, P.B. 85090, 3508, Utrecht, The Netherlands,
M.Toet@WKZ.AZU.nl.

Objective: To monitor the pattern of cerebral oxygen saturation (rSat), by use
of NIRS, in term infants before, during and after the arterial switch operation
and to evaluate its relation to neurodevelopmental outcome. Methods: In 20
neonates without pre-existing brain damage hemodynamics and arterial oxygen
saturation (AO(2)-Sat) were monitored simultaneously with rSat and
amplitude-integrated EEG (aEEG) from 4 h to 12 h before up to 36 h after
cardiopulmonary bypass (CPB) and short duration of cardiac arrest during deep
hypothermia (DHCA). The Bayleys developmental scale was performed at 30 months.
Results: Before surgery rSat was <50% in 16 patients. During CPB rSat increased
to normal values, with a sharp decrease during brief CA (median 6.5 min).
Post-CPB rSat showed a transient decrease (30-45%) despite normal PaO(2) with
sustained normalization after 6-26 h. Recovery time of the rSat seemed longer
when pre-operative rSat was below 35%, and for lower minimum nasopharyngeal
temperature and longer duration of CPB and of DHCA. Recovery time of the aEEG
varied and did not correlate with normalization of rSat. Neurodevelopmental
outcome was normal in all but two patients. Patients with lower pre-operative
rSat (<35%) tended to have lower DQ (developmental quotient) scores at 30-36
months. (median: mental 102 and motor 101 (range 58-125) compared with mental
100 and motor 110 (range 83-125)) Conclusion: Despite prompt normalization of
circulation and oxygenation after surgery, recovery of rSat of the brain took
6-26 h, probably because of higher energy demand after CPB. Pre-operative
cerebral oxygenation may be underestimated as a possible cause of adverse
post-operative outcome.

Eur J Cardiothorac Surg. 2005 Jun 3; [Epub ahead of print] 

Metabolic alkalosis after pediatric cardiac surgery.

van Thiel RJ, Koopman SR, Takkenberg JJ, Derk Jan Ten Harkel A, Bogers AJ.

Department of Cardiothoracic Surgery, Thoraxcenter, Bd 156, Erasmus MC, P.O. Box
2040, 3000 CA Rotterdam, The Netherlands.

Objective: To determine occurrence, causes and associated mortality of
postoperative metabolic alkalosis in pediatric cardiac surgery. Methods: We
retrospectively analyzed clinical and biochemical variables of 186 consecutive
cardiac operations other than ductal ligations on children less than 2 years old
during the years 1999 and 2000. Metabolic alkalosis was defined as a pH>7.48
corrected for PCO(2), with a base excess >/=5 on two or more consecutive
measurements during an 8h period. Results: Median age was 15 weeks [range 2
days-95 weeks] and median weight 4.5kg [range 2.1-15.7kg]. In 157 cases,
cardiopulmonary bypass was used. In 92 [49%] procedures, metabolic alkalosis
occurred with the highest corrected pH 24.3h after operation. Multivariate
regression analysis associated age [P<0.001], cardiopulmonary bypass [P<0.001]
and preoperative ductal dependency [P=0.04] with postoperative metabolic
alkalosis. Of the surgical procedures the arterial switch for transposition of
the great arteries [n=19] was strongly associated with metabolic alkalosis
[100%, P<0.001]. Hemodilution appeared to enhance the development of alkalosis:
those who experienced alkalosis had been hemodiluted to a greater extent
[P=0.007]. Nearly 95% of patients experienced some increase in bicarbonate, but
patients with metabolic alkalosis experienced more than those without [5.9
versus 3.5mmol/l, P<0.001]. There were four postoperative deaths, only one
coincidental with metabolic alkalosis. Conclusions: Metabolic alkalosis has a
high incidence after pediatric cardiac surgery, strongly associated with younger
age, cardiopulmonary bypass, preoperative ductal dependency and perioperative
hemodilution. Early recognition allows for timely therapeutic intervention.