Heart. 2006 Jun 27; [Epub ahead of print] 

Early outcomes in the elderly: a meta-analysis of 4921 patients undergoing
coronary artery bypass grafting - a comparison between off-pump and on-pump
techniques.

Panesar SS, Athanasiou T, Nair S, Rao C, Jones C, Nicolaou M, Darzi A.

St. Mary's Hospital, Imperial College London, United Kingdom.

BACKGROUND: The elderly patients undergoing coronary artery bypass grafting
constitute a challenging group due to increased risk of particular postoperative
complications which are directly related to age. This study aims to assess these
early outcomes in the elderly population undergoing coronary revascularization
with and without cardiopulmonary bypass. 

METHODS: A meta-analysis of all retrospective, non-randomized studies comparing 
OPCAB (off-pump coronary artery bypass) and CPB (cardiopulmonary bypass) 
techniques in the elderly (>70 years) between 1999 and 2005 was performed. 
Age-related early outcomes of interest were
mortality, stroke, atrial fibrillation, renal failure and length of stay in
hospital. The random effects model was used. Sensitivity and heterogeneity were
analysed. 

RESULTS: Analysis of fourteen non-randomized studies comprising 4921
patients [OPCAB=1533(31.1%) and CPB=3388(68.9%)], showed a significantly lower
incidence of mortality in the OPCAB group (OR 0.48[95%CI 0.28 to 0.84]). This
effect was greater in OPCAB octogenarians (OR 0.26[95%CI 0.12 to 0.57]). A
similar pattern was detected in the incidence of stroke amongst the OPCAB
octogenarians (OR 0.19[95%CI 0.07 to 0.56]). The incidence of atrial
fibrillation was lower in the OPCAB group (OR 0.77[95%CI 0.61 to 0.97]). No
difference was identified in the incidence of renal failure. Length of hospital
stay was shorter in the OPCAB group although significant heterogeneity was
identified. 

CONCLUSIONS: Our study demonstrates that OPCAB may be associated
with lower incidence of mortality, stroke and AF in the elderly which may result
in shorter length of hospital stay. A large randomized trial would confirm
whether the elderly will benefit more from OPCAB surgery.

Can J Anaesth. 2006 Jun;53(6 Suppl):S21-9. 

Pharmacological approaches to reducing blood loss and transfusions in the
surgical patient: [Approches pharmacologiques de reduction des pertes sanguines
et des transfusions en chirurgie].

Ozier Y, Schlumberger S.

Department of Anesthesia and Intensive Care, Groupe Hospitalier Cochin, 27, rue
du Fbg Saint-Jacques, F-75629 Paris, France. yves.ozier@cch.aphp.fr.

PURPOSE: To review the efficacy, effectiveness and safety of hemostatic drugs to
reduce surgical blood loss. 

METHODS: Analysis of randomized controlled trials and meta-analyses exploring the 
efficacy of desmopressin, aprotinin, lysine analogues and recombinant activated factor 
VII (rFVIIa) on clinically important endpoints.Main findings: Although potentially useful in 
surgical patients with mild hemophilia or type I von Willebrand's disease, desmopressin 
has no proven benefit in patients without previous hemostatic defects. Aprotinin has been
studied extensively in cardiopulmonary bypass surgery, with evidence of a blood
sparing effect. Additional benefits are suggested. The drug is less consistently
effective in liver transplantation and major orthopedic surgery. Although rare,
hypersensitivity reactions to aprotinin may occur, especially on re-exposure.
Tranexamic acid can reduce blood transfusion in cardiac surgery, liver
transplantation and total knee arthroplasty surgery with a satisfactory safety
profile. Epsilon aminocaproic acid has not been investigated adequately, despite
its widespread use. While rFVIIa may be beneficial in controlling massive
coagulopathic bleeding in trauma and surgical patients, there is currently no
evidence to support its prophylactic use in elective surgical patients.

CONCLUSION: Aprotinin and tranexamic acid are valuable pharmacologic options for
reducing surgical bleeding. The expected benefit of these drugs is highly
dependent on the actual blood usage for a given procedure at the institutional
level. More studies using clinically significant endpoints are necessary to
assess the relative efficacy and optimal dosing of these drugs.

Crit Care Med. 2006 Jun 6; [Epub ahead of print] 

Tumor necrosis factor-alpha and interleukin-10 gene expression in peripheral
blood mononuclear cells after cardiac surgery.

Duggan E, Caraher E, Gately K, O'dwyer M, McGovern E, Kelleher D, McManus R,
Ryan T.

From the Departments of Anaesthesia (ED, MO, TR) and Cardiothoracic Surgery
(EM), St James's Hospital, Dublin, Ireland; and the Department of Clinical
Medicine and Dublin Molecular Medicine Centre, Trinity Centre for Health
Sciences, Dublin, Ireland (EC, KG, DK, RM).

OBJECTIVE:: Cytokine response after cardiac surgery may be genetically
influenced. A study was carried out to investigate the relation between cytokine
gene expression in peripheral blood mononuclear cells genotype and clinical
events after cardiac surgery. 

DESIGN:: A case-control study was performed.

SETTING:: Cardiac intensive care unit in a university hospital. 

SUBJECTS:: A total of 82 patients having elective cardiac surgery were divided into those
having uncomplicated recovery (n = 48) or recovery complicated by
hyperlactatemia or requirement for inotropic support (n = 34). 

INTERVENTIONS:: The relative change in peripheral blood mononuclear cell tumor necrosis
factor-alpha (TNF-alpha) and interleukin-10 (IL-10) messenger RNA 1 and 6 hrs
after cardiopulmonary bypass was compared with a baseline preoperative level
using quantitative reverse transcriptase polymerase chain reaction. DNA was
analyzed for carriage of TNF-alpha and IL-10 polymorphic alleles. 

MEASUREMENTS AND MAIN RESULTS:: Cardiopulmonary bypass was longer in duration in the
complicated group. TNF-alpha gene expression decreased and IL-10 gene expression
increased in peripheral blood mononuclear cells after surgery when compared with
preoperative levels. One hour after cardiopulmonary bypass, the complicated
group had more TNF-alpha and less IL-10 messenger RNA production than the
uncomplicated group. The IL-10/TNF-alpha ratio was greater in uncomplicated than
in complicated recovery patients. An IL-10 haplotype was identified that was
less frequent in the complicated group. There was no difference between groups
in TNF-alpha genotype. On multivariate analysis, cardiopulmonary bypass time and
the IL-10/TNF-alpha messenger RNA ratio were independent predictors of outcome.

CONCLUSIONS:: There is a predominant anti-inflammatory cytokine response after
uneventful cardiac surgery. IL-10 may have a protective role after cardiac
surgery.

Pediatr Crit Care Med. 2006 Jun 5; [Epub ahead of print] 

A review of the natriuretic hormone system's diagnostic and therapeutic
potential in critically ill children*

Costello JM, Goodman DM, Green TP.

From the Division of Cardiac Intensive Care, Department of Cardiology,
Children's Hospital Boston and Harvard Medical School, Boston, MA (JMC); and
Division of Pulmonary and Critical Care Medicine, Department of Pediatrics,
Children's Memorial Hospital and Northwestern University Feinberg School of
Medicine, Chicago, IL (DMG, TPG).

OBJECTIVE:: To review the natriuretic hormone system and discuss its diagnostic,
prognostic, and therapeutic potential in critically ill children. 

DATA SOURCE:: A thorough literature search of MEDLINE was performed using search terms
including heart defects, congenital; cardiopulmonary bypass, atrial natriuretic
factor; natriuretic peptide, brain; carperitide; nesiritide. Preclinical and
clinical investigations and review articles were identified that describe the
current understanding of the natriuretic hormone system and its role in the
regulation of vascular tone and fluid balance in healthy adults and children and
in those with underlying cardiac, pulmonary, and renal disease. 

RESULTS:: A predictable activation of the natriuretic hormone system occurs in children with
congenital heart disease and congestive heart failure. Further study is needed
to confirm preliminary reports that measurement of natriuretic hormone levels in
critically ill children provides diagnostic and prognostic information, as has
been demonstrated in adult cardiac populations. Natriuretic hormone infusions
provide favorable hemodynamic changes and symptomatic relief when used in adults
with decompensated congestive heart failure, and uncontrolled case series
suggest that similar benefits may exist in children. The biological activity of
the natriuretic hormone system may be decreased following pediatric
cardiopulmonary bypass, and additional studies are needed to determine whether
natriuretic hormone infusions provide clinical benefit in the postoperative
period. Preliminary reports suggest that natriuretic hormone infusions cause
physiologic improvements in adults with acute lung injury and asthma but not in
those with acute renal failure. 

CONCLUSIONS:: Although important perturbations
of the natriuretic hormone system occur in critically ill infants and children,
further investigation is needed before the measurement of natriuretic peptides
and the use of natriuretic hormone infusions are incorporated into routine practice.

Heart Surg Forum. 2006 Jun;9(4):E686-9. 

Whole-Body Perfusion under Moderate-Degree Hypothermia during Aortic Arch
Repair.

Emrecan B, Yilik L, Tulukoglu E, Kestelli M, Ozsoyler I, Lafci B, Ozbek C,
Gurbuz A.

Department of Cardiovascular Surgery, Izmir Ataturk Training and Research
Hospital, Izmir, Turkey.

Introduction. There continue to be some controversies concerning aortic arch
reconstruction, especially the cerebral protection methods. We report our
operative and postoperative outcomes for cases of aortic arch replacement using
whole-body perfusion during aortic reconstruction under 28 degrees C moderate
hypothermia.

Materials and Methods. A total of 12 patients were operated on
between March 2003 and November 2005. Two of the patients were female. The mean
age of the patients was 53.5 x 7.3 years (range, 42-65 years). We cannulated the
right axillary artery for cerebral perfusion and the right femoral artery for
body perfusion. Arch replacement was done under continuous antegrade cerebral
perfusion through the right axillary artery and continuous body perfusion
through the right femoral artery via intra-aortic occlusion of the proximal
descending aorta with an intra-aortic occlusion catheter. Perioperative data and
postoperative outcomes, blood urea nitrogen, serum creatinine, and alanin
aminotransferase values were evaluated retrospectively in the patients.

Results. There was only 1 hospital mortality. There were no neurologic complications.
Postoperative levels of blood urea nitrogen and creatinin did not show
significant difference but the alanin aminotransferase levels were significantly
higher in the postoperative period, which was within the normal ranges of
cardiopulmonary bypass effect.

Discussion. Whole-body perfusion through the axillary and femoral arteries may provide 
more time for the surgeon and good cerebral and visceral protection, which are especially 
important for surgical teams in the learning curve.

Int J Cardiol. 2006 Jun 3; [Epub ahead of print] 

Impact of cardiac surgery on plasma levels of B-type natriuretic peptide in
children with congenital heart disease.

Koch A, Kitzsteiner T, Zink S, Cesnjevar R, Singer H.

Paediatric Cardiology, Department of Paediatrics and Adolescent Medicine,
University of Erlangen-Nurnberg, Germany.

OBJECTIVE: To examine prospectively the effect of cardiac surgery on plasma
concentration of B-type natriuretic peptide (BNP) in children with congenital
heart disease. 

SETTING: Tertiary referral center. 

METHODS: BNP plasma concentration was measured by sandwich immunoassay 
(Biosite(R)) in 65 consecutive patients with congenital heart disease (age 4 days to 17.1 years,
mean (S.D.) age 3.6 (4.7) years, median age 1.0 years) on the day before and
after surgical therapy. BNP levels were compared to perioperative data and to
healthy subjects. 

RESULTS: BNP increased significantly (p<0.001) after cardiac
surgery from median 31 pg/ml (mean 189 pg/ml) to median 453 pg/ml (mean 607
pg/ml) and remained significantly elevated during the first week (p<0.001).
After a first peak mean (S.D.) 1.3 (0.7) days after surgery, there was a
significant decrease of plasma BNP followed by a second peak 5.1 (1.1) days
after surgery. Postoperative BNP plasma concentration was correlated to BNP
before surgery (r=0.58, p<0.001), to cardiopulmonary bypass duration (r=0.52,
p<0.001) and to serum lactate concentration at the first day after surgery
(r=0.49, p<0.001). 

CONCLUSIONS: In children with congenital heart defects plasma
BNP increased immediately after cardiac surgery despite haemodynamic unloading.
The correlation to cardiopulmonary bypass time and serum lactate concentration
and the similarity between the pattern of BNP release after surgery and after
myocardial ischaemia might be explained by a cytoprotective role for BNP after
cardiac surgery.

Pediatrics. 2006 Jul;118(1):e76-e84. Epub 2006 Jun 2. 

Hypertonic-Hyperoncotic Solutions Improve Cardiac Function in Children After
Open-Heart Surgery.

Schroth M, Plank C, Meissner U, Eberle KP, Weyand M, Cesnjevar R, Dotsch J,
Rascher W.

Kinder- und Jugendklinik, Friedrich-Alexander-University Erlangen-Nuremberg,
Loschgestrabetae 15, D-91054 Erlangen, Germany. michael_schroth@yahoo.de.

OBJECTIVES. Hypertonic-hyperoncotic solutions are used for the improvement of
micro- and macrocirculation in various types of shock. In pediatric intensive
care medicine, controlled, randomized studies with hypertonic-hyperoncotic
solutions are lacking. Hypertonic-hyperoncotic solutions may improve cardiac
function in children. The primary objective of this controlled, randomized,
blinded study was to evaluate the hemodynamic effects and safety of
hypertonic-hyperoncotic solution infusions in children shortly after open-heart
surgery for congenital cardiac disease. The secondary objective was to determine
whether the administration of hypertonic-hyperoncotic solutions could be a
potential and effective therapeutic option for preventing a probable capillary
leakage syndrome that frequently occurs in children after open-heart surgery.

METHODS. The children were randomly assigned to 2 groups of 25. The
hypertonic-hyperoncotic solution group received Poly-(O-2)-hydroxyethyl-starch
60.0 g, with molecular weight of 200 kDa, Na(+) 1232 mmol/L and osmolality of
2464 mOsmol/L (7.2% sodium chloride with 6% hydroxyethyl-starch 200 kDa). The
isotonic saline solution group received isotonic saline solution (0.9% sodium
chloride). Atrial and ventricular septal defects were corrected using a
homograft patch. Monitoring consisted of an arterial, a central venous, and a
thermodilution catheter (PULSIOCATH). Cardiac index, extravascular lung water
index, stroke volume index, mean arterial blood pressure, and systemic vascular
resistance index were measured (Pulse Contour Cardiac Output technique).
Immediately after surgery, patients were loaded either with
hypertonic-hyperoncotic solution or with isotonic saline solution (4 mL/kg).
Blood samples (sodium concentration, osmolality, thrombocyte count, fibrinogen,
and arterial blood gases) were drawn directly before; immediately after; 15
minutes after; and, 1, 4, 12, and 24 hours after the end of volume loading.
Hemodynamic parameters were registered at the same time. The total amount of
dobutamine required was documented, as well as the 24- and 48-hour fluid
balances. 

RESULTS. In the hypertonic-hyperoncotic solution group, cardiac index
was 3.6 +/- 0.26 L/min per m(2) before volume administration and increased to
5.96 +/- 0.27 after the administration of the study solution (64%). Fifteen and
60 minutes after administration, the cardiac index remained significantly
elevated (5.55 +/- 0.29 L/min per m(2) and 4.65 +/- 0.18 L/min per m(2),
respectively) and returned to preadministration values after 4 hours. In the
isotonic saline solution group, the cardiac index did not change during the
entire observation period (3.39 +/- 0.21 before and 3.65 +/- 0.23 L/min per m(2)
after isotonic saline solution). The systemic vascular resistance index
decreased in the hypertonic-hyperoncotic solution group after administration
from 1396 +/- 112 to 868 +/- 63 dyn/sec per cm(-5)/m(2). The decrease of
systemic vascular resistance index in the hypertonic-hyperoncotic solution group
was transiently significant within 60 minutes after administration but stayed
lower than before volume load (999 +/- 70 dyn/sec per cm-(5)/m(2)). In the
isotonic saline solution group, we found no statistically relevant change in
systemic vascular resistance index. Stroke volume index significantly increased
after hypertonic-hyperoncotic solution infusion (53.9 +/- 3.0 mL/m(2) directly
after, 48.8 +/- 2.46 mL/m(2) 15 minutes after, and 41.4 +/- 2.2 mL/m(2) 60
minutes after) when compared with stroke volume index before administration
(32.4 +/- 2.6 mL/m(2)). In the hypertonic-hyperoncotic solution group, an
increase in mean arterial blood pressure remained transiently significant within
60 minutes after administration when compared with the isotonic saline solution
group, in which the mean arterial blood pressure remained unchanged. Both
central venous pressure and heart rate were unchanged during the whole time of
observation in both groups. In the hypertonic-hyperoncotic solution group,
extravascular lung water index decreased from 10.6 +/- 1.2 to 5.6 +/- 1.2 mL/kg
and remained significantly decreased 15 minutes after (6.5 +/- 1.2 mL/kg) when
compared with before volume administration. In the isotonic saline solution
group, extravascular lung water index increased from 12.3 +/- 1.1 mL/kg to 18.1
+/- 1.7 mL/kg directly after administration and remained elevated for 60 minutes
after volume loading (15.6 +/- 1.5 mL/kg). In all patients, no hypoxia
(Pao(2)<60 mm Hg) or hypercapnia (Paco(2) >60 mm Hg) was observed. Arterial
blood gas analysis showed pH and base excess within physiologic range, and this
did not change throughout the whole period of observation. After infusion of
hypertonic-hyperoncotic solution, sodium concentration increased from 139.2 +/-
0.7 to 147.5 +/- 0.7 mmol/L. The maximum sodium concentration was 153 mmol/L,
measured immediately after hypertonic-hyperoncotic solution in 1 patient. The
total amount of fluid infused was similar in both groups. The postoperative need
for infused dobutamine in the patients in the hypertonic-hyperoncotic solution
group was decreased compared with the isotonic saline solution group (46.9 +/-
8.8 mug/kg vs 308.2 +/- 46.6 mug/kg). No patient presented with severe bleeding.
Short- and long-term cardiac and neurologic outcome was not reduced and all
patients left the hospital in a clinically sufficient state. 

DISCUSSION. This study demonstrates a profound increase of cardiac index after the administration
of hypertonic-hyperoncotic solution in children after uncomplicated open-heart
surgery, suggesting a positive inotropic effect. The total amount of
catecholamine was lower, assuming that hypertonic-hyperoncotic solution reduces
the need for positive inotropic support. The observed positive cardiac effect of
hypertonic-hyperoncotic solution may even be intensified by the decreased
afterload (decreased systemic vascular resistance index). According to the
Frank-Starling relation, an effective tool in the treatment of low cardiac
output are an elevated preload while afterload is diminished. Therefore, we
postulate that hypertonic-hyperoncotic solution may be helpful in preventing or
attenuating low cardiac output failure in childhood. Capillary leakage syndrome
also is a frequent problem after cardiopulmonary bypass. For quantification of
edema formation, extravascular lung water index measurement is a useful tool.
Using this approach, we provided evidence that the infusion of
hypertonic-hyperoncotic solution is transiently able to reduce extravascular
lung water index. This reduction was transient but might prevent the triggering
of a clinically relevant capillary leakage syndrome. This is in line with in
vitro studies demonstrating that hypertonic-hyperoncotic solution improves
microcirculation by reducing vascular permeability. The single administration of
hypertonic-hyperoncotic solution infusion was safe, and no adverse effects, such
as hemostatic disturbances, were observed. 

CONCLUSIONS. A single infusion of hypertonic-hyperoncotic saline solution after 
cardiac surgery is safe despite the hypertonicity and the colloid component of the hypertonic-hyperoncotic
saline solution. In children after cardiopulmonary bypass surgery, the
administration of hypertonic-hyperoncotic saline solution increased cardiac
index by elevating stroke volume index in combination with a lowered systemic
vascular resistance index. Extravascular lung water index transiently decreased,
suggesting that hypertonic-hyperoncotic saline solution effectively counteracts
the capillary leakage that often occurs after cardiac surgery in children.
Additional investigations might elucidate whether the temporary effects of
hypertonic-hyperoncotic saline solution are beneficial in the treatment of
severe capillary leakage after complicated cardiac surgery. It has to be shown
that hypertonic-hyperoncotic saline solution is a long-lasting, effective
treatment strategy for low cardiac output failure in children that is caused by
sepsis, multiorgan failure, and endothelial edema. We have provided evidence to
pediatric intensive care clinicians that the single administration of
hypertonic-hyperoncotic saline solution might be a useful and safe treatment in
the amelioration of contractility, inotropy, and the possible treatment of
early-onset capillary leakage.

J Am Coll Cardiol. 2006 Jun 6;47(11):2277-82. Epub 2006 May 15. 

Randomized controlled trial of the effects of remote ischemic preconditioning on
children undergoing cardiac surgery: first clinical application in humans.

Cheung MM, Kharbanda RK, Konstantinov IE, Shimizu M, Frndova H, Li J, Holtby HM,
Cox PN, Smallhorn JF, Van Arsdell GS, Redington AN.

Division of Cardiology and Cardiovascular Surgery, Hospital for Sick Children,
Toronto, Canada.

OBJECTIVES: We conducted a randomized controlled trial of the effects of remote
ischemic preconditioning (RIPC) in children undergoing repair of congenital
heart defects. 

BACKGROUND: Remote ischemic preconditioning reduces injury caused
by ischemia-reperfusion in distant organs. Cardiopulmonary bypass (CPB) is
associated with multi-system injury. We hypothesized that RIPC would modulate
injury induced by CPB. 

METHODS: Children undergoing repair of congenital heart
defects were randomized to RIPC or control treatment. Remote ischemic
preconditioning was induced by four 5-min cycles of lower limb ischemia and
reperfusion using a blood pressure cuff. Measurements of lung mechanics,
cytokines, and troponin I were made pre- and postoperatively. RESULTS:
Thirty-seven patients were studied. There were 20 control patients and 17
patients in the RIPC group. The mean age and weight of the RIPC and control
patients were not different (0.9 +/- 0.9 years vs. 2.2 +/- 3.4 years, p = 0.4;
and 6.9 +/- 2.9 kg vs. 11.5 +/- 10 kg, p = 0.06). Bypass and cross-clamp times
were not different (80 +/- 24 min vs. 88 +/- 25 min, p = 0.3; and 55 +/- 13 min
vs. 59 +/- 13 min, p = 0.4). Levels of troponin I postoperatively were greater
in the control patients compared with the RIPC group (p = 0.04), indicating
greater myocardial injury in control patients. Postoperative inotropic
requirement was greater in the control patients compared with RIPC patients at
both 3 and 6 h (7.9 +/- 4.7 vs. 10.9 +/- 3.2, p = 0.04; and 7.3 +/- 4.9 vs. 10.8
+/- 3.9, p = 0.03, respectively). The RIPC group had significantly lower airway
resistance at 6 h postoperatively (p = 0.009). 

CONCLUSIONS: This study demonstrates the myocardial protective effects of RIPC using a simple
noninvasive technique of four 5-min cycles of lower limb ischemia and
reperfusion. These novel data support the need for a larger study of RIPC in
patients undergoing cardiac surgery.

J Thorac Cardiovasc Surg. 2006 Jun;131(6):1382-1382.e10. 

Intra-aortic balloon pumping in children undergoing cardiac surgery: an update
of the Liverpool experience.

Kalavrouziotis G, Karunaratne A, Raja S, Ciotti G, Purohit M, Corno AF, Pozzi M.

Department of Pediatric Cardio-Thoracic Surgery, Royal Liverpool Children's NHS
Trust, Alder Hey Hospital, Liverpool, United Kingdom. gkalavrouziotis@yahoo.com

OBJECTIVE: Intra-aortic balloon pumping in children remains a rarity. We report
our experience in supporting pediatric cardiac surgical patients with
intra-aortic balloon pumping. 

METHODS: We reviewed the cases of 24 children supported with intra-aortic balloon 
pumping after cardiac surgery in our institution from 1994 through 2003. 

RESULTS: Mean age at the time of the operation was 5.0 +/- 5.6 years (range, 7 days-17.5 years). 
Ten patients were infants less than 6 months old. Mean weight was 18.9 +/- 18.1 kg (range,
3.5-58.7 kg). Indications for intra-aortic balloon pump deployment were
postoperative hemodynamic deterioration (n = 11, 8 survivors), failure to wean
off cardiopu(n = 7, 5 survivors), and prophylaxis before weaning off
cardiopulmonary bypass (n = 6, 5 survivors). The balloon was inserted through
the ascending aorta in infants and through the femoral artery in children.
Eighteen children (7 infants) were weaned off the intra-aortic balloon pump
successfully (intra-aortic balloon pump survival, 75%). Mean duration of
intra-aortic balloon pump support was 121.3 +/- 140.60 hours (range, 8-670
hours). There were 3 post-intra-aortic balloon pump in-hospital deaths (survival
to hospital discharge, 62.5%). Severe intra-aortic balloon pump-related
complications were mesenteric ischemia in 1 patient and lower limb ischemia
requiring intra-aortic balloon pump removal in 1 patient. At a mean follow-up of
85 +/- 31 months (range, 18-124 months), all 15 long-term survivors were alive
and well. 

CONCLUSIONS: Use of an intra-aortic balloon pump is an effective
modality of cardiac support in properly selected pediatric cardiac surgical
patients with refractory low cardiac output. It can be safely used in small
infants and neonates. In selected cases with known left ventricular dysfunction,
there is a place for prophylactic use of an intra-aortic balloon pump.

J Thorac Cardiovasc Surg. 2006 Jun;131(6):1352-7. 

Hemodynamic effects of cardiotomy suction blood.

Westerberg M, Gabel J, Bengtsson A, Sellgren J, Eidem O, Jeppsson A.

Department of Cardiothoracic Surgery, Sahlgrenska University Hospital,
Gothenburg, Sweden.

OBJECTIVE: Cardiac surgery induces a systemic inflammatory activation, which in
severe cases is associated with peripheral vasodilation and hypotension.
Cardiotomy suction blood contains high levels of inflammatory mediators, but the
effect of cardiotomy suction blood on the vasculture is unknown. We investigated
the effect of cardiotomy suction blood on systemic vascular resistance in vivo
and whether cell-saver processing of suction blood affects the vascular
response. 

METHODS: Twenty-five patients undergoing coronary surgery (mean age,
68 +/- 2 years; 80% men) were included in a prospective randomized study. The
patients were randomized to retransfusion of cell-saver processed (n = 13) or
cell-saver unprocessed (n = 12) suction blood during full cardiopulmonary
bypass. Mean arterial blood pressure was continuously registered during
retransfusion, and systemic vascular resistance was calculated. Plasma
concentrations of tumor necrosis factor alpha, interleukin 6, and complement
factor C3a were measured in suction blood. 

RESULTS: Retransfusion of cardiotomy suction blood induced a transient reduction 
in systemic vascular resistance in all patients. The peak reduction was significantly less 
pronounced in the group receiving cell-saver processed blood (-12% +/- 2% vs -28% +/- 3%, P = .001).
There was a significant correlation between tumor necrosis factor alpha
concentration in retransfused cardiotomy suction blood and peak reduction of
systemic vascular resistance (r = 0.60, P = .002). 

CONCLUSIONS: The results suggest cardiotomy suction blood is vasoactive and might influence vascular
resistance and blood pressure during cardiac surgery. The observed vasodilation
is proportional to the inflammatory activation of suction blood and can be
reduced by processing suction blood with a cell-saving device before
retransfusion.