Curr Med Res Opin. 2007 Jun 26; [Epub ahead of print]

Preoperative statins and infectious complications following cardiac surgery.

Coleman CI, Lucek DM, Hammond J, Michael C.

PURPOSE: Recent observational studies have suggested that statins can decrease
the incidence and severity of various infections including pneumonia and
bacteremia. However, the effect of statins on post-cardiac surgery infection has
not been adequately evaluated. Therefore we sought to determine whether
preoperative statin use resulted in a reduction in infection following cardiac
surgery.METHODS: This was a cohort evaluation of all consecutive patients who
underwent coronary artery bypass graft (CABG) and/or valve surgery at our
institution between January 1, 2004 and August 31, 2006. Our primary outcome
measure was the occurrence of at least one of the following postoperative
infectious complications (pneumonia, bacteremia, sternal wound, leg vein harvest
site infection, urinary tract infection, or tracheotomy site infection). We used
multivariable logistic regression to control for potential confounding and to
calculate adjusted odds ratios (AORs) and 95% confidence intervals (CIs).RESULTS:
A total of 1934 patients were included in this evaluation of which 1248 received
a statin preoperatively and 686 did not. Our study population was 66.3 +/- 11.6
years of age, 71.3% male; 37.2% underwent complex surgery, 3.6% were morbidly
obese, and 32.0% were diabetic (each being previously identified as an
independent predictor of infection following cardiac surgery). Patients receiving
a statin preoperatively and not receiving a statin preoperatively varied in
respect to a number of important pre- and peri- operative characteristics.
Patients receiving preoperative statin therapy were more likely to have had a
history of diabetes, chronic obstructive pulmonary disease or high cholesterol
and to be smokers, but less likely to be undergoing urgent/emergent surgery or
surgery utilizing a cardiopulmonary bypass pump (p < 0.05 for all comparisons).
In total, 151 (7.8%) patients developed an infectious complication. Upon
multivariable logistic regression, preoperative statin use was associated with a
significant reduction in the development of infection (AOR; 0.67 (95% CI
0.46-0.99), p = 0.04). The use of a statin was not associated with a
statistically significant reduction in any individual infection on its own (p >
0.08 for all).Limitations: Patients were not randomized to receive statins or
not. We did not have adequate power to evaluate individual
infections.CONCLUSIONS: Preoperative statin use is associated with a reduction in
patients odds of developing a postoperative infection following cardiac surgery.

Eur J Anaesthesiol. 2007 Jun 27;:1-7. [Epub ahead of print]

Intra-operative myocardial ischaemia cannot be detected by analysis of
transmitral inflow patterns in patients undergoing off-pump coronary surgery.

Wang J, Seeberger MD, Skarvan K, Michaux I, Bernet F, Arsenic R, Buser P,
Filipovic M.

University Hospital Basel, Department of Anaesthesia, Basel, Switzerland.

SummaryBackground and objectiveTransmitral inflow patterns have been used for
detection of myocardial ischaemia. However, its diagnostic value has not been
tested in anaesthetized and mechanically ventilated patients undergoing coronary
artery bypass graft surgery. METHODS: Transmitral inflow patterns were studied by
transoesophageal Doppler echocardiography in 43 patients undergoing coronary
artery bypass graft surgery without cardiopulmonary bypass after opening of the
sternum (baseline) and during grafting of the left anterior descending artery.
Peak early (E) and peak late (A) transmitral velocities and their ratio (E/A)
were recorded. Myocardial ischaemia was defined by standard criteria using
two-dimensional echocardiography and seven-lead electrocardiogram. RESULTS:
Thirty-one patients (64 +/- 8 yr, 9 women) fulfilled the predefined inclusion
criteria for analysis. During distal revascularization, 16 patients showed
myocardial ischaemia and 15 did not. The use of vasoactive drugs, haemodynamic
findings and transmitral inflow patterns were similar in both groups at baseline
and during grafting. In the ischaemic group, E was 67.1 +/- 13.9 cm s-1 at
baseline and 69.5 +/- 23.2 cm s-1 during grafting, and the E/A ratios were 1.3
+/- 0.3 and 1.4 +/- 0.9, respectively. In the non-ischaemic group, E was 64.0 +/-
17.1 cm s-1 at baseline and 60.9 +/- 14.8 cm s-1 during grafting, and the E/A
ratios were 1.4 +/- 0.7 and 1.2 +/- 0.3, respectively. CONCLUSIONS: Analysis of
Doppler findings of transmitral inflow patterns did not allow for detection of
myocardial ischaemia during surgical revascularization of the myocardium.

Ann Thorac Cardiovasc Surg. 2007 Jun;13(3):159-64.

A first postoperative day predictive score of mortality for cardiac surgery.

Gomes RV, Tura B, Mendonça Filho HT, Almeida Campos LA, Rouge A, Matos Nogueira
PM, Oliveira Fernandes MA, Rocha Dohmann HF, Cunha AB.

Surgical Intensive Care Unit, Hospital Pró-Cardíaco, Rio de Janeiro, Brazil.

Purpose: Several prognostic scores for cardiac surgery based on preoperative
variables are available. We propose a new one based on pre-and intraoperative and
first postoperative day variables for cardiac surgery patients admitted to a
surgical intensive care unit. Materials and Methods: Classical cohort of data
consecutively collected from June 2000 to March 2003 (1,458 patients). Forty-six
risk variables were identified. The statistical study comprised univariate
analysis followed by logistic regression with receiver operating characteristics
(ROC) curve. Results: After logistic regression, the selected variables and
respective odds ratios were: age >65 and <75 years (2.05); age >/=75 years
(4.79); left atrial diameter >45 mm (2.58); preoperative creatinine >2 mg/dL
(4.84); and cardiopulmonary bypass time >/=180 min (4.93+/-2). The first
postoperative day variables were as follows: the worst PaO(2)/FiO(2) <100 (9.47);
epinephrine or norepinephrine dose >/=0.1 microg/kg/min (6.78); and mechanical
ventilation time >12 h (2.24). The area under the ROC curve was 0.84. Conclusion:
The score shows the strength of first postoperative day variables, probably
related to intraoperative conditions. It also evidences the importance of left
atrial diameter as a new marker of preoperative risk.

PMID: 17592423 [PubMed - in process]

Anaesth Intensive Care. 2007 Jun;35(3):398-405.

In vivo validation of the M-COVX metabolic monitor in patients under anaesthesia.

Stuart-Andrews CR, Peyton P, Robinson GJ, Terry D, O'Connor B, Van der Herten C,
Lithgow B.

Department of Anaesthesia and Perioperative Medicine, The Alfred Hospital,
Melbourne, Victoria, Australia. Christopher.Stuart-Andrews@eng.monash.edu.au

A practical method of breath-by-breath monitoring of metabolic gas exchange has
been developed by GE Healthcare/Datex Ohmeda and incorporated into existing
anaesthetic and critical care monitoring systems (M-COVXO). This device relates
flow measurements made at the mouth by pneumotachograph to measurements of
inspired and expired gas composition by matching the two waveforms thereby
allowing continuous, breath-by-breath monitoring of an intubated patient's oxygen
uptake and carbon dioxide production. Given that there is a paucity of data
comparing this new device against methods more widely used clinically, we tested
the device on 11 patients undergoing cardiopulmonary bypass surgery. Using a
standard anaesthetic machine (Datex Ohmeda Excel 210 SE) with a semi-closed
circle absorber system, oxygen uptake was measured at the mouth continuously
throughout the operation at approximately six-second intervals. The data were
compared against the reverse Fick method and against standard indirect
calorimetry using the Haldane transformation. When compared to the calculated
reverse Fick oxygen uptake, a mean difference of +16.5% was found pre-bypass and
+9.9% post-bypass, consistent with uptake of oxygen by lung tissue, which is not
taken into account by the reverse Fick method. Measurements made comparing the
M-COVX metabolic monitor against standard Haldane showed a mean difference of
+5.1% pre-bypass and -2.1% post-bypass. Given the ease with which this device can
be incorporated into existing anaesthetic monitoring systems and its accuracy in
measuring oxygen uptake, the M-COTVX module is an attractive addition to existing
perioperative monitoring.

Clinics. 2007 Jun;62(3):215-24.

Propranolol plasma monitoring in children submitted to surgery of tetralogy of
Fallot by a micromethod using high performance liquid chromatography.

Sanches C, Galas FR, Silva AG, Carmona MJ, Auler JO, Santos SR.

School of Pharmaceutical Sciences, University of Sao Paulo Medical School, Sao
Paulo, SP, Brazil.

OBJECTIVE: To evaluate the analytical micromethod using liquid chromatography for
the quantification of propranolol in children submitted to surgery of tetralogy
of Fallot (TLF). Methods: Only 0.2 mL of plasma is required for the assay. Peaks
eluted at 8.4 (Propranolol) and 17.5 min (verapamil, internal standard) from a
C18 column, with a mobile phase 0.1 M acetate buffer, pH 5.0, and acetonitrile
(60:40, v/v) at flow rate 0.7 mL/min, detected at 290 nm (excitation) and 358 nm
(emission). Surgery was started 776 min of drug administration (8.7 mg, mean);
seven blood samples were collected from six patients (4M/2F; 2.1 yrs;11.5 kg;
0.80 m; 18.9 kg/m(2)). RESULTS: Confidence limits of the method showed high
selectivity and recovery, sensitivity of 0.02ng/mL, good linearity (0.05-1000
ng/mL), precision of 8.6% and accuracy of 3.1%. The mean duration of surgery was
283.2 min, with the patients remaining under cardiopulmonary bypass (CPB) for 114
min. A declining curve of propranolol plasma concentration was obtained after the
last dose in the night that preceded the day of surgery. Plasma concentration
also was normalized with hematocrit due to the hemodilution caused by the CPB
procedure. On the other hand a decrease on drug plasma concentration was obtained
between periods, the beginning of surgery to the postoperative day 2 (7.09 ng/mL
and 0.05 ng/mL, p<0.05 respectively) and from the end of CPB to the postoperative
day 2 (2.79 ng/mL e 0.05 ng/mL, p<0.05). CONCLUSION: Propranolol monitoring of
plasma concentrations of children (TLF) normalized after the last preoperative
dose revealed a decline from the beginning of surgery to the second postoperative
day, suggesting that, once redistribution was restored, propranolol washout was
complete.

Eur J Anaesthesiol. 2007 Jun 21;:1-7. [Epub ahead of print]

Emergency cardiac mechanical assistance: place of mucosal gastric tonometry as
prognostic indicator.

Rosamel P, Flamens C, Paulus S, Cannesson M, Bastien O.

*Service d’Anesthésie et Réanimation, Hôpital Cardiovasculaire et Pneumologique
Louis Pradel, Lyon, France.

SummaryBackground and objectivesThe death of patients treated by ventricular
assist device is usually related to multiorgan failure for which a disorder of
splanchnic circulation is blamed. Gastric tonometry (measurement of gastric
intra-mucosal pressure of CO2) has already been studied in many fields and
especially in cardiac surgery. The aim of this study was to investigate the
prognostic value of gastric tonometry monitoring after implantation of a
ventricular assist device. METHODS: In this prospective study, all consecutive
patients scheduled for a ventricular assist device were included. Gastric
tonometry was added to standard monitoring. Data were collected (lactate, gastric
CO2 (PgCO2) during cardiopulmonary bypass, at admission to ICU, 24 and 48 h later
and when norepinephrine was stopped. Preoperative biologic and haemodynamic data
were also collected. The primary endpoint was death. RESULTS: Fifty-six patients
(50 men and 6 women) were included. In 91% of the cases, the mechanical
assistance was biventricular. The objective of the assistance was a bridge to
transplant in 93% (n = 27). Twenty-seven deaths (48%) occurred during the study,
59% (n = 16) of them took place before the cardiac transplantation (mean time =
18 +/- 16 days after assist device insertion). Many factors were found to be
associated with death: weight (P = 0.018), red cells administration (P = 0.025),
length of surgery (P = 0.016), PgCO2 on admission to ICU (P = 0.040) and
norepinephrine dose at 24 h. CONCLUSIONS: Gastric tonometry has a prognostic
value in the early postoperative hours after the implantation of a ventricular
assist device.

Cardiol Young. 2007 Jun 18;:1-4. [Epub ahead of print]

What is the optimal time to repair atrioventricular septal defect and common
atrioventricular valvar orifice?

Kogon BE, Butler H, McConnell M, Leong T, Kirshbom PM, Kanter KR.

1Department of Cardiothoracic Surgery, Emory University, Atlanta, Georgia, United
States of America.

OBJECTIVE: With improvements in technology and surgical technique, paediatric
cardiologists are challenging surgeons to repair balanced atrioventricular septal
defects in smaller patients. Early repair minimizes aggressive medical therapy to
prevent heart failure, maintains growth, and limits exposure to elevated
pulmonary pressures. We compare the outcomes of repair among different-sized
children. METHODS: From December 2002 to July 2005, 92 patients underwent repair
of an atrioventricular septal defect with common atrioventricular valvar orifice
and balanced ventricles. We reviewed operative and postoperative data. We
excluded patients weighing more than 10 kilograms, but included those who
underwent concomitant closure of a patent oval foramen or atrial septal defect,
or ligation of a patent arterial duct. Those requiring other concomitant
procedures were excluded from the analysis. RESULTS: The median weight at repair
was 4.9 kilograms, with a range from 2.93 to 7.9 kilograms, and the median age
was 5.1 months, with a range from 0.39 to 9.6 months. Operative data included the
time required for cardiopulmonary bypass, aortic cross-clamping, and the overall
procedure. These times were not significantly affected by decreasing weight.
Postoperative continuous data included duration of ventilation and length of
intensive care unit and hospital stay. Stay in intensive care (p = 0.006) and
hospital (p = 0.007) both increased significantly with decreasing weight.
Postoperative categorical data included presence of residual ventricular septal
defects, regurgitation across the left atrioventricular valve, and complications.
While there was no difference in residual defects (p = 0.166) or valvar
regurgitation (p = 0.729), there was a significantly higher presence of
complications with decreasing weight (p = 0.0043). There was no mortality, and no
persistent heart block requiring placement of a permanent pacemaker. CONCLUSIONS:
Our data shows that, with the exception of a slightly longer and more complicated
postoperative course, early surgery for symptomatic patients with
atrioventricular septal defects and common atrioventricular valvar orifice can be
undertaken safely and effectively in smaller children with excellent outcomes.

Thorac Cardiovasc Surg. 2007 Jun;55(4):233-8.

Recombinant hirudin for cardiopulmonary bypass anticoagulation: a randomized,
prospective, and heparin-controlled pilot study.

Riess FC, Poetzsch B, Madlener K, Cramer E, Doll KN, Doll S, Lorke DE, Kormann J,
Mueller-Berghaus G.

Department of Cardiac Surgery, Albertinen Heart Center, Hamburg, Germany.
Friedrich-Christian.Riess@albertinen.de

BACKGROUND: Lepirudin, a recombinant hirudin, is a direct acting thrombin
inhibitor that has been used as a heparin alternative in patients with
heparin-induced thrombocytopenia requiring on-pump cardiac surgery. To evaluate
the efficacy, safety, and clinical utility of lepirudin as a cardiopulmonary
bypass (CPB) anticoagulant, we compared lepirudin with heparin in a routine CPB
setting. METHODS: Twenty patients were randomly assigned to receive lepirudin
(0.25 mg/kg b. w. bolus and 0.2 mg/kg b. w. added to the CPB priming) or heparin
(400 U/kg b. w. bolus) with protamine reversal. Lepirudin and heparin
anticoagulation during CPB was monitored using the ecarin clotting time or ACT,
respectively and additional lepirudin (5 mg) or heparin (5000 U) boluses were
administered. RESULTS: The CPB circuit was performed in both groups without
thromboembolic complications. Median blood loss during the first 36 hours was
statistically higher ( P = 0.007) in the lepirudin group (1.226 +/- 316 ml)
compared to the heparin group (869 +/- 189 ml). One patient of the lepirudin
group developed pulmonary embolism 24 hours after surgery. This patient was
tested homozygous for the FV-Leiden mutation. CONCLUSION: Lepirudin provides
effective CPB anticoagulation but induces a higher postoperative blood loss than
heparin. Lepirudin should be restricted to patients undergoing CPB who cannot be
exposed to heparin.

J Thorac Cardiovasc Surg. 2007 Jun;133(6):1559-65.

Reliability of temperatures measured at standard monitoring sites as an index of
brain temperature during deep hypothermic cardiopulmonary bypass conducted for
thoracic aortic reconstruction.

Akata T, Setoguchi H, Shirozu K, Yoshino J.

Department of Anesthesiology and Critical Care Medicine, Faculty of Medicine,
Kyushu University Hospital, Fukuoka, Japan. akata@kuaccm.med.kyushu-u.ac.jp

OBJECTIVE: It is essential to estimate the brain temperature of patients during
deliberate deep hypothermia. Using jugular bulb temperature as a standard for
brain temperature, we evaluated the accuracy and precision of 5 standard
temperature monitoring sites (ie, pulmonary artery, nasopharynx, forehead
deep-tissue, urinary bladder, and fingertip skin-surface tissue) during deep
hypothermic cardiopulmonary bypass conducted for thoracic aortic reconstruction.
METHODS: In 20 adult patients with thoracic aortic aneurysms, the 5 temperature
monitoring sites were recorded every 1 minute during deep hypothermic (<20
degrees C) cardiopulmonary bypass. The accuracy was evaluated by the difference
from jugular bulb temperature, and the precision was evaluated by its standard
deviation, as well as by the correlation with jugular bulb temperature. RESULTS:
Pulmonary artery temperature and jugular bulb temperature began to change
immediately after the start of cooling or rewarming, closely matching each other,
and the other temperatures lagged behind these two temperatures. During either
situation, the accuracy of pulmonary artery temperature measurement (0.3 degrees
C-0.5 degrees C) was much superior to the other measurements, and its precision
(standard deviation of the difference from jugular bulb temperature = 1.5 degrees
C-1.8 degrees C; correlation coefficient = 0.94-0.95) was also best among the
measurements, with its rank order being pulmonary artery > or = nasopharynx >
forehead > bladder > fingertip. However, the accuracy and precision of pulmonary
artery temperature measurement was significantly impaired during and for several
minutes after infusion of cold cardioplegic solution. CONCLUSIONS: Pulmonary
artery temperature measurement is recommended to estimate brain temperature
during deep hypothermic cardiopulmonary bypass, even if it is conducted with the
sternum opened; however, caution needs to be exercised in interpreting its
measurements during periods of the cardioplegic solution infusion.

Ann Thorac Surg. 2007 Jun;83(6):2060-5.

Efficacy and safety of aprotinin use for reoperative valvular surgery.

Rodrigues AJ, Evora PR, Bassetto S, Luciano PM, Alves L, Filho AS, Vicente WV.

Division of Cardiothoracic Surgery, Department of Surgery and Anatomy, Faculty of
Medicine of Ribeirão Preto, University of São Paulo, Ribeirão Preto, SP, Brazil.
alfredo@fmrp.usp.br 

BACKGROUND: Preservation of the hemostatic system during cardiac surgery is a
main concern, primarily after repeated cardiac operations. METHODS: We compared
the outcomes of adult patients undergoing isolated reoperative valvular surgery
receiving full-dose of aprotinin (redo group, n = 70) with patients experiencing
primary isolated valvular surgery not receiving aprotinin (primary group, n =
135). RESULTS: The mean age was lower in the redo group (45 +/- 14 years vs 50
+/- 17 years, p = 0.036). The redo group had more female patients (73% vs 51%, p
= 0.003), patients in functional class IV (15% vs 4% p = 0.009), and patients
with chronic atrial fibrillation (48% vs 24%, p = 0.001). The cardiopulmonary
bypass duration was longer in the redo group (119 +/- 50 minutes vs 103 +/- 41
minutes, p = 0.014). However, the blood loss was significantly lower (300 +/- 279
mL vs 776 +/- 584 mL, p = 0.001) and fewer patients needed transfusions (3.0% vs
13%, p = 0.023) in the redo group. The postoperative morbidity was similar in
both groups. The postoperative in-hospital mortality was 7% in the primary group
and 10% in the redo group (p = 0.419). Factors associated with postoperative
in-hospital mortality were the following: age greater than 60 years (p = 0.040,
odds ratio [OR] 3.0), New York Heart Association class IV (p = 0.022, OR 5.0),
preoperative critical state (p < 0.001, OR 12), emergent operation (p = 0.012, OR
7.0), endocarditis (p = 0.004, OR 10.0), and reoperation due to mechanical mitral
prosthesis dysfunction (p = 0.009, OR 7). CONCLUSIONS: The mortality and
morbidity in redo valve surgery with aprotinin administration was comparable with
primary valve surgery without aprotinin. Bleeding and transfusion requirements
were significantly lower in redo patients receiving aprotinin.