Kyobu Geka 2001 Jul;54(7):550-4

Serum cytokine levels response to cardiac surgery with cardiopulmonary bypass.

Hirai S, Sueda T, Orihashi K, Watari M, Okada K.

Department of Thoracic Surgery, Hiroshima Prefecture Hospital, Hiroshima, Japan.

The response of tumor necrosis factor alpha (TNF alpha), interleukin-6 (IL-6),
interleukin-8 (IL-8), interleukin-10 (IL-10), interleukin-1 receptor antagonist
(IL-1ra), macrophage colony stimulating factor (MCSF), white blood cell (WBC),
platelet (Plt), lactic acid (LAC) to cardiopulmnary bypass (CPB) were studied
until 48 hours after aortic declamping in 11 patients who underwent elective
CABG (n = 4), mitral valve plasty or replacement with modified maze procedure (n
= 5), and both procedures (n = 2). The highest levels of the cytokines IL-6,
IL-8, IL-10, and IL-1ra were observed after the removal of the cross clamp.
These cytokines just after the aortic declamping are likely to be occurred not
only by an interaction of the blood components with the artificial surfaces, but
also by ischemia-reperfusion injury upon discontinuation of the aortic clamping.
MCSF increased gradually in the late post-CPB phase and reached a peak at 48 hr
after aortic declamping. MCSF may play an important role in regulating
hematopoiesis on the postoperative days 1 and 2 in patients. In conclusion, the
therapy based on the kinetics of these cytokines would be useful for patients
undergoing CPB.

Circulation 2001 Jul 10;104(2):131-3

Cardiac gene delivery with cardiopulmonary bypass.

Davidson MJ, Jones JM, Emani SM, Wilson KH, Jaggers J, Koch WJ, Milano CA.

Departments of Surgery (M.J.D., J.M.J., S.M.E., J.J., W.J.K., C.A.M.), Medicine,
and Biochemistry (K.H.W.), Duke University Medical Center, Durham, NC.

BACKGROUND: Cardiac gene therapy offers the possibility of enhancing myocardial
performance in the compromised heart. However, current gene delivery techniques
have limited myocardial transgene expression and pose the risk of extracardiac
expression. Isolation of the coronary circulation during cardiac surgery may
allow for more efficient and cardiac-selective gene delivery in a clinically
relevant model. Methods and Results-- Neonatal piglets (3 kg) underwent a median
sternotomy and cardiopulmonary bypass, followed by aortic cross-clamping with 30
minutes of cardioplegic arrest. Adenoviral vectors containing transgenes for
either beta-galactosidase (adeno-beta-gal, n=11) or the human beta(2)-adrenergic
receptor (adeno-beta(2)-AR, n=15) were administered through the cardioplegia
cannula immediately after arrest and were allowed to dwell in the coronary
circulation during the cross-clamp period. After 1 week, the animals were
killed, and their heart, lungs, and liver were excised and examined for gene
expression. Analysis of beta-galactosidase staining revealed transmural
myocardial gene expression among animals receiving adeno-beta-gal. No marker
gene expression was detected in liver or lung tissue. beta-AR density in the
left ventricle after adeno-beta(2)-AR delivery was 396+/-85% of levels in
control animals (P<0.01). Animals receiving adeno-beta(2)-AR and control animals
demonstrated similar beta-AR density in both the liver (114+/-8% versus
100+/-9%, P=NS) and lung (114+/-7% versus 100+/-9%, P=NS). There was no evidence
of cardiac inflammation. CONCLUSIONS: By using cardiopulmonary bypass and
cardioplegic arrest, intracoronary delivery of adenoviral vectors resulted in
efficient myocardial uptake and expression. Undetectable transgene expression in
liver or lung tissue suggests cardiac-selective expression.

Crit Care Med 2001 Jul;29(7):1343-9

Tissue oxygenation and perfusion in patients with systemic sepsis.

Sair M, Etherington PJ, Peter Winlove C, Evans TW.

Unit of Critical Care (MS, PJE, TWE), Imperial College School of Medicine and
Royal Brompton Hospital, London; and the Physiological Flow Studies Group (CPW),
Imperial College of Science, Technology and Medicine, London.

OBJECTIVE: Multiple organ dysfunction is associated with systemic sepsis. To
investigate whether this is attributable to peripheral tissue hypoperfusion
and/or cellular hypoxia, simultaneous measurements of tissue perfusion and
oxygenation were made in patients with severe sepsis and in controls. DESIGN:
Prospective, observational study. SETTING: Adult intensive care unit, tertiary
referral center. PATIENTS: Volunteers (group C, n = 7), patients undergoing
cardiopulmonary bypass (group B, n = 6), and patients with severe sepsis (group
S, n = 6). INTERVENTIONS: Limb ischemia and reperfusion. MEASUREMENTS AND MAIN
RESULTS: Tissue oxygenation and microvascular flow were measured by using
microelectrodes inserted into brachoradialis muscle and overlying subcutaneous
tissue. Forearm cutaneous red cell flux and regional blood flow were measured
simultaneously. Responses to 20 mins of limb ischemia and subsequent reperfusion
were observed. Baseline muscle tissue oxygenation was greater in sepsis (1.7 +/-
0.2, 1.5 +/- 0.7, and 4.4 +/- 0.6 kPa for groups C, B, and S, respectively, mean
+/- sem, p <.05), although baseline subcutaneous tissue oxygenation did not vary
between groups. During ischemia tissue oxygenation, values decreased in muscle
(to 1.3 +/- 0.2, 1.0 +/- 0.4, and 1.5 +/- 0.4 kPa for groups C, B, and S,
respectively) and subcutaneous tissue (to 2.0 +/- 0.3, 1.7 +/- 0.5, and 2.3 +/-
0.2 kPa for groups C, B, and S, respectively). Decline in tissue oxygen tension
was initially more rapid in septic muscle compared with controls (25% decrease,
68 +/- 23 vs. 176 +/- 38 for group S vs. group C, p <.05, and 50% decrease, 126
+/- 34 vs. 398 +/- 72 secs for group S vs. group C, p <.01). However, overall
rate of tissue decline was similar (95% decrease, 444 +/- 122 vs. 614 +/- 96 for
group S vs. group C, p >.05). After reperfusion, significant differences in
muscle tissue oxygenation reappeared between groups (2.0 +/- 0.3, 1.5 +/- 0.7,
and 4.0 +/- 0.4 kPa for groups C, B, and S, respectively, p <.05). There were no
differences in time to 25%, 50%, or 95% tissue oxygen recovery. Whole limb
reperfusion was significantly less in patient groups compared with controls
(10.6 +/- 0.9, 4.5 +/- 1.2, and 4.3 +/- 1.6 mL.100 mL-1.min-1 for groups C, B,
and S, respectively, p <.05). CONCLUSIONS: Significant differences in tissue
oxygenation distribution between muscle and subcutaneous tissues occur in
patients with severe sepsis. High baseline muscle tissue oxygen levels are
accompanied by rapid extraction of oxygen during stagnant ischemia.

Eur Heart J 2001 Jul;22(14):1235-43

Cardiac surgery in octogenarians. Peri-operative outcome and long-term results.

Kolh P, Kerzmann A, Lahaye L, Gerard P, Limet R.

Cardiothoracic Surgery Department, University Hospital of Liege, Liege, Belgium

Aims Because the elderly are increasingly referred for operation, we reviewed
the results of cardiac surgery in patients of 80 years or older.Methods and
Results Records of 182 consecutive octogenarians who had had cardiac operations
between 1992 and 1998 were reviewed. Follow-up was 100% complete. Seventy
patients had coronary grafting (CABG), 70 aortic valve replacement, 30 aortic
valve replacement+CABG, and 12 mitral valve repair/replacement. Rates of
hospital death, stroke, and prolonged stay (>14 days) were as follows: CABG: 7
(10%), 2 (2.8%) and 41 (58%); aortic valve replacement: 6 (8.5%), 2 (2.8%) and
32 (45.7%); aortic valve replacement+CABG: 8 (26.5%), 1 (3.8%) and 14 (46.6%);
mitral valve repair/replacement: 3 (25%), 1 (8.3%) and 5 (41.6%). Multivariate
predictors (P<0.05) of hospital death were New York Heart Association functional
class, urgent procedure, prolonged cardiopulmonary bypass time, and, after
aortic valve replacement, previous percutaneous aortic valvuloplasty. Ascending
aortic atheromatous disease was predictive of stroke, while pre-operative
myocardial infarction was predictive of prolonged hospital stay. Actuarial
5-year survival was as follows: CABG, 65.8+/-8.8%; aortic valve replacement,
63.6+/-7.1%; aortic valve replacement+CABG, 62.4+/-6.8%; mitral valve
repair/replacement, 57.1+/-5.6%; and total, 63.0+/-5.6%. Multivariate predictors
of late death were pre-operative myocardial infarction, and urgent procedure.
Ninety percent of long-term survivors were in New York Heart Association class I
or II, and 87% believed having a heart operation after age 80 years was a good
choice.Conclusion Cardiac operations are successful in most octogenarians with
increased hospital mortality, and longer hospital stay. Long-term survival and
quality of life are good. 

J Thorac Cardiovasc Surg 2001 Jul;122(1):123-8

Effect of aprotinin on endothelial cell activation.

Asimakopoulos G, Lidington EA, Mason J, Haskard DO, Taylor KM, Landis RC.

British Heart Foundation, Cardiac Surgery and Cardiovascular Medicine Units,
Hammersmith Hospital, National Heart and Lung Institute, Imperial College School
of Medicine, London, United Kingdom.

BACKGROUND: Cardiopulmonary bypass surgery is often accompanied by a systemic
inflammatory response, which can lead to postoperative complications in
high-risk patients. This is mediated in part through a systemic rise in
inflammatory cytokine levels and the sequestration of leukocytes within organs.
Aprotinin has previously been shown to exert an anti-inflammatory effect by
preventing the capacity of leukocytes to transmigrate through vascular
endothelium. Here we have focused on whether aprotinin has an effect on
endothelial cell activation and adhesion molecule expression in response to
tumor necrosis factor-alpha, particularly with reference to whether aprotinin
inhibits tumor necrosis factor-stimulated neutrophil transendothelial
migration.Methods and Results: Intercellular adhesion molecule-1, vascular cell
adhesion molecule-1, and E-selectin expression was studied in tumor necrosis
factor-alpha-activated human umbilical vein endothelial cells in the presence of
aprotinin at 200, 800, and 1600 kIU/mL. Aprotinin inhibited tumor necrosis
factor-alpha-stimulated expression of intercellular adhesion molecule-1 (P =.019
at 1600 kIU/mL) and vascular cell adhesion molecule-1 (P =.003 at 1600 kIU/mL)
but not E-selectin. Similar results were obtained in the dermal microvascular
endothelial cell line, HMEC-1, which exhibited diminished intercellular adhesion
molecule-1 expression in the presence of aprotinin (P =.040 at 800 kIU/mL and P
<.001 at 1600 kIU/mL). Aprotinin also significantly inhibited neutrophil
transmigration across tumor necrosis factor-alpha-activated human umbilical vein
endothelial cells (P =.046 at 1600 kIU/mL). CONCLUSIONS: We have demonstrated
that aprotinin inhibits intercellular adhesion molecule-1 and vascular cell
adhesion molecule-1, but not E-selectin, expression on tumor necrosis
factor-alpha-activated endothelial cells and that transendothelial migration by
neutrophils is also specifically suppressed under these conditions. Our results
indicate that endothelial cells can be specifically targeted by aprotinin,
therefore adding to our understanding of the anti-inflammatory mechanism of
action of aprotinin during cardiopulmonary bypass.

J Thorac Cardiovasc Surg 2001 Jul;122(1):113-22

Inhibition of complement, neutrophil, and platelet activation by an anti-factor
D monoclonal antibody in simulated cardiopulmonary bypass circuits.

Fung M, Loubser PG, Undar A, Mueller M, Sun C, Sun WN, Vaughn WK, Fraser CD Jr.

Tanox, Inc; the Departments of Anesthesiology and Surgery, Baylor College of
Medicine; Texas Children's Hospital; and Texas Heart Institute, Houston, Tex.

OBJECTIVES: Patients undergoing cardiopulmonary bypass frequently manifest
generalized systemic inflammation and occasionally manifest serious multiorgan
failure. Inflammatory responses of bypass are triggered by contact of blood with
artificial surfaces of the bypass circuits, surgical trauma, and
ischemia-reperfusion injury. We studied the effects of specific inhibition of
the alternative complement cascade by using an anti-factor D monoclonal antibody
(166-32) in extracorporeal circulation of human whole blood used as a simulated
model of cardiopulmonary bypass. METHODS: Five healthy blood donors were used in
the study. Monoclonal antibody 166-32 was added to freshly collected,
heparinized human blood recirculated in a pediatric cardiopulmonary bypass
circuit at a final concentration of 18 &mgr;g/mL. An irrelevant monoclonal
antibody was used as a negative control with the same donor blood in a parallel
bypass circuit on the same day. Blood samples were collected at different time
points during recirculation for measurement of activation of complement,
neutrophils, and platelets by immunofluorocytometric methods and enzyme-linked
immunosorbent assays. RESULTS: Monoclonal antibody 166-32 inhibited the
alternative complement activation and the production of Bb, C3a, sC5b-9, and
C5a. Upregulation of CD11b on neutrophils and CD62P on platelets was also
significantly inhibited by monoclonal antibody 166-32. This is consistent with
the inhibition of the release of neutrophil-specific myeloperoxidase and
elastase and platelet thrombospondin. The production of proinflammatory cytokine
interleukin 8 was also suppressed by the antibody. CONCLUSIONS: The alternative
complement cascade is predominantly activated during extracorporeal circulation.
Anti-factor D monoclonal antibody 166-32 is effective in inhibiting the
activation of complement, neutrophils, and platelets. Inhibition of the
alternative complement pathway by targeting factor D could be useful in reducing
systemic inflammation in patients undergoing cardiopulmonary bypass.

J Thorac Cardiovasc Surg 2001 Jul;122(1):65-73

Human angiopoietin gene expression is a marker for severity of pulmonary
hypertension in patients undergoing pulmonary thromboendarterectomy.

Thistlethwaite PA, Lee SH, Du LL, Wolf PL, Sullivan C, Pradhan S, Deutsch R,
Jamieson SW.

Division of Cardiothoracic Surgery, University of California, San Diego, the
Department of Pathology, Veterans Affairs Medical Center, and the Department of
Family and Preventive Medicine, University of California, San Diego, Calif.

OBJECTIVE: A consistent pathologic feature seen in lungs of patients with
pulmonary hypertension from thromboembolic disease is hyperplasia of the media
of pulmonary arterioles. The molecular factors responsible for these vessel wall
changes are unknown. Angiopoietin-1 is a gene responsible for the formation of
the media of blood vessels in utero. We hypothesized that aberrant expression of
the angiopoietin-1 gene in the adult lung would be a major contributing factor
in the development of pulmonary hypertension. METHODS: From April 1999 to March
2000, a total of 35 patients (18 men, 17 women, mean age 52 years) with
pulmonary hypertension and pulmonary vascular resistance ranging from 407 to
2006 dynes. sec. cm(-5) underwent pulmonary endarterectomy at our institution.
Before cardiopulmonary bypass, lung biopsy specimens were taken from each
patient. Biopsy specimens were also obtained from 10 patients (5 women, 5 men,
mean age 55 years) undergoing lung resection for causes other than pulmonary
hypertension. All specimens were blindly scored by a pathologist for degree of
medial hyperplasia. Quantitative reverse transcriptase-polymerase chain
reaction, Western blot, and immunohistochemistry were used to quantitate
angiopoietin-1 messenger RNA and protein in each sample. RESULTS: Lung specimens
from all patients with pulmonary hypertension demonstrated up-regulation of
angiopoietin-1 at the messenger RNA level. The degree of angiopoietin-1
transcription was directly proportional to the preoperative pulmonary vascular
resistance and medial wall hyperplasia/hypertrophy in each patient. By
immunohistochemistry, angiopoietin-1 protein was confined to the media of
pulmonary arterioles. Lung biopsy specimens from patients without pulmonary
hypertension had no detectable expression of angiopoietin-1 at the messenger RNA
or protein level. CONCLUSION: Angiopoietin-1, a gene responsible for vessel
development in the embryonic lung, is up-regulated in the lung parenchyma of
patients with pulmonary hypertension. The level of expression of angiopoietin-1
at messenger RNA and protein levels correlates to the severity of pulmonary
hypertension in patients with thromboembolic disease and serves as a target for
strategies to treat this disease.

Anesth Analg 2001 Jul;93(1):28-32

The relationship between hirudin and activated clotting time: implications for
patients with heparin-induced thrombocytopenia undergoing cardiac surgery.

Despotis GJ, Hogue CW, Saleem R, Bigham M, Skubas N, Apostolidou I, Qayum A,
Joist JH.

Departments of Anesthesiology, Pathology and ImmunologyWashington University
School of Medicine, St. Louis, Missouri 63110, USA.

Anticoagulation with recombinant hirudin (r-hirudin) (Refludan) has been
suggested as an alternative to heparin for patients with heparin-induced
thrombocytopenia requiring cardiac surgery. We sought to develop a modified
activated coagulation time (ACT) that would allow quantification of the levels
of r-hirudin required during cardiopulmonary bypass (CPB). Twenty-one patients
scheduled for elective cardiac surgical procedures requiring CPB were enrolled
in this IRB-approved study. R-hirudin was added to blood specimens obtained
before heparin administration (before CPB) and 30 min after heparin
neutralization with protamine (after CPB) to result in concentrations of 0, 2,
4, 6, 7, or 8 microg/mL. Kaolin/ACT and complete blood count measurements were
assayed in native specimens (first 10 patients, Phase I) or in specimens mixed
with equal volumes of commercial normal plasma (second 11 patients, Phase II).
In Phase I, good (r(2) = 0.83) linear relationships between ACT values and
r-hirudin concentrations (< or =4 microg/mL) were observed in specimens obtained
before CPB. However, ACT values were markedly prolonged (P < 0.0001) by
r-hirudin in specimens obtained after CPB, with ACT values generally exceeding
the ACT's detection limit (>999 s) at hirudin concentrations >2 microg/mL. In
patient specimens mixed with normal plasma (Phase II), ACT/hirudin relationships
(i.e., hirudin/ACT slope values obtained with hirudin concentration < or =4
microg/mL) in the post-CPB period (0.022 +/- 0.004 microg. mL(-1). s(-1)) were
similar (P = 0.47) to those (0.019 +/- 0.004 microg. mL(-1). s(-1)) obtained in
the pre-CPB period. Accordingly, a significant relationship between normal
plasma-supplemented ACT values and predilution hirudin concentration was
obtained in the post-CPB (hirudin = 0.039ACT - 4.34, r(2) = 0.91) period.
Although our data demonstrate that the ACT test cannot be used to monitor
hirudin during CPB, the addition of 50% normal plasma to post-CPB hemodiluted
blood specimens yields a consistent linear relationship between hirudin
concentration and ACT values up to a predilution concentration of 8 microg/mL.
Plasma-modified ACT may be useful in monitoring hirudin anticoagulation during
CPB. Implications: A modified activated clotting time test system that may be
helpful in monitoring hirudin anticoagulation in patients with heparin-induced
thrombocytopenia during cardiac surgery with cardiopulmonary bypass is
described.

Anesth Analg 2001 Jul;93(1):20-7

The effects of heparin, protamine, and heparin/protamine reversal on platelet
function under conditions of arterial shear stress.

Griffin MJ, Rinder HM, Smith BR, Tracey JB, Kriz NS, Li CK, Rinder CS.

Departments of Anesthesiology, Laboratory Medicine, Internal Medicine, and
Pediatrics, Yale University School of Medicine and Yale-New Haven Hospital, New
Haven, Connecticut 06520-8051, USA. michael.griffin@yale.edu

Platelet dysfunction contributes to blood loss after cardiopulmonary bypass.
This study examined the antiplatelet effects of heparin, protamine, and varying
heparin/protamine ratios in an in vitro physiologic model and further elucidated
the mechanism of the antiplatelet and anticoagulant effects of protamine. We
used the Clot Signature Analyzer (CSA(TM)), a system that analyzes coagulation
in flowing whole blood, to test two aspects of platelet function, with different
concentrations of heparin and protamine, under conditions simulating arterial
flow: collagen-induced thrombus formation (CITF) under moderate shear and high
shear platelet activation, platelet hemostasis time (PHT). In addition, platelet
aggregometry, celite activated clotting time (Hepcon(TM) ACT), prothrombin time
(PT), and partial thromboplastin time (PTT) were measured. Both PHT and the CITF
were prolonged by heparin at 20 microg/mL, protamine at 20 and 40 microg/mL, and
heparin/protamine ratios of 1:1 and 1:2, but not at 1:1.5. The Hepcon ACT was
prolonged by heparin 20 microg/mL and protamine alone at 20 and 40 microg/mL,
was normal at a ratio of 1:1, and was prolonged at 1:1.5 and 1:2. Protamine 80
microg/mL prolonged the PT and PTT. Dependency on thrombin, protein kinase C
activation, and nonspecific charge effects were examined. The direct thrombin
inhibitor D-phenylalanyl-L-prolyl-L-arginyl-chloromethyl ketone prolonged the
PHT and ACT, but not the CITF, whereas the polycationic molecules polyarginine
and polylysine prolonged the CITF, but not the PHT. The effect of protamine on
the PTT, but not PT, could be shortened by the addition of excess phospholipid.
Therefore, heparin inhibits both high shear collagen-independent and moderate
shear collagen-dependent platelet activation; however, the latter is not
mediated by its antithrombin activity. Protamine's antithrombin effect may
explain its inhibition of platelet activation at high shear stress. Protamine's
nonspecific charge effects are more important for inhibiting moderate shear
collagen-induced platelet activation. Implications: This study suggests that
protamine reversal of heparin's antiplatelet effect occurs within a narrow
window because of the direct antiplatelet effects of protamine. Antithrombin
effects may explain the inhibition of shear activation of platelets by both
heparin and protamine. Nonspecific charge effects of protamine may explain the
inhibition of collagen platelet activation in the presence of medium shear.