Rev Esp Cardiol. 2005 Jul;58(7):815-821. 

Risk Factors Associated With Arterial Switch Operation for Transposition of the
Great Arteries.

[Article in English, Spanish]

Garcia Hernandez JA, Montero Valladares C, Martinez Lopez AI, Romero Parreno A,
Grueso Montero J, Gil-Fournier Carazo M, Cayuela Dominguez A, Loscertales Abril
M, Tovaruela Santos A.

Servicio de Cuidados Criticos y Urgencias. Unidad de Cuidados Intensivos
Pediatricos. Hospital Universitario Virgen del Rocio. Hospital Infantil.
Sevilla. Espana.

Introduction and objectives. The present study was undertaken to determine the
risk factors for early mortality following an arterial switch operation.
Patients and method. From January 1994 through October 2003, 78 pediatric
patients underwent surgical repair. Simple transposition was present in 48
patients (61.5%), 29 (37.2%) had an associated ventricular septal defect, and
one had a Taussig-Bing anomaly. The risk factors analyzed were: the patient's
age and weight at the time of the intervention, repair of a coexisting
ventricular septal defect, coronary artery anatomical pattern, duration of
cardiopulmonary bypass, duration of aortic cross-clamping, and duration of
circulatory arrest. All factors were evaluated for strength of association with
the duration of mechanical ventilation, the length of intensive care unit stay,
and mortality. RESULTS. Overall, the early mortality rate was 9% (7/78). Some 14
patients (17.9%) underwent simultaneous repair of a ventricular septal defect.
Patients with an intramural coronary artery (n=3, 3.8%) or a single coronary
ostium (n=5, 6.4%) were the only ones who had a significant (P<.05) mortality
risk, at 50% (4/8). Circulatory arrest was implemented in 53 (68%) patients.
There were significant correlations between the duration of circulatory arrest
and the ventilator support time (r=0.3, P<.05) and the duration of stay in the
intensive care unit (r=0.3, P<.05). CONCLUSIONS. The risk of early death was
increased when more complex coronary artery anatomical variants were present. As
the period of circulatory arrest lengthened, the mechanical ventilation time and
duration of intensive care unit stay increased.

Crit Care Med. 2005 Jul;33(7):1507-12. 

Cortisol antiinflammatory effects are maximal at postoperative plasma
concentrations.

Yeager MP, Rassias AJ, Fillinger MP, Discipio AW, Gloor KE, Gregory JA, Guyre
PM.

Department of Anesthesiology, Dartmouth Medical School, Hanover, NH, USA.

OBJECTIVE: To determine the plasma concentration of cortisol that is needed for
maximal suppression of the systemic inflammatory response to cardiac surgery
with cardiopulmonary bypass. DESIGN: Prospective, randomized, double-blind
clinical study of cardiac surgical patients. SETTING: Operating room and
inpatient care facility of a university medical center. SUBJECTS: Sixty elective
cardiac surgical patients scheduled for coronary artery bypass graft, cardiac
valve replacement, or both. INTERVENTIONS: Patients were randomized to receive
one of three different hydrocortisone doses, by intravenous infusion, for 6 hrs
before, during, and immediately after surgery while also receiving etomidate to
suppress endogenous cortisol production. MEASUREMENTS AND MAIN RESULTS: Serial
determinations of plasma interleukin-6 were studied as a marker of systemic
inflammation. Measurements of interleukin-10 were used as a marker of the
compensatory antiinflammatory response. Plasma cortisol concentrations in an
untreated control group rose from 17 microg/dL before surgery to a mean of 43
microg/dL by 4 hrs after surgery. A dose of hydrocortisone (4 microg/kg/min for
6 hrs) that maintained plasma cortisol between 40 and 50 microg/dL, starting
60-90 mins before surgery, significantly suppressed plasma interleukin-6 after
surgery compared with control while significantly increasing plasma
interleukin-10 during surgery. Plasma interleukin-6 after surgery was not
suppressed further by increasing the dose of hydrocortisone to 8 microg/kg/min,
although the mean peak plasma interleukin-10 concentration increased further
compared with the group that received the 4 microg/kg/min hydrocortisone dose.
CONCLUSIONS: At the doses studied, cortisol-induced suppression of plasma
interleukin-6 during and after cardiac surgery appears to be a saturable
phenomenon at the concentration of plasma cortisol that is normally achieved
after surgery in untreated patients.

J Thorac Cardiovasc Surg. 2005 Jul;130(1):54-60. 

Monocyte function-associated antigen expression during and after pediatric
cardiac surgery.

Gessler P, Pretre R, Burki C, Rousson V, Frey B, Nadal D.

Divisions of Pediatric Intensive Care Medicine, University Children's Hospital
of Zurich, Steinwiesstrasse 75, CH-8032 Zurich, Switzerland.
peter.gessler@kispi.unizh.ch

OBJECTIVE: Systemic inflammatory response syndrome and infectious complications
are major causes of morbidity and mortality after cardiopulmonary bypass. Recent
work in adult patients suggests that the balance between proinflammatory and
anti-inflammatory mediators is important. We hypothesized that the expression of
different function-related receptors on circulating monocytes might reflect the
net response of the inflammatory reaction. METHODS: We performed a prospective
and observational study in a tertiary pediatric cardiac center in a population
of children (n = 40) undergoing elective cardiac surgery. Expression of
receptors on the surface of monocytes was assessed before, during, and after
surgical intervention. RESULTS: Early monocyte activation was demonstrated by
changes of the expression of the chemokine receptor CCR2, which was inversely
correlated with plasma levels of monocyte chemotactic protein 1 (rho = -0.54, P
= .002). High levels of monocyte chemotactic protein 1 were found in children
with high expression of the adhesion receptor CD11b/CD18 on circulating
monocytes. The intensity of human leukocyte antigen DR expression rapidly
decreased in all children after the onset of cardiopulmonary bypass ( P < .001).
Low human leukocyte antigen DR expression was correlated with increased plasma
levels of interleukin 10 postoperatively. Children who had signs of bacterial
pneumonia postoperatively had lower levels of human leukocyte antigen DR
expression before surgical intervention (relative risk, 13.3; P = .007).
CONCLUSIONS: The expression of monocyte function-related receptors is altered
after cardiac surgery. Early activation of monocytes by monocyte chemotactic
protein 1 possibly released from the heart is followed by an anti-inflammatory
response with suppression of monocyte human leukocyte antigen DR expression. The
increased risk of bacterial infection after pediatric cardiac surgery can be
anticipated by surveillance of monocyte function before surgical intervention.

Thromb Res. 2005 Jul 1; [Epub ahead of print] 

Strategies to reduce hemostatic activation during cardiopulmonary bypass.

Eisses MJ, Velan T, Aldea GS, Chandler WL.

Department of Anesthesiology, Children's Hospital and Regional Medical Center,
University of Washington, Seattle, United States.

INTRODUCTION: We evaluated whether a modified protocol for cardiopulmonary
bypass (CPB) could reduced the systemic hemostatic activation associated with
this procedure. MATERIALS AND METHODS: The in vivo rates of thrombin, fibrin,
plasmin and D-dimer generation were determined in each subject during CPB using
measured levels of hemostatic factors combined with a computer model of the
cardiovascular and hemostatic systems. A standard CPB group using uncoated
circuits, standard heparin levels and direct shed blood reinfusion (n=9) was
compared to a modified CPB group using heparin-coated circuits, shed blood
collection, washing and reinfusion post-operatively, lower heparin levels and
epsilon-amino-caproic acid (n=10). RESULTS AND CONCLUSIONS: Standard CPB
increased average thrombin generation 9-fold, decreased fibrin generation
2-fold, increased plasmin generation 11-fold and increased fibrin degradation
and D-dimer generation 19-fold. During CPB in the modified group thrombin
generation was not increased beyond surgical levels, lower heparin
concentrations allowed each thrombin to make more fibrin prior to inhibition,
while fibrin degradation was suppressed by epsilon-amino-caproic acid. At
baseline for every 100 fibrins formed only 1-2 were degraded to D-dimer. During
standard CPB for every 100 fibrins generated on average 34 fibrins were degraded
with some subjects showing a net fibrin loss. In contrast, in the modified CPB
group for every 100 fibrins formed only 4 fibrins were degraded (p<0.0001 vs.
standard group). Kinetic modeling of hemostasis in individual patients showed
that a modified CPB protocol could reduce excessive thrombin generation during
CPB and suppress fibrin degradation moving hemostatic regulation back towards
normal.

Resuscitation. 2005 Jul;66(1):99-104. Epub 2005 Apr 18. 

Thoracic lavage in accidental hypothermia with cardiac arrest - report of a case
and review of the literature.

Plaisier BR.

Trauma Program, Bronson Methodist Hospital, 601 John Street, Mailbox #67,
Kalamazoo, MI 49007, USA.

BACKGROUND:: Accidental hypothermia resulting in cardiac arrest poses numerous
therapeutic challenges. Cardiopulmonary bypass (CPB) should be used if feasible
since it optimally provides both central rewarming and circulatory support.
However, this modality may not be available or is contraindicated in certain
cases. Thoracic lavage (TL) provides satisfactory heat transfer and may be
performed by a variety of physicians. This paper presents the physiological
rationale, technique, and role for TL in accidental hypothermia with cardiac
arrest. METHODS:: A patient with hypothermic cardiac arrest, treated by the
author using TL, serves as the basis for this report. A search of the English
language literature using PubMed((R)) (National Library of Medicine, Bethesda,
Maryland) was conducted from 1966 to 2003 and 13 additional patients were
identified. Demographic information, lavage method, rewarming rate,
complications, and neurological outcome were analysed. RESULTS:: There were
numerous causes for hypothermia, with drug and alcohol intoxication being the
most common (n=4; 28.6%). Patient age ranged from 8 to 72 years (median=36
years). Mean core temperature was 24.5+/-0.60 degrees C. Most patients were
without blood pressure or pulse upon presentation to the Emergency Department
and the predominant cardiac rhythm was ventricular fibrillation (VF) (n=9;
64.3%). Thoracic lavage was accomplished by thoracotomy in seven patients and
tube thoracotomy in the remaining seven. Median rewarming rate was 2.95 degrees
C/h. Median time until sinus rhythm was restored was 120min. Median length of
hospital stay was 2 weeks. Four (28.6%) patients died. Complications were seen
in 12 (85.7%) patients. Among survivors, neurological outcome was normal in 8
(80%) while two were left with residual impairments. CONCLUSIONS:: Patients
presenting in cardiac arrest from accidental hypothermia may be rewarmed
effectively using TL. Among survivors, normal neurological recovery is seen.
Thoracic lavage should be strongly considered for these patients if CPB is not
available or contraindicated.

Eur J Cardiothorac Surg. 2005 Jul;28(1):133-7. Epub 2005 Feb 24. 

Antiphospholipid syndrome in cardiac surgery-an underestimated coagulation
disorder?

Massoudy P, Cetin SM, Thielmann M, Kienbaum P, Piotrowski JA, Marggraf G,
Specker C, Jakob H.

Klinik fur Thorax- und Kardiovaskulare Chirurgie, Universitatsklinikum Essen,
Hufelandstr. 55, 45147 Essen, Germany. parwis.massoudy@uni-essen.de

OBJECTIVE: Antiphospholipid syndrome (APS) is a rare coagulation disorder
associated with recurrent arterial and venous thrombotic events. We analysed our
experience with five APS patients who underwent cardiac surgery. In three of
them the diagnosis of APS had been established before surgery, two patients were
diagnosed after surgery. METHODS: From March 1999 to March 2004 five patients
with APS underwent cardiac surgery using cardiopulmonary bypass (CPB). We
retrospectively reviewed their clinical data, operative and postoperative
courses, and the long-term results. RESULTS: Procedures performed were heart and
lung transplantation (patient 1), endoventriculoplasty and CABG (patient 2),
biventricular resection of endoventricular fibrosis and thrombus (patient 3),
mitral valve repair repair and coronary artery bypass grafting (CABG, patient
4), and mitral valve replacement with closure of a patent foramen ovale (patient
5). There were three perioperative deaths (patients 1, 2 and 3), two of three
patients in whom the diagnosis was known before surgery, survived (patients 4
and 5). In these patients, only half the dose of protamin (patient 4) and no
protamin at all (patient 5) was applied to reduce the probability of
postoperative thromboembolic complications. At 1 year follow up, only patient 4
had survived, patient 5 had died of the complications of intestinal
thromboembolism. CONCLUSIONS: Patients with APS undergoing cardiac surgery
belong to a high risk subgroup. Thus, though rare, APS can be a critical issue
in cardiac surgery. Some of the cardiac patients with unexplained perioperative
thromboembolic complications, such as graft occlusion, may turn out to have an
undiagnosed APS.

Pediatr Crit Care Med. 2005 Jul;6(4):441-444. 

Steroid use before pediatric cardiac operations using cardiopulmonary bypass: An
international survey of 36 centers.

Checchia PA, Bronicki RA, Costello JM, Nelson DP.

Divisions of Critical Care Medicine and Cardiology, Department of Pediatrics,
Washington University School of Medicine, St. Louis Children's Hospital, St.
Louis, MO; Division of Critical Care Medicine, Children's Hospital of Orange
County, Orange, CA, and Harbor-UCLA Medical Center, University of California-Los
Angeles School of Medicine, Los Angeles, CA; Department of Cardiology,
Children's Hospital Boston, Harvard Medical School, Boston, MA; and the
Divisions of Cardiology and Molecular Cardiovascular Biology, Cincinnati
Children's Hospital Medical Center, Cincinnati, OH. E-mail: response.

OBJECTIVE: Steroid administration before pediatric cardiac operations using
cardiopulmonary bypass has been shown to modulate the inflammatory response and
reduce myocardial injury. We hypothesized that current steroid administration
practices among pediatric cardiac surgical centers are highly variable. DESIGN:
Questionnaire survey. SETTING: Pediatric intensive care units. SUBJECTS: All
members of the Pediatric Cardiac Intensive Care Society. INTERVENTIONS: A
self-administered survey was sent to >130 members and 70 institutions
participating in the Pediatric Cardiac Intensive Care Society. MEASUREMENTS AND
MAIN RESULTS: Thirty-six questionnaires were returned: 14 international and 22
domestic centers. Cumulatively, these centers treat >11,000 pediatric cardiac
patients per year. Ninety-seven percent (35 of 36) of these centers report the
use of steroids before cardiopulmonary bypass, yet only 40% (14 of 35)
administer steroids with every case. Of the 21 centers that selectively use
steroids, 12 do so only for neonates, five administer steroids based on surgeon
preference, and four administer steroids for cases anticipated to involve bypass
time >2 hrs or deep hypothermic circulatory arrest. Of the 35 centers using
steroids, 11 deliver a single dose in the circuit prime, 18 administer a single
dose to the patient, and six give multiple doses. The timing of the steroid dose
to the patient is variable; 12 centers administer a dose on induction of
anesthesia; six centers administer the dose 2-12 hrs before operation. Regimens
in the six centers using multiple doses of steroids before cardiopulmonary
bypass are as follows: administration at induction and in the prime (two
centers); 12 hrs preoperatively and at induction (one center); prime, induction,
and 6 hrs preoperatively (one center); prime and midnight preoperatively (one
center); and prime plus 2 and 8 hrs preoperatively (one center). Eight centers
continue steroid administration following bypass. CONCLUSION: Although nearly
all centers surveyed administer steroids before cardiopulmonary bypass, the
type, dosing, route, and timing of administration are highly variable. The
inconsistencies in these data and the pediatric literature would support the
undertaking of a large, multiple-center clinical trial to evaluate the risks and
benefits of steroid administration before pediatric cardiopulmonary bypass.

Artif Organs. 2005 Jul;29(7):541-6. 

Heparin influences human platelet behavior in cardiac surgery with or without
cardiopulmonary bypass.

Laga S, Bollen H, Arnout J, Hoylaerts M, Meyns B.

Department of Cardiac Surgery, Catholic University Hospitals Leuven, Leuven,
Belgium.

The objective was to investigate whether the platelet dysfunction in cardiac
surgery is caused by hemodilution or by shear stress due to cardiopulmonary
bypass (CPB). Platelet count and function were prospectively analyzed in two
groups of patients undergoing cardiac surgery either with or without CPB (n =
40). In the first study (n = 20; 10 patients with and 10 without CPB), platelet
counts were assessed at seven time points. In the second study (n = 20; 10
patients with and 10 without CPB), platelet function was studied with platelet
aggregometry at different points during surgery: (a) after induction of
anesthesia; (b) after sternotomy; and (c) 1 h after heparin. In the first study,
the CPB group showed a significant decrease in platelet count starting after
sternotomy (230 +/- 34 vs. 182 +/- 25, P < 0.05) and a maximum decrease at day 1
postoperative (96 +/- 34, P < 0.05). A similar observation was made in the
non-CBP group. In the second study, a significant decrease of ADP (54 +/- 13%
vs. 38 +/- 9%, P < 0.05), AA (76 +/- 16% vs. 22 +/- 14%, P < 0.05), and Collagen
(66 +/- 13% vs. 37 +/- 11%, P < 0.05) induced platelet aggregation was observed
at MOMENT d compared to the beginning of surgery in the CPB group. In the
non-CBP group a significant decrease was observed in AA-induced platelet
aggregation at MOMENT d (83% +/- 4 vs. 44% +/- 14, P < 0.05). The reduction in
platelet count is similar with or without cardiopulmonary bypass and is due to
pure hemodilution. Platelet function reduces significantly after heparin
administration. Hemodilution and predominantly heparin are the causes of
platelet dysfunction after cardiac surgery.

Ann Thorac Surg. 2005 Jul;80(1):22-8. 

High flow rates during modified ultrafiltration decrease cerebral blood flow
velocity and venous oxygen saturation in infants.

Rodriguez RA, Ruel M, Broecker L, Cornel G.

Department of Anesthesiology, Cardiac Division, Ottawa, Ontario, Canada.
rrodriguez@ottawaheart.ca

BACKGROUND: The intracranial hemodynamic effects of modified ultrafiltration in
children are unknown. We investigated the effects of different blood flow rates
during modified ultrafiltration on the cerebral hemodynamics of children with
weights above and below 10 kg. METHODS: Thirty-one children (weights: < or = 10
kg, n = 21; > 10 kg, n = 10) undergoing cardiopulmonary bypass were studied.
Middle-cerebral artery blood flow velocities and cerebral mixed venous oxygen
saturations were measured before, five minutes from the beginning, and at the
end of ultrafiltration. Patients were classified according to their blood flow
rates during ultrafiltration in three groups: high (> or = 20 mL/kg/min),
moderate (10-19 mL/kg/min), and low flow rates (< 10 mL/kg/min). RESULTS: During
modified ultrafiltration, blood pressures and hematocrit increased (p < 0.001),
but cerebral blood flow velocities and mixed venous oxygen saturations decreased
(p < 0.001). A significant correlation was found between blood flow rates of
ultrafiltration and the decline in mean cerebral blood flow velocity (r = -
0.48; p = 0.005) and cerebral oxygen saturation (r = - 0.49; p = 0.005) or
hematocrit increase (r = 0.59; p = 0.001). Infants exposed to high flow rates
had greater reduction of cerebral blood flow velocity and regional mixed venous
saturation and higher hematocrit at the end of ultrafiltration compared with
those subjected to moderate and low flow rates (p < 0.04). No significant
difference was found between moderate and low flow groups. The flow rate of
ultrafiltration was the only independent predictor of the changes in cerebral
mixed venous oxygen saturation (p = 0.033). CONCLUSIONS: High blood flow rates
through the ultrafilter during modified ultrafiltration transiently decrease the
cerebral circulation in young infants compared with lower blood flow rates.
These effects may be related to an increased diastolic runoff from the aorta
into the ultrafiltration circuit that leads to a "stealing" effect from the
intracranial circulation, which may be important in infants with dysfunctional
cerebral autoregulation.

Ann Thorac Surg. 2005 Jul;80(1):6-13; discussion 13-4. 

Using a miniaturized circuit and an asanguineous prime to reduce
neutrophil-mediated organ dysfunction following infant cardiopulmonary bypass.

Karamlou T, Schultz JM, Silliman C, Sandquist C, You J, Shen I, Ungerleider RM.

Division of Pediatric Cardiac Surgery and Pediatric Perfusion Services,
Doernbecher Children's Hospital, Oregon Health & Science University, Portland,
Oregon 97201, USA.

BACKGROUND: Contemporary infant cardiopulmonary bypass circuits require a blood
prime. Blood, especially when stored, generates an inflammatory response, and
may contribute to organ dysfunction following cardiopulmonary bypass. We
determined whether using a miniaturized circuit and an asanguineous prime
attenuated the post-bypass inflammatory response, and improved right ventricular
and pulmonary function. METHODS: Sixteen infant piglets were placed into 3
groups based on prime components: group I (fresh blood), group II (stored
blood), and group III (miniaturized circuit and asanguineous prime). Piglets
were placed on cardiopulmonary bypass (100 mL.kg(-1).min(-1)), cooled to 18
degrees C, and underwent continuous perfusion (50 mL.kg(-1).min(-1)) for 30
minutes. They were rewarmed and separated from bypass. Serum tumor necrosis
factor-alpha, right ventricular function, and pulmonary function were measured
before and 30 minutes after bypass. Neutrophil priming activity in fresh and
stored donor blood was also assessed. RESULTS: Animals in group III had
significantly improved cardiopulmonary function than the groups receiving blood
(right ventricular cardiac index [mL.kg(-1).min(-1)]: group I [18.8 +/- 4.8],
group II [21.5 +/- 6.2], and group III [81.2 +/- 11.4], p < 0.001; and pulmonary
vascular resistance index [dynes.mL(-1).kg(-1)]: group I [1169 +/- 409], group
II [1610 +/- 486], and group III [214 +/- 63], p = 0.03). Tumor necrosis
factor-alpha (pg.mL(-1)) was lower in group III (1465 +/- 39) than in the groups
receiving blood (3940 +/- 777), p = 0.002. Neutrophil priming activity
(nmol.min(-1)) was also higher in stored blood (3.7 +/- 6) than in fresh blood
(1.9 +/- 0.2), p = 0.02. CONCLUSIONS: We have devised a unique miniaturized
circuit that allows an asanguineous prime without hemodilution in an infant
swine model. The employment of this circuit attenuates the post-bypass
inflammatory response and has salutary effects on cardiopulmonary function.