Eur J Echocardiogr. 2007 Jul 4; [Epub ahead of print]

Cardiac metastasis due to pulmonary metastasis from a transitional cell
carcinoma.

Sobczyk D, Nosal M, Myc J, Trybowski G, Gorkiewicz-Kot I, Olejniczak P, Sadowski 
J.

Department of Cardiovascular Surgery and Transplantology, Institute of
Cardiology, Medical College of Jagiellonian University, Pradnicka 80, 31-202
Krakow, Poland.

We report a rare case of symptomatic cardiac metastasis from a transitional cell 
carcinoma of the renal pelvis diagnosed by echocardiography. A 75-year-old
patient with a long history of neoplasm since 1999 and coronary artery disease
with CABG in 2003 was admitted to our department. He underwent cardiac surgery
using cardiopulmonary bypass with tumor excision. Histologically it was the same 
type of transitional cell neoplasm which was operated 7 years before. We present 
all medical history, detailed 2D and 3D echocardiography, intraoperative pictures
and discuss possible chain of changes from renal pelvis cancer to clinical
manifestation of cardiac mass. There is proven rapid progression of cardiac tumor
with clinical manifestation few months after control TEE examination without any 
evidence of cardiac mass. It is important that this is a very rare case of left
heart metastasis form right side of circulatory system through pulmonary stage of
cancer progression.

Circulation. 2007 Jul 31;116(5):471-9. Epub 2007 Jul 9.

Comment in:
    Circulation. 2007 Jul 31;116(5):458-60.

Impact of preoperative anemia on outcome in patients undergoing coronary artery
bypass graft surgery.

Kulier A, Levin J, Moser R, Rumpold-Seitlinger G, Tudor IC, Snyder-Ramos SA,
Moehnle P, Mangano DT; Investigators of the Multicenter Study of Perioperative
Ischemia Research Group; Ischemia Research and Education Foundation.

Department of Anesthesiology and Intensive Care Medicine, Medical University of
Graz, Graz, Austri. akulier@aon.at

BACKGROUND: The risk of preoperative anemia in patients undergoing heart surgery 
has not been described precisely. Specifically, the impact of low hemoglobin per 
se or combined with other risk factors on postoperative outcome is unknown. Thus,
we determined the effects of low preoperative hemoglobin and comorbidities on
postoperative adverse outcomes in patients with coronary artery bypass graft in a
large comprehensive multicenter study. METHODS AND RESULTS: The Multicenter Study
of Perioperative Ischemia investigated 5065 patients with coronary artery bypass 
graft at 70 institutions worldwide, collecting approximately 7500 data points per
patient. In 4804 patients who received no preoperative transfusions, we
determined the association between lowest preoperative hemoglobin levels and
in-hospital cardiac and noncardiac morbidity and mortality and the impact of
concomitant risk factors, assessed by EuroSCORE, on this effect. In patients with
EuroSCORE < 4 (n=2054), only noncardiac outcomes were increased, whereas patients
with EuroSCORE > or = 4 (n=2750) showed an increased incidence of all
postoperative events, starting at hemoglobin < 11 g/dL. Low preoperative
hemoglobin was an independent predictor for noncardiac (renal > cerebral;
P<0.001) outcomes, whereas the increase in cardiac events was due to other
factors associated with preoperative anemia. CONCLUSIONS: Anemic patients
undergoing cardiac surgery have an increased risk of postoperative adverse
events. Importantly, the extent of preexisting comorbidities substantially
affects perioperative anemia tolerance. Therefore, preoperative risk assessment
and subsequent therapeutic strategies, such as blood transfusion, should take
into account both the individual level of preoperative hemoglobin and the extent 
of concomitant risk factors.

J Surg Res. 2007 Jul 11; [Epub ahead of print]

Endotoxin Removal with a Polymyxin B-Immobilized Hemoperfusion Cartridge Improves
Cardiopulmonary Function After Cardiopulmonary Bypass.

Ohki S, Oshima K, Takeyoshi I, Matsumoto K, Morishita Y.

Department of Thoracic and Visceral Organ Surgery, Gunma University Graduate
School of Medicine, Gunma, Japan.

BACKGROUND: Cardiac surgery using cardiopulmonary bypass (CPB) is performed
widely, given the progress in cardioprotective methods. However, endotoxemia
caused by CPB leads to systemic inflammatory response syndrome and deterioration 
of organ function. We evaluated the effectiveness of endotoxin removal with a
polymyxin B-immobilized hemoperfusion cartridge (PMX) in CPB. MATERIALS AND
METHODS: Pigs weighing about 25 kg were divided into control (n = 5) and PMX (n =
5) groups. Normothermic CPB was performed in the control group, while endotoxin
was removed with PMX under normothermic CPB in the PMX group. Endotoxin removal
was performed from the start to end of CPB. The end-systolic pressure-volume
ratio (E(max)), left ventricular pressure (LVP), maximum and minimum rates of
increase in LVP (+/-LVdp/dt), and cardiac output (CO) were measured 2 h after
CPB, and the recovery rates of the parameters were compared between the two
groups. A histopathological study was also conducted. RESULTS: The recovery rates
of E(max), CO, and LVP were significantly better (P < 0.05) in the PMX group than
in the control group. The PaO(2) 2 h after CPB was significantly higher (P <
0.05) in the PMX group than in the control group. The interleukin (IL)-8 level 2 
h after CPB was significantly lower (P < 0.05) in the PMX group.
Histopathologically, the heart and pulmonary tissues were better preserved in the
PMX group. CONCLUSION: The PMX treatment reduced the inflammatory reaction caused
by CPB, and cardiac and pulmonary functions after normothermic CPB were well
preserved.

Pediatr Cardiol. 2007 Jul 12; [Epub ahead of print]

Long-Term Behavior and Quality of Life After Corrective Cardiac Surgery in
Infancy for Tetralogy of Fallot or Ventricular Septal Defect.

Hövels-Gürich HH, Konrad K, Skorzenski D, Minkenberg R, Herpertz-Dahlmann B,
Messmer BJ, Seghaye MC.

Department of Pediatric Cardiology, Aachen University of Technology,
Pauwelsstrasse 30, 52057, Aachen, Germany, hhoevels-guerich@ukaachen.de.

The objective of this study was to evaluate behavior and quality of life in
children after corrective cardiac surgery in infancy. Twenty cyanotic (tetralogy 
of Fallot) and 20 acyanotic children (ventricular septal defect), operated at a
mean age of 0.7 years with deep hypothermic circulatory arrest (DHCA) and
low-flow cardiopulmonary bypass (CPB), were assessed at a mean age of 7.4 years
by the Child Behavior Checklist (CBCL) and the German KINDL. Test results were
related to perioperative and neurodevelopmental outcome. Compared to healthy
children and not significantly different between the groups, internalizing and
externalizing problems were elevated, school performance and total competence
were reduced, and self- and parent-reported quality of life was not reduced.
Parent-reported problems and reduced physical status were correlated with longer 
durations of DHCA and CPB. Internalizing and externalizing problems, reduced
school competence, and reduced self-esteem were associated with reduced endurance
capacity. Externalizing problems were related to reduced gross motor function.
Poor school competence was related to reduced intelligence and academic
achievement. Children with preoperative hypoxemia in infancy due to cyanotic
cardiac defects are not at significantly higher risk for behavioral problems and 
reduced quality of life than those with acyanotic heart defects. The risk of
long-term psychosocial maladjustment after corrective surgery in infancy is
increased compared to that for normal children and related to the presence of
neurodevelopmental dysfunction.

Cardiol Young. 2007 Jul 18;:1-6 [Epub ahead of print]

A transthoracic Doppler echocardiography study of C-reactive protein and coronary
microcirculation in children after open heart surgery.

Aburawi EH, Liuba P, Berg A, Pesonen E.

1Department of Paediatrics, Division of Paediatric Cardiology, Lund University
Hospital, Lund, Sweden.

BACKGROUND: Systemic inflammation has been suggested to underlie in part the
elevated risk of arrhythmias and myocardial dysfunction during the first weeks
after cardiac surgery. Recent transthoracic Doppler studies from our centre
indicated increased basal coronary arterial flow in children 5 days after
cardiopulmonary bypass surgery. In these children, we investigated whether the
inflammatory mediator, C-reactive protein, could influence this association.
METHODS: The peak flow velocity, velocity time-integral in diastole and systole, 
and basal blood flow in the proximal part of the left anterior descending artery,
were assessed by transthoracic Doppler echocardiography 1 day before, and 5 days 
after, cardiac surgery in 17 children with ventricular and atrioventricular
septal defects whose mean age at surgery was 6 months. Levels of C-reactive
protein in the plasma were measured at both time-points. RESULTS: Prior to
surgery, all children had levels of C-reactive protein under the limit for
detection, that is less than 0.8 milligrams per litre. The levels of the protein 
had increased significantly by the second day, when the median value was 25, and 
the range from 20 to 142 milligrams per litre. They remained elevated on the
fifth day after surgery, when the median was 11, and the range from 3 to 20
milligrams per litre. On the fifth day, the percentage increase in velocity time 
integral corrected for left ventricular mass was significantly lower in those
patients with C-reactive protein greater than or equal to 10 milligrams per litre
than in the remaining patients. Also, both the velocity time integral and the
velocity of diastolic peak flow correlated inversely with log C-reactive protein,
r being equal to -0.54 and p less than 0.02 and r equal to -0.74 and p less than 
0.01, respectively, particularly among those patients in whom clamping of the
aorta lasted for more than 1 hour, r for this statistic being equal to
-0.8.ConclusionThe postsurgical increase in the velocity of coronary arterial
flow in children is inversely associated with rising levels of C-reactive
protein. The duration of the aortic cross-clamping during surgery strengthens the
association between levels of C-reactive protein and the microcirculatory
changes.

J Card Surg. 2007 Jul-Aug;22(4):320-2.

Off-pump insertion of continuous flow left ventricular assist devices.

Selzman CH, Sheridan BC.

Division of Cardiothoracic Surgery, University of North Carolina at Chapel Hill, 
Chapel Hill, North Carolina 27599-7065, USA. selzman@med.unc.edu

BACKGROUND AND AIM OF THE STUDY: Traditional left ventricular assist device
(LVAD) implantation requires extensive dissection and use of cardiopulmonary
bypass (CPB). Potential adverse effects of CPB in very ill end-stage heart
failure patients include right ventricular dysfunction, end-organ injury, and
bleeding. We sought to evaluate the feasibility and outcome of LVAD insertion
without CPB. METHODS: The Jarvik 2000 is an axial-flow pump newly involved in a
phase I clinical trial in status I patients as a bridge to transplantation. Seven
patients received this pump through thoracotomy or sternotomy with or without the
use of CPB. RESULTS: All patients had NYHA class IV heart failure with end-organ 
dysfunction requiring inotropic therapy. Two were in cardiogenic shock,
necessitating full CPB support. Five patients had the Jarvik implanted off-CPB.
The off-CPB patients were associated with decreased length of surgery, mechanical
ventilation, blood transfusions, inotropic support, and hospital stay including
rehabilitation. Nearly all of the patients had complete resolution of liver and
kidney dysfunction. CONCLUSION: We have demonstrated that off-CPB insertion of
axial flow LVADs is feasible, safe, and potentially advantageous. Although we are
encouraged by the perioperative simplicity of this strategy, we acknowledge that 
additional implants and comparisons of outcomes with traditional pulsatile and
continuous flow device techniques will be necessary to advocate its widespread
adoption.

J Card Surg. 2007 Jul-Aug;22(4):307-13.

Does the type of surgery effect systemic response following cardiopulmonary
bypass?

Takayama H, Soltow LO, Chandler WL, Vocelka CR, Aldea GS.

Department of Surgery, Division of Cardiothoracic Surgery, University of
Washington School of Medicine, Seattle, Washington 98195, USA.

BACKGROUND: Clinical studies conducted to elucidate the systemic response to
cardiopulmonary bypass (CPB) did not differentiate possible effect of different
types of cardiac surgical pathologies and operations on outcomes and have
typically combined different procedures. We hypothesized that valve surgery
induces more prominent systemic reaction compared to isolated on-pump CABG.
METHODS: Twenty-seven patients undergoing primary on-pump CABG (Group 1, n = 14) 
or valve surgery with or without CABG (Group 2, n = 13) were prospectively
enrolled. Heparin-bonded circuits were used in all patients. Cardiotomy suction
was only used in Group 2. Clinical and laboratory markers were evaluated.
RESULTS: Clinical measurements, including chest tube output, blood transfusion
requirement, inotropic support requirement, and duration of ICU stay were not
significantly different. Thrombin generation (PF-1.2) was significantly higher in
Group 2 (p = 0.001). tPA was also significantly higher in Group 2 at 15 and 60
minutes on CPB (p < 0.01). Group 2 had significantly higher inflammatory response
shown by elevation of IL6 (p = 0.005). Neuronal injury markers, S100beta and NSE,
were significantly higher at the termination of CPB in Group 2 (p < 0.01). At no 
point of time course for any marker, Group 1 had significantly higher response
compared to Group 2. CONCLUSIONS: Valve surgery induced more prominent systemic
response than CABG. The possible explanations include the difference in baseline 
disease pathophysiology, and/or difference associated with the procedures such as
open systems and use of cardiotomy suction. Future clinical studies assessing
systemic response to CPB and therapies to blunt these need consider and account
for these observed differences.

Curr Med Res Opin. 2007 Aug;23(8):1783-90.

Preoperative statins and infectious complications following cardiac surgery.

Coleman CI, Lucek DM, Hammond J, White CM.

Division of Cardiology, Hartford Hospital, Hartford, CT 06102, USA.

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.

Pharmacotherapy. 2007 Jul;27(7):988-94.

Aprotinin use in cardiac surgery patients at low risk for requiring blood
transfusion.

Kristeller JL, Stahl RF, Roslund BP, Roke-Thomas M.

Department of Pharmacy Practice, Wilkes University, Wilkes-Barre, Pennsylvania
18766, USA.

STUDY OBJECTIVES: To determine if aprotinin is safe and effective in patients at 
low risk for requiring blood transfusion after cardiac surgery by evaluating
whether there is any significant difference in blood product use or other
significant clinical outcomes between patients who received aprotinin versus
those who did not. DESIGN: Retrospective review. SETTING: Inpatient community
nonteaching hospital. PATIENTS: Three hundred thirty-five patients who underwent 
primary cardiac surgery involving cardiopulmonary bypass between November 1,
2003, and December 31, 2005, and were considered at low risk for requiring
postoperative blood transfusion; 162 patients received aprotinin and 173 patients
received aminocaproic acid (control). MEASUREMENTS AND MAIN RESULTS: Comparison
of patients in the aprotinin group versus those in the aminocaproic acid group
revealed no difference in total donor exposures to blood products (1.86 vs 1.16
units/patient, p=0.07), total packed red blood cells (PRBCs) received (1.25 vs
0.86 units/patient, p=0.09), postoperative donor exposures to blood products
(0.91 vs 0.48 unit/patient, p=0.13), or postoperative PRBCs received (0.61 vs
0.40 unit/patient, p=0.23). No difference was noted in any other clinical outcome
in the aprotinin group versus the aminocaproic acid group, including
postoperative azotemia (13.0% vs 10.4%, p=0.46), new onset of atrial fibrillation
(14.8% vs 15.0%, p=0.95), myocardial infarction, stroke, or death. Mean +/- SD
total hospital length of stay was similar in the aprotinin group versus the
aminocaproic acid group (8.1 +/- 3.8 vs 7.4 +/- 2.8 days, p=0.08), but length of 
stay from surgery to discharge was longer in the aprotinin group than in the
aminocaproic acid group (5.9 +/- 0.17 vs 5.4 +/- 0.12 days, p=0.032). CONCLUSION:
Although aprotinin appeared to be safe in this low-risk patient population, it
was not more effective than aminocaproic acid in reducing blood product use after
cardiac surgery. More robust evidence is needed from a controlled randomized
trial to demonstrate the safety, efficacy, and pharmacoeconomic benefit of
aprotinin.

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.