Ann Thorac Surg 2001 Aug;72(2):607-8

Resuscitation in near drowning with extracorporeal membrane oxygenation.

Thalmann M, Trampitsch E, Haberfellner N, Eisendle E, Kraschl R, Kobinia G.

Department of Cardiothoracic Surgery, General Hospital Klagenfurt, Austria.
herz-thorax.abteilung@lkh-klu.at

We report a case of near drowning of a 3-year-old girl, who was admitted to our
emergency room with a core temperature of 18.4 degrees C. After rewarming on
cardiopulmonary bypass and restitution of her circulation, respiratory failure
resistant to conventional respiratory therapy prohibited weaning from
cardiopulmonary bypass. Therefore, we instituted extracorporeal membrane
oxygenation (ECMO). Fifteen hours later, she could be weaned from ECMO but
required assisted ventilation for another 12 days. Twenty months later there are
no neurologic deficits.

Ann Thorac Surg 2001 Aug;72(2):565-70

Endothelin receptor blockade reduces ventricular dysfunction and injury after
reoxygenation.

Pearl JM, Nelson DP, Wagner CJ, Lombardi JP, Duffy JY.

Division of Pediatric Cardiothoracic Surgery, Children's Hospital Medical
Center, Cincinnati, Ohio 45229, USA. pearj0@chmcc.org

BACKGROUND: Reoxygenation of hypoxic myocardium during repair of congenital
heart defects results in poor ventricular function and cellular injury.
Endothelin-1 (ET-1), a potent vasoconstrictor that increases during hypoxia, may
suppress myocardial function and activate leukocytes. The objective was to
determine whether administration of an endothelin receptor antagonist could
improve ventricular function and decrease cardiac injury after hypoxia and
reoxygenation. METHODS: Fourteen piglets underwent 90 minutes of ventilator
hypoxia, 1 hour of reoxygenation on cardiopulmonary bypass, and 2 hours of
recovery (controls). Nine additional animals received an infusion of Bosentan,
an ET(A/B) receptor antagonist, (5 mg/kg per hour) during hypoxia and
reoxygenation. RESULTS: Right and left ventricular dP/dt in controls decreased
to 78% and 52% of baseline, respectively, after recovery (p < 0.05). In
contrast, Bosentan-treated animals had complete preservation of RV dP/dt and
less depression of LV dP/dt. Bosentan reduced the hypoxia and
reoxygenation-induced elevation of ET-1 and iNOS mRNA at the end of recovery (p
< 0.05). Bosentan-treated animals had diminished myocardial myeloperoxidase
activity and lipid peroxidation compared with controls (p < 0.05). Myocardial
apoptotic index, elevated by hypoxia and reoxygenation, was lower in the
Bosentan-treated animals (p < 0.05). CONCLUSIONS: Endothelin-1 receptor
antagonism improved functional recovery and decreased leukocyte-mediated injury
after reoxygenation. The reduction in cardiac cell death might also improve
long-term outcome after reoxygenation injury.

Arq Bras Cardiol 2001 Aug;77(2):114-9

Cytokines and troponin-I in cardiac dysfunction after coronary artery grafting
with cardiopulmonary bypass.

Savaris N, Polanczyk C, Clausell N.

Hospital de Clinicas de Porto Alegre, Federal University of Rio Grande do Sul,
Porto Alegre, 90035-003, Brazil.

OBJECTIVE: The association between cytokines and troponin-I with cardiac
function after cardiac surgery with cardiopulmonary bypass remains a topic of
continued investigation. METHODS: Serial measurements, within 24h following
surgery, of tumor necrosis factor-alpha, its soluble receptors, and troponin-I
were performed in patients with normal ejection fraction undergoing coronary
artery bypass grafting. Ejection fraction was measured by radioisotopic
ventriculography preoperatively, at 24h and at day 7 postoperatively. RESULTS:
Of 19 patients studied (59+/-8.5 years), 10 (group 1) showed no changes in
ejection fraction, 53+/-8% to 55+/-7%, and 9 (group 2) had a decrease in
ejection fraction, 60+/-11% to 47+/-11% (p=0.015) before and 24h after coronary
artery bypass grafting, respectively. All immunological variables, except tumor
necrosis factor-alpha soluble receptor I at 3h postoperation (5.5+/- 0.5 in
group 1 versus 5.9+/-0.2 pg/ml in group 2; p=0.048), were similar between
groups. Postoperative troponin-I had an inverse correlation with ejection
fraction at 24h (r= -0.44). CONCLUSIONS: Inflammatory activity, assessed based
on tumor necrosis factor-alpha and its receptors, appears to play a minor role
in cardiac dysfunction after cardiac surgery. Troponin I levels are inversely
associated with early postoperative ejection fraction.

Acta Med Okayama 2001 Aug;55(4):245-52

Significance of adrenomedullin under cardiopulmonary bypass in children during
surgery for congenital heart disease.

Takeuchi M, Morita K, Iwasaki T, Toda Y, Oe K, Taga N, Hirakawa M.

Department of Anesthesiology and Resuscitology, Okayama University Medical
School, Japan. take0412@cc.okayama-u.ac.jp

To elucidate the effect of adrenomedullin (AM) on fluid homeostasis under
cardiopulmonary bypass (CPB), we investigated the serial changes in plasma AM
and other parameters related to fluid homeostasis in 13 children (average age,
28.2 months) with congenital heart disease during cardiac surgery under CPB.
Arterial blood and urine samples were collected just after initiation of
anesthesia, just before commencement of CPB, 10 min before the end of CPB, 60
min after CPB, and 24 h after operation. Plasma AM levels increased
significantly 10 min before the end of CPB and decreased 24 h after operation.
Urine volume increased transiently during CPB, which paralleled changes in AM.
Simple regression analysis showed that plasma AM level correlated significantly
with urinary vasopressin, urine volume, urinary sodium excretion, and plasma
osmolarity. Stepwise regression analysis indicated that urine volume was the
most significant determinant of plasma AM levels. Percent rise in AM during CPB
relative to control period correlated with that of plasma brain natriuretic
peptide (r = 0.57, P < 0.01). Our results suggest that AM plays an important
role in fluid homeostasis under CPB in cooperation with other hormones involved
in fluid homeostasis.

J Cardiothorac Vasc Anesth 2001 Aug;15(4):469-73

Effect of C1-esterase-inhibitor on capillary leak and inflammatory response
syndrome during arterial switch operations in neonates.

Tassani P, Kunkel R, Richter JA, Oechsler H, Lorenz HP, Braun SL, Eising GP,
Haas F, Paek SU, Bauernschmitt R, Jochum M, Lange R.

Departments of Anesthesiology, Laboratory Analysis, Cardiovascular Surgery and
Pediatric Cardiology, German Heart Center Munich; and Division of Clinical
Biochemistry, Department of Surgery City, Ludwig-Maximilians-University of
Munich, Munich, Germany.

OBJECTIVE: To determine if prophylactic administration of C1-esterase-inhibitor
would have a beneficial effect on postoperative weight gain and the inflammatory
response in neonates undergoing cardiac surgery with cardiopulmonary bypass
(CPB). DESIGN: Randomized, double-blinded study. SETTING: University-affiliated
heart center. PARTICIPANTS: Twenty-four neonates with transposition of the great
arteries. INTERVENTIONS: In group inhibitor (INH) patients (n = 12), 100 IU/kg
of C1-esterase-inhibitor (Berinert) was given 30 minutes before CPB. In group
placebo (P) patients (n = 12), placebo was administered instead. Interleukin
(IL)-6, C3a anaphylatoxin, C1 activity, prekallikrein, Hageman factor, D-dimers,
and clinical parameters were measured 6 times perioperatively. Measurements and
Main Results: All 24 patients had an uneventful clinical course. Mean arterial
pressure and pulmonary oxygenation after CPB were superior in group INH
patients. The weight gain on postoperative days 1 to 4 was significantly less in
group INH patients compared with group P (55 +/- 59 g vs. 340 +/- 121 g, day 1).
The concentration of IL-6 (76 +/- 17 pg/mL vs. 262 +/- 95 pg/mL during CPB) was
significantly lower in group INH patients compared with group P patients. In
contrast, no influence on C3a anaphylatoxin and coagulation factors was found.
CONCLUSION: Prophylactic application of C1-esterase-inhibitor in neonates
undergoing arterial switch operations produces less inflammatory response
compared with placebo. This difference may have contributed to improved clinical
parameters, including less weight gain postoperatively. 

J Cardiothorac Vasc Anesth 2001 Aug;15(4):418-21

Does isoflurane optimize myocardial protection during cardiopulmonary bypass?

Haroun-Bizri S, Khoury SS, Chehab IR, Kassas CM, Baraka A.

Anesthesiology Department, American University of Beirut Medical Center, Beirut,
Lebanon.

OBJECTIVE: To investigate the possible myocardial protective effect of
isoflurane during aortic cross-clamp and cardioplegic cardiac arrest in patients
undergoing conventional coronary artery bypass graft surgery. DESIGN:
Prospective, randomized. SETTING: University medical center. PARTICIPANTS:
Forty-nine patients undergoing elective coronary artery bypass graft surgery
divided into 2 groups: control group (n = 21) and isoflurane group (n = 28).
INTERVENTION: Isoflurane was administered in the pre-cardiopulmonary bypass
(CPB) period to the isoflurane group. Measurements And Main Results:
Hemodynamics and ST- segment variations were monitored in the pre-CPB period and
after weaning from CPB in both groups. Incidence of reperfusion arrhythmias
after release of aortic cross-clamp was compared. In the isoflurane group, the
mean cardiac index after CPB was significantly higher than the pre-CPB value,
whereas no difference between the 2 values was found in the control group. The
higher cardiac index in the isoflurane group was associated with a lesser degree
of ST- segment changes than in the control group. There was no significant
difference between the 2 groups in the incidence of reperfusion arrhythmias
after release of aortic cross-clamp. CONCLUSION: The present report suggests
that administration of isoflurane before aortic cross-clamping in patients
undergoing coronary artery bypass graft surgery may optimize the myocardial
protective effect of cardioplegia. Isoflurane may be particularly advantageous
whenever prolonged periods of aortic cross-clamping or inadequate delivery of
cardioplegia is expected. 

Br J Anaesth 2001 Aug;87(2):223-8

Continuous intra-jugular venous blood-gas monitoring with the Paratrend 7 during
hypothermic cardiopulmonary bypass.

Endoh H, Honda T, Oohashi S, Nagata Y, Shibue C, Shimoji K.

Department of Emergency and Critical Care Medicine and Department of
Anesthesiology, Niigata University Faculty of Medicine, 1-757 Asahimachi,
Niigata 951-8150, JapanCorresponding author.

We measured the accuracy of the continuous intra-vascular blood-gas monitoring
system (Paratrend 7, PT7) placed in the jugular venous bulb in 18 adult patients
having cardiac or aortic surgery with hypothermic cardiopulmonary bypass (CPB).
After induction of anaesthesia, a PT7 sensor was inserted through a 20-gauge
venous catheter into the right jugular venous bulb. Blood samples were drawn
from the venous catheter and measured with a blood gas analyser (BGA). Five to
eight paired measurements using the PT7 and blood samples were made per patient,
and bias and precision were calculated for each patient using the Bland-Altman
method. The ranges for the blood sample measurements were: pH 7.12 to 7.59,
PCO(2) 3.7 to 9.6 kPa, PO(2) 3.5 to 16.0 kPa, oxygen saturation 40 to 99%,
bicarbonate 18.6 to 34.4 mmol l(-1), and base excess -7.8 to 12.5 mmol l(-1).
Bias and precision values were 0.014/0.071 for pH, 0/0.90 kPa for PCO(2), and
-0.16/1.18 kPa for PO(2). These values were comparable with those previously
made on arterial blood. However, precision for oxygen saturation in each patient
varied 2.3 to 23.6% (95% CI: 6.3 to 12.9%), which was unsatisfactory for
clinical measurements. Deep hypothermia ( approximately 19.6 degrees C) and
marked haemodilution ( approximately 13.5%) during CPB did not influence the
reliability of the PT7 sensor. Thus, we concluded that continuous intra-jugular
venous blood-gas monitoring is clinically feasible using the PT7 and may provide
valuable information during CPB.

Anaesthesia 2001 Aug;56(8):733-8

Hypertension as a risk factor for cerebral injury during cardiopulmonary bypass.
Protein S100B and transcranial Doppler findings.

Schmidt M, Scheunert T, Steinbach G, Schirmer U, Marx T, Freitag N, Reinelt H.

Department of Cardiac Anaesthesia, University of Ulm, 89070 Ulm, Germany.
michael.schmidt@medizin.uni-ulm.de

We studied 22 patients aged 53-78 years scheduled for cardiac surgery under
cardiopulmonary bypass. Blood pressure, cardiac output, transcranial Doppler
blood flow velocity, arterial blood gases, body temperature and protein S100B,
as a marker for cerebral integrity, were evaluated in normotensive and
hypertensive patients. Pre-operative mean (SD) arterial blood pressure was 93
(11) mmHg in the normotensive group compared with 116 (15) mmHg in the
hypertensive group. We found an increase in protein S100B levels in both groups.
Serum protein S100B concentrations in the hypertensive group were significantly
higher than in the normotensive group (p < 0.001). The highest mean (SD) values
were 2.04 (0.65) micromol x l(-1) in the normotensive group and 7.02 (4.55)
micromol x l(-1) in the hypertensive group. These results suggest that
cardiopulmonary bypass is associated with a significantly higher rate of
cerebral injury in hypertensive patients than in normotensive patients. This may
be due to altered autoregulation and insufficient cerebral perfusion.
Modifications of cardiopulmonary bypass management for hypertensive patients
might be made to decrease the risk of cerebral injury.

J Thorac Cardiovasc Surg 2001 Aug;122(2):220-8

A prospective randomized study comparing volume-standardized modified and
conventional ultrafiltration in pediatric cardiac surgery.

Thompson LD, McElhinney DB, Findlay P, Miller-Hance W, Chen MJ, Minami M,
Petrossian E, Parry AJ, Reddy VM, Hanley FL.

Division of Cardiothoracic Surgery, University of California, San Francisco,
Calif.

BACKGROUND: Modified ultrafiltration has been touted as superior to conventional
ultrafiltration for attenuating the consequences of hemodilution after cardiac
surgery with cardiopulmonary bypass in children. We conducted a prospective
randomized study to test the hypothesis that modified and conventional
ultrafiltration have similar clinical effects when a standardized volume of
fluid is removed. METHODS: From October 1998 to September 1999, 110 children
weighing 15 kg or less (median weight 6.1 kg, median age 6.3 months) undergoing
surgery with cardiopulmonary bypass for functionally biventricular congenital
heart disease were randomized to conventional (n = 67) or arteriovenous modified
ultrafiltration (n = 43) for hemoconcentration. The volume of fluid removed with
both methods was standardized as a percentage of effective fluid balance (the
sum of prime volume and volume added during cardiopulmonary bypass minus urine
output): in patients weighing less than 10 kg, 50% of effective fluid balance
was removed, whereas 60% was removed in patients weighing 10 to 15 kg.
Hematocrit, hemodynamics, ventricular function, transfusion of blood products,
and postoperative resource use were compared between groups. RESULTS: There were
no significant differences between groups in age, weight, or duration of
cardiopulmonary bypass. The total volume of fluid added in the prime and during
bypass was greater in patients undergoing conventional ultrafiltration than in
those receiving modified ultrafiltration (205 +/- 123 vs 162 +/- 74 mL/kg; P
=.05), although the difference was due primarily to a greater indexed priming
volume in patients having conventional ultrafiltration. There was no difference
in the percentage of effective fluid balance that was removed in the 2 groups.
Accordingly, the volume of ultrafiltrate was greater in patients receiving
conventional than modified ultrafiltration (95 +/- 63 vs 68 +/- 28 mL/kg; P
=.01). Preoperative and postoperative hematocrit levels were 35.6% +/- 6.6% and
36.3% +/- 5.6% in patients having conventional ultrafiltration and 34.4% +/-
6.7% and 38.7% +/- 7.5% in those having modified ultrafiltration. By
repeated-measures analysis of variance, patients receiving modified and
conventional ultrafiltration did not differ with respect to hematocrit value (P
=.87), mean arterial pressure (P =.85), heart rate (P =.43), or left ventricular
shortening fraction (P =.21) from baseline to the postbypass measurements. There
were no differences between groups in duration of mechanical ventilation, stay
in the intensive care unit, or hospitalization. CONCLUSIONS: When a standardized
volume of fluid is removed, hematocrit, hemodynamics, ventricular function,
requirement for blood products, and postoperative resource use do not differ
between pediatric patients receiving conventional and modified ultrafiltration
for hemoconcentration after cardiac surgery.