Med Sci Monit. 2003 Aug;9(8):CR369-76.  

Predictors of outcome after coronary artery bypass grafting in patients older
than 75 years of age.

Islamoglu F, Reyhanoglu H, Berber O, Ozbaran M, Buket S, Yuksel M, Telli A,
Durmaz I.

Department of Cardiovascular Surgery, Ege University Medical Faculty, Izmir,
Turkey.

BACKGROUND: This study was designed to identify risk factors affecting mortality
and morbidity in patients older than 75 years who underwent coronary artery
bypass grafting (CABG) with cardiopulmonary bypass. MATERIAL/METHODS: The
preoperative, perioperative, and postoperative data of 116 patients older than
75 years who underwent isolated CABG from January 1997 through April 2002 were
evaluated retrospectively. peoperatively, 82 patients (70.7%) were in CCS class
III-IV and 65 (56%) were in NYHA class III-IV. Besides mortality, morbidity and
survival rates, the statistical significance of predictors of outcome were
investigated. RESULTS: Overall mortality and hospital mortality rates were 12.9%
(15 patients) and 4.3%, (5 patients), respectively. Postoperative complications
were observed in 56 patients (48.3%). In 25.1I17.6 months of follow-up, 96
(86.5%) and 101 (91%) of the surviving 111 patients (95.7%) were in NYHA class I
and CCS class I, respectively. Prolonged cross-clamp time (>50 min) (p=0.018),
COPD (p=0.028), and emergency operation (p=0.001) were found to be the
determinants of postoperative complications. The cumulative 5-year survival rate
was 77.2I0.8%. CONCLUSIONS: Elective CABG in older patients with shorter bypass
and cross-clamp times, after the management of comorbid diseaes, such as COPD,
is a safe procedure with low mortality and morbidity rates, showing
postoperative improvements in functional capacity and angina class.

Chin Med J (Engl). 2003 Aug;116(8):1179-82.  

Autotransfusion of shed mediastinal blood after open heart surgery.

Zhao K, Xu J, Hu S, Wu Q, Wei Y, Liu Y.

Department of Cardiac Surgery, Fuwai Hospital, Peking Union Medical College,
Chinese Academy of Medical Science, Beijing 100037, China (Email:
KangliKangli@prodigy.net)

OBJECTIVE: To determine the safety and effectiveness of autotransfusion of shed
mediastinal blood after open heart surgery. METHODS: Sixty patients undergoing
coronary artery bypass grafting (CABG) were selected randomly to receive either
nonwashed shed mediastinal blood (Group 1, n = 30) or banked blood (Group 2, n =
30). Drainage and transfusion volume were determined after the operation. Hb,
RBC, HCT and PLT were detected immediately before and after the operation, as
well as 24 hours and 7 days after the operation. Data were analyzed using
Fisher's exact test. A P < 0.05 was considered significant. RESULTS: There were
no significant differences in Hb, HCT, PLT or length of cardiopulmonary bypass
(CPB) (P > 0.05). In the two groups, no significant difference in the mean blood
loss was observed during 24 hours after the operation (660 +/- 300 ml in Group 1
and 655 +/- 280 ml in Group 2, P > 0.05). In Group 1, the mean volume
autotransfused was 280 +/- 160 ml, and the patients required 360 +/- 80 ml
banked blood compared with 660 +/- 120 ml in Group 2. In other words, the banked
blood requirement in Group 1 was 40% lower. CONCLUSIONS: Autotransfusion of shed
mediastinal blood after an open heart operation is safe and effective.

J Thorac Cardiovasc Surg. 2003 Aug;126(2):428-35.  

Pharmacologic platelet anesthesia by glycoprotein IIb/IIIa complex antagonist
and argatroban during in vitro extracorporeal circulation.

Kanemitsu S, Nishikawa M, Onoda K, Shimono T, Shimpo H, Yazaki A, Tanaka K,
Shiku H, Yada I.

OBJECTIVE: Contact between blood and the synthetic surfaces of a cardiopulmonary
bypass circuit leads to platelet activation, and resultant platelet dysfunction
contributes to postoperative bleeding. We compared the effects of various
platelet inhibitors on preservation of platelet function during simulated
cardiopulmonary bypass circulation. METHODS: Fresh human blood was recirculated
in an in vitro cardiopulmonary bypass model circuit. We measured various
platelet activation markers including expressions of PAC-1 and P-selectin,
annexin V binding, and microparticle formations by means of whole-blood flow
cytometry. RESULTS: Two types of glycoprotein IIb/IIIa complex antagonists,
peptide-mimetic FK633 and abciximab and prostaglandin E(1), significantly
prevented platelet loss and the increase in binding of PAC-1, an antibody
specific for fibrinogen receptor on activated platelets, during extracorporeal
circulation of heparinized blood. These antagonists significantly suppressed but
did not abolish P-selectin expression, annexin V binding, and microparticle
formation. Anti-von Willebrand factor monoclonal antibody and aurin
tricarboxylic acid (an inhibitor of glycoprotein Ib) had no effect on platelet
activation during simulated cardiopulmonary bypass circulation. These data
suggest that inhibition of fibrinogen binding glycoprotein IIb/IIIa complex is
partly effective in attenuating platelet activation in a heparinized
cardiopulmonary bypass model circuit. The direct thrombin inhibitor argatroban
prevented platelet loss and expression of P-selectin significantly more than did
heparin. A combination of FK633 with argatroban as a substitute for heparin
further prevented platelet loss and platelet secretion during simulated
cardiopulmonary bypass circulation, although the inhibition of microparticle
formation was less. CONCLUSION: The inhibition of both platelet adhesion and
thrombin may be effective to preserve platelet number and function during
cardiopulmonary bypass circulation.

World J Surg. 2003 Aug 21 [Epub ahead of print].  

Relation of Cytokines to Vasodilation after Coronary Artery Bypass Grafting.

Wei M, Kuukasjarvi P, Laurikka J, Kaukinen S, Honkonen EL, Metsanoja R, Tarkka
M.

Division of Cardiovascular Surgery, University of Tampere, PO Box 2000,
Fin-33521 Tampere, Finland.

Hemodynamic instability is frequent after coronary surgery. The present study
tested the hypothesis that inflammation, as determined by circulating cytokine
levels, may contribute to the difficulty of controlling arterial blood pressure
after coronary artery bypass grafting. A group of 44 male patients undergoing
elective coronary artery bypass grafting with cardiopulmonary bypass were
studied. Plasma levels of tumor necrosis factor-alpha, interleukin-6 (IL-6),
IL-8, and IL-10 were measured before anesthesia induction, 5 minutes and 1 hour
after reperfusion to the myocardium, and 2 and 18 hours after arriving in the
intensive care unit (ICU). The 29 patients who did not need a vasopressor
(norepinephrine) during their ICU stay were designated group I. They were
compared to group II, which consisted of 15 patients who required a pressor
agent in the ICU. Although no significant differences between groups were found
regarding their hemodynamic variables, IL-6 and IL-8 levels were higher in the
patients who used a pressor agent in the ICU. The norepinephrine dosage used in
the ICU correlated with plasma IL-8 levels 2 hours after arriving in the ICU ( r
= 0.56, p = 0.031). Circulating IL-6 levels in group II were significantly
higher than those in group I 2 hours after arriving in the ICU (126.5 +/- 90.5
vs. 66.5 +/- 48.2 pg/ml; p < 0.05). The mean IL-8 levels were higher in group II
at 5 minutes (34.9 +/- 25.7 vs. 17.3 +/- 11.3 pg/ml) and 1 hour (38.6 +/- 30.5
vs. 22.4 +/- 16.7 pg/ml) after reperfusion, and 2 hours (33.0 +/- 21.6 vs. 22.8
+/- 16.7 pg/ml) after arriving in the ICU ( p = 0.036). Postoperative
vasodilation was associated with increased circulating IL-8 levels. Strategies
that modulate cytokine responses may improve hemodynamic stability after
coronary artery bypass grafting.

Artif Organs. 2003 Aug;27(8):676-680.  

Decreased 2,3-Diphosphoglycerate Concentration in Low Cardiac Output Patients
and Its Influence on the Determination of In Vivo P50.

Piccioni MA, Cestari IA, Strunz CM, Auler JO.

Department of Anesthesiology, Bioengineering Division, and Biochemistry
Laboratory of the Heart Institute (InCor), University of Sao Paulo Medical
School, Sao Paulo, SP, Brazil.

We investigated whether 2,3-diphosphoglycerate (2,3-DPG) is altered in patients
with low cardiac output and the influence of its concentration on the
calculation of in vivo P50. Biochemical and blood gas analysis were performed
along with the measurement of cardiac output and body temperature in 13 patients
submitted to cardiopulmonary bypass surgeries without the use of donor blood. In
vivo P50 was calculated using the measured (P50m) and the estimated 2,3-DPG
(P50e). 2,3-DPG concentration was lower in these patients when compared to the
values obtained in normal volunteers (6.9 +/- 2.2 vs. 11.9 +/- 2.4
micromol/gHb). P50m was lower than P50e (21.6 +/- 1.1 vs. 30.1 +/- 1.2 mm Hg) at
all time points. Our data show that in patients with low cardiac output, 2,3-DPG
concentration is reduced. Therefore, in these patients, the use of standard
values for this variable may introduce an error in the calculation of in vivo
P50.

Ann Thorac Surg. 2003 Aug;76(2):638-48.  

Heparin-induced thrombocytopenia and cardiac surgery.

Warkentin TE, Greinacher A.

Department of Pathology and Molecular Medicine, McMaster University, Hamilton,
Ontario, Canada. twarken@mcmaster.ca

Unfractionated heparin given during cardiopulmonary bypass is remarkably
immunogenic, as 25% to 50% of postcardiac surgery patients develop
heparin-dependent antibodies during the next 5 to 10 days. Sometimes, these
antibodies strongly activate platelets and coagulation, thereby causing the
prothrombotic disorder, heparin-induced thrombocytopenia. The risk of
heparin-induced thrombocytopenia is 1% to 3% if unfractionated heparin is
continued throughout the postoperative period. When cardiac surgery is urgently
needed for a patient with acute or subacute heparin-induced thrombocytopenia,
options include an alternative anticoagulant (bivalirudin, lepirudin, or
danaparoid) or combining unfractionated heparin with a platelet antagonist
(epoprostenol or tirofiban). As heparin-induced thrombocytopenia antibodies are
transient, unfractionated heparin alone is appropriate in a patient with
previous heparin-induced thrombocytopenia whose antibodies have disappeared.

Ann Thorac Surg. 2003 Aug;76(2):576-80.  

Early postoperative prediction of cerebral damage after pediatric cardiac
surgery.

Trittenwein G, Nardi A, Pansi H, Golej J, Burda G, Hermon M, Boigner H, Wollenek
G; Verein zur Durchfuhrung wissenschaftlichter Forschung auf dem Gebeit der
Neonatologie und Padiatrischen Intensivmedizin.

Department of Neonatology and Pediatric Critical Care, PICU, and the ECMO
Project, University of Vienna, Austria. g.trittenwien@a1.net

BACKGROUND: Cerebral damage is a serious complication of pediatric cardiac
surgery. Early prediction of actual risk can be useful in counseling of parents,
and in early diagnosis and rehabilitation therapy. Also, if all children at risk
could be identified therapeutic strategies to limit perioperative cerebral
damage might be developed. The aim of this study is to create a mathematical
model to predict risk of neurologic sequelae within 24 hours after surgery using
simple and readily available clinical measurements. METHODS: The hospital
records of 534 children after cardiac surgery were reviewed. Variables examined
were age at operation, diagnosis, use of cardiopulmonary bypass, arterial and
central venous oxygen saturation, serum glucose, lactate and creatine kinase,
mean arterial pressure, and body temperature. The endpoint for each study
patient was the occurrence or lack of occurrence of seizures, movement or
developmental disorders, cerebral hemorrhage, infarction, hydrocephalus, or
marked cerebral atrophy. Univariate and multivariate regression analyses were
used to evaluate the predictive power of the investigated factors as well as to
create a predictive model. RESULTS: In 6.26% of children symptoms of cerebral
damage were found. Significant risk factors were age at surgery, more complex
malformations, metabolic acidosis, and increased lactate (odds ratio: age,
0.882/yr [0.772-1.008]; complex malformations, 10.32 [1.32-80.28]; arterial pH
more than 7.35 to 0.4 [0.18-0.89]; lactate -1.018 per mg/dL [1.006-1.03]).
CONCLUSIONS: It is possible to quantify the risk of appearance of symptoms of
cerebral damage after cardiac surgery within 24 hours using simple and readily
available clinical measurements.

Eur J Cardiothorac Surg. 2003 Aug;24(2):243-8.  

Modified ultrafiltration may not improve neurologic outcome following deep
hypothermic circulatory arrest.

Myung RJ, Kirshbom PM, Petko M, Golden JA, Judkins AR, Ittenbach RF, Spray TL,
Gaynor JW.

Division of Cardiothoracic Surgery, The Children's Hospital of Philadelphia,
34th Street and Civic Center Boulevard, Suite 8527, 19104, Philadelphia, PA, USA

OBJECTIVE: Modified ultrafiltration (MUF) improves systolic blood pressure and
left ventricular performance, as well as lowering transfusion requirements,
after cardiopulmonary bypass (CPB). MUF has also been shown to enhance acute
cerebral metabolic recovery after deep hypothermic circulatory arrest (DHCA),
but whether this improves neurologic outcome is unknown. METHODS: Sixteen
neonatal piglets underwent CPB and 90 min of DHCA. The hematocrit was maintained
between 25 and 30%. Alpha-stat blood gas management was used. After separation
from CPB, animals were randomized to 15 min of MUF (n=8) or no intervention
(n=8). Neurologic injury was assessed with behavior scores and histologic
examination. Standardized behavior scores were obtained on post-operative days
1, 3, and 6 (0=no deficit to 95=brain death). The percentage of injured neurons
by hematoxylin and eosin staining and the degree of reactive astrocytosis by
glial filbrillary acidic protein (GFAP) immunohistochemistry were assessed to
determine histologic scores in the neocortex and hippocampus (0=no injury to
4=diffuse injury). RESULTS: There were no statistically significant differences
between groups during CPB. After MUF, the hematocrit was significantly higher
(40%+/-5.7 vs. 28%+/-3.9, P<0.001). There were no significant differences in
behavior scores between groups (p>0.1). There was resolution of deficits by day
6 in all animals. Neuronal injury was present in 81% (13/16) of the animals with
no statistically significant differences between groups in incidence or
severity. CONCLUSIONS: Use of MUF after DHCA does not prevent neuronal injury or
improve neurologic outcome in this neonatal swine model.

Ann Thorac Surg. 2003 Aug;76(2):523-7.  

Impaired oxygenation and increased hemolysis after cardiopulmonary bypass in
patients with glucose-6-phosphate dehydrogenase deficiency.

Gerrah R, Shargal Y, Elami A.

Department of Cardiothoracic Surgery, Hebrew University, Hadassah Medical
School, Jerusalem, Israel. rgerrah@yahoo.com

BACKGROUND: The purpose of this study was to determine whether the damaging
effects of cardiopulmonary bypass, ischemia, and reperfusion would be more
pronounced in patients with glucose-6-phosphate dehydrogenase deficiency
undergoing cardiac surgery. METHODS: Forty-two patients with glucose-6-phosphate
dehydrogenase deficiency underwent open heart procedures using cardiopulmonary
bypass. This group was matched with a control group of identical size for
comparison of operative course and postoperative outcome. The perioperative
variables were compared between the two groups using univariate and multivariate
analysis. RESULTS: The duration of ventilation after the operation was
significantly longer in the glucose-6-phosphate dehydrogenase-deficient group
(13.7 +/- 7.6 hours versus 7.7 +/- 2.8 hours; p < 0.0001). Minimal value of
arterial oxygen tension was lower in patients with glucose-6-phosphate
dehydrogenase deficiency (66 +/- 12 mm Hg versus 85 +/- 14 mm Hg; p < 0.0001),
and more cases of hypoxia (arterial oxygen tension < 60 mm Hg) were found in
this group (11 versus 1; p = 0.001). Compared with the control group, patients
with glucose-6-phosphate dehydrogenase deficiency had significantly elevated
hemolytic indices expressed by bilirubin levels (26 +/- 10 mmol/L versus 17 +/-
6.7 mmol/L; p < 0.0001) and lactic dehydrogenase levels (970 +/- 496 U/L versus
505 +/- 195 U/L; p < 0.0001). They also required significantly more blood
transfusion perioperatively (1.9 +/- 1.4 packed cell units/patient versus 0.8
+/- 1.0 packed cell units/patient; p = 0.0001). CONCLUSIONS: Patients with
glucose-6-phosphate dehydrogenase deficiency who are undergoing cardiac surgery
may have a more complicated course with a longer ventilation time, more hypoxia,
increased hemolysis, and a need for more blood transfusion. Because this
difference may be caused by subnormal free radical deactivation, strategies that
minimize bypass in general and free radicals specifically may be beneficial.