J Heart Lung Transplant.  2004 Aug;23(8):948-53.  

Heart transplantation to a physiologic single lung in patients with congenital
heart disease.

Lamour JM, Hsu DT, Quaegebeur JM, Pinney SP, Mital SR, Mosca RS, Chen JM,
Addonizio LJ.

Division of Pediatric Cardiology, Columbia University College of Physicians and
Surgeons, New York, NY, USA. jml14@columbia.edu

BACKGROUND: Heart-lung transplantation has been recommended for patients with
end-stage congenital heart disease (CHD) and single-lung physiology due to
either discontinuous pulmonary arteries (PAs) and unilateral PA hypertension
(HTN) or absence of 1 PA. METHODS: Eleven patients with CHD and single-lung
physiology underwent heart transplantation (HT). Diagnoses included: tetralogy
of Fallot, absent left PA (n = 4); single-ventricle s/p classic Glenn (n = 7),
with absent left PA (n = 1); and severe left PA HTN (n = 6). RESULTS: Mean time
from last surgery was 13 +/- 8 years; mean number of operations (op) was 3.2 +/-
1.7. Mean age was 21 +/- 11 years (range 9.5 to 43). Complications and
procedures before HT included hemoptysis (n = 2), plastic bronchitis (n = 1) and
interventional catheterization (n = 6). Mean cardiopulmonary bypass and ischemic
time was 275 +/- 72 and 268 +/- 75 minutes, respectively. Mean time to
extubation was 4.6 +/- 3.2 days, and mean length of stay was 19 +/- 7 days.
Post-operative morbidity included bleeding (n = 4), vocal cord paralysis (n = 1)
and coil embolization of aortopulmonary collaterals (n = 3). Early
post-operative survival was 82%. Cause of death was aortic rupture (n = 1) and
bleeding (n = 1). Eight patients are alive 4 years (range 0.9 to 7.6) after HT.
PA continuity was established in 6 patients; post-HT lung perfusion scan showed
no increase in perfusion to the left PA. One patient died from rejection 3 years
post-HT. CONCLUSIONS: HT can be performed successfully in patients with
single-lung physiology. HT is the procedure of choice in patients with end-stage
CHD and a physiologic single lung.

Can J Anaesth.  2004 Aug;51(7):712-717.  

Propofol offers no advantage over isoflurane anesthesia for cerebral protection
during cardiopulmonary bypass: a preliminary study of S-100{beta} protein
levels: [L'anesthesie au propofol, compare a l'isoflurane, n'a pas d'avantage
pour la protection cerebrale pendant la circulation extracorporelle : une etude
preliminaire des niveaux de proteines S-100{beta}].

Kanbak M, Saricaoglu F, Avci A, Ocal T, Koray Z, Aypar U.

Department of Anesthesiology and Reanimation, Hacettepe University, Faculty of
Medicine, 06100 Ankara, Turkey. orhankan@ttnet.net.tr

PURPOSE: Despite advances in anesthesia, cardiopulmonary bypass (CPB) and
surgical techniques, cerebral injury remains a major source of morbidity after
cardiac surgery. We compared the effects of two different anesthetic techniques,
isoflurane vs propofol on neurological outcome by serum S-100ss protein and
neuropsychological tests after coronary artery bypass grafting (CABG). METHODS:
Twenty patients undergoing CABG, randomly allocated into two groups, were
enrolled in this prospective, controlled, preliminary study. Isoflurane was used
in group I and propofol in group P. Neurological examination and a
neuropsychologic test battery consisting of the mini mental state examination
(MMSET) and the visual aural digit span test (VADST) were obtained
preoperatively and on the third and sixth postoperative days. Blood samples for
analysis of S-100ss protein were collected before anesthesia (T1), after
heparinization (T2), 15 min into CPB (T3), after CPB (T4) and at the 24(th) hr
postoperatively (T5). RESULTS: Postoperative neurological examinations of the
patients were normal. VADST performance declined significantly on the third day
(P < 0.05) in both groups, and there were no significant differences on VADST
and MMSET scores between the two groups. In group P, S-100ss protein levels
increased significantly at T3 and T4 compared to preoperative and isoflurane
levels (P < 0.05). CONCLUSIONS: Despite reports about the neuroprotective
effects of propofol, S-100ss protein levels were significantly elevated in group
P. Although there was no deterioration in neuropsychological outcome, propofol
appeared to offer no advantage over isoflurane for cerebral protection during
CPB in this preliminary study of 20 patients.

Surgery.  2004 Aug;136(2):190-8.  

Determinants of regional myocardial acidosis during cardiac surgery.

Kumbhani DJ, Healey NA, Birjiniuk V, Crittenden MD, Josa M, Treanor PR, Khuri
SF.

Surgical Service, VA Boston Healthcare System, Harvard Medical School, and
Brigham and Women's Hospital, Boston, MA 02132,USA.

BACKGROUND: Intraoperative regional myocardial acidosis (RMA) during cardiac
surgery has been shown to be reflective of regional myocardial ischemia and an
independent predictor of adverse postoperative outcomes. This study identifies
the determinants of intraoperative RMA. METHODS: Intramyocardial tissue pH(37C)
in the anterior and posterior LV walls was measured in 641 adult patients during
cardiac surgery. RMA at two intraoperative periods was quantified as integrated
mean pH(37C) < 6.35 during aortic clamping (AC) and pH(37C) < 6.73 at the end of
cardiopulmonary bypass (CPB). These pH thresholds were chosen because of their
demonstrated relationship to long-term patient survival. Multivariate logistic
regression models were constructed. An acidosis prediction score was constructed
based on the factors determining RMA at the end of CPB. RESULTS: Independent
determinants of RMA during AC were preoperative New York Heart Association class
III/IV (P = .007), current smoker (P = .0088), pH(37C) < 6.63 prior to AC (P <
.0001), and intraoperative myocardial management technique (P = .0001).
Independent determinants of RMA at end of CPB were ASA class IV/V (P = .0042),
pH(37C) < 6.63 prior to AC (P = .035), pH(37C) < 6.35 during AC (P = .001), and
total duration of CPB > or = 212 minutes (P = .001). CONCLUSIONS: RMA during
cardiac surgery is determined by patient risk factors, the magnitude of
preceding regional myocardial acidosis, and the duration of CPB. Copyright 2004
Elsevier Inc.

Eur J Cardiothorac Surg.  2004 Aug;26(2):311-7.  

Prophylactic tranexamic acid in elective, primary coronary artery bypass surgery
using cardiopulmonary bypass.

Andreasen JJ, Nielsen C.

Department of Cardiothoracic Surgery, Aalborg University Hospital, University of
Aarhus, Hobrovej, Postboks 365, DK-9100 Aalborg, Denmark. jjandreasen@dadlnet.dk

OBJECTIVE: Perioperative use of tranexamic acid (TA), a synthetic
antifibrinolytic drug, decreases perioperative blood loss, and the proportion of
patients receiving blood transfusion in cardiac surgery, but the results may
vary in different clinical settings. The primary objective of the present study
was to determine the efficacy of TA to decrease chest tube drainage and the
proportion of patients requiring perioperative allogeneic transfusions following
primary, elective, on-pump coronary artery bypass grafting (CABG) in patients
with a low baseline risk of postoperative bleeding. METHODS: In a
double-blinded, prospective, placebo-controlled study, 46 patients were
randomized into two groups. One group received TA 1.5 g as a bolus, followed by
a constant infusion of 200 mg/h until 1.5 g. The other group received placebo
(0.9% saline). Among exclusion criteria were treatment with acetylsalicylic
acid, non-steroidal anti-inflammatory drugs or other platelet inhibitors within
7 days before surgery. RESULTS: Preoperative demographics, biochemical and
surgical characteristics were comparable between groups. At 6 h postoperatively,
there was a trend towards a greater blood loss (median and interquartile range)
in the placebo group (710 and 460-950 ml) compared to the TA group (400 and
350-550 ml), but the difference did not reach statistical significance. Neither
were transfusion rates and the amount of autotransfused shed mediastinal blood
different between the groups postoperatively. Postoperative d-dimer
concentrations were significantly higher in the placebo group compared to the TA
group (P < 0.001) This difference could not be explained by differences in the
amount of autotransfused shed mediastinal blood alone. Plasma concentrations of
beta-thromboglobulin and platelet factor 4 were significantly increased
postoperatively in both groups, but without any intergroup differences. Seven
patients (15%), one in the TA group and six in the placebo group, were
reoperated due to excessive bleeding. Surgical correctable bleeding was found in
all except two patients from the placebo group. CONCLUSIONS: An antifibrinolytic
effect following prophylactic use of TA in elective, primary CABG among patients
with a low risk of postoperative bleeding, did not result in any significant
decrease in postoperative bleeding compared to a placebo group.

Clin Gastroenterol Hepatol.  2004 Aug;2(8):719-23.  

Predicting outcome after cardiac surgery in patients with cirrhosis: a
comparison of Child-Pugh and MELD scores.

Suman A, Barnes DS, Zein NN, Levinthal GN, Connor JT, Carey WD.

Department of Gastroenterology, Cleveland Clinic Foundation, Ohio, USA.

BACKGROUND & AIMS: This study aims to quantify the risk of cardiac surgery in
patients with cirrhosis. METHODS: Records of all adult patients with cirrhosis
undergoing cardiac surgery using cardiopulmonary bypass at the Cleveland Clinic
(Cleveland, OH) from January 1992 to June 2002 were analyzed for any
relationship of Child-Pugh class and/or score and Model for End-Stage Liver
Disease (MELD) score with outcome measures of hepatic decompensation and death
during the first 3 months after surgery. RESULTS: Forty-four patients underwent
coronary artery bypass grafting (16 patients), valve surgery (16 patients), a
combination of the 2 procedures (10 patients), or pericardiectomy (2 patients).
Twelve patients (27%) developed hepatic decompensation, and 7 patients (16%)
died. Proportions of hepatic decompensation were 3 of 31, 8 of 12, and 1 of 1
patients, and death, 1 of 31, 5 of 12, and 1 of 1 patients in Child-Pugh classes
A, B, and C, respectively. The association of hepatic decompensation and
mortality with Child-Pugh class, Child-Pugh score, and MELD score was
significant (P < 0.005). Areas under the receiver operating characteristic
curves for mortality were similar for Child-Pugh (0.84 +/- 0.09) and MELD scores
(0.87 +/- 0.09). A cutoff Child-Pugh score >7 was found to have a sensitivity
and specificity of 86% and 92% for mortality, with a negative predictive value
of 97% (95% confidence interval [CI], 83-99) and positive predictive value of
67% (95% CI, 31-91), respectively. However, a similar cutoff value for MELD
score could not be established. CONCLUSIONS: Child-Pugh score and/or class and
MELD score are significantly associated with hepatic decompensation and
mortality after cardiac surgery using cardiopulmonary bypass in patients with
cirrhosis. Such surgery can be conducted safely in patients with a Child-Pugh
score </=7. Patients with a Child-Pugh score >/=8 have a significant risk for
mortality.

J Thorac Cardiovasc Surg.  2004 Aug;128(2):189-96.  

Recombinant hirudin enhances cardiac output and decreases systemic vascular
resistance during reperfusion after cardiopulmonary bypass in a porcine model.

Jormalainen M, Vento AE, Wartiovaara-Kautto U, Suojaranta-Ylinen R, Ramo OJ,
Petaja J.

Department of Cardiothoracic Surgery, Helsinki University Central Hospital,
University of Helsinki, Haartmaninkatu 4, FIN-00290 Helsinki, Finland.
mikko.jormalainen@hus.fi

OBJECTIVE: Cardiopulmonary bypass and surgical stress are accompanied by a
systemic inflammatory response and activation of coagulation. Thrombin forms
fibrin and activates platelets and neutrophils. Consequently, disseminated
microthrombosis might increase capillary vascular resistance and thus impair
reperfusion. We hypothesized that recombinant hirudin, a direct inhibitor of
thrombin, could attenuate coagulation and enhance microvascular flow during
reperfusion. METHODS: Twenty pigs undergoing 60 minutes of aortic clamping and
75 minutes of normothermic perfusion were randomized in a blinded setting to
receive an intravenous bolus of recombinant hirudin (10 mg, 0.4 mg/kg; n = 10)
or placebo (n = 10) 15 minutes before aortic declamping and then continued with
an intravenous 135-minute infusion of recombinant hirudin (3.75 mg/h, 0.15
mg/kg) or placebo. Thrombin-antithrombin complexes, activated clotting times,
and several hemodynamic parameters were measured before cardiopulmonary bypass,
after weaning from cardiopulmonary bypass, and at 30, 60, 90, and 120 minutes
after aortic declamping. Intramucosal pH and Pco(2) were measured from the
luminal surface of ileum simultaneously with arterial gas analysis at 30-minute
intervals. RESULTS: Recombinant hirudin inhibited thrombin formation after
aortic declamping; at 120 minutes, thrombin-antithrombin complexes levels
(microg/L, mean +/- SD) were 75 +/- 21 and 29 +/- 44 (P <.001) for placebo and
pigs receiving recombinant hirudin, respectively. When compared with the placebo
group, pigs receiving recombinant hirudin showed significantly higher stroke
volume, cardiac output, and lower systemic vascular resistance at 60 and 90
minutes after aortic declamping (P <.05). Based on arteriomucosal Pco(2) and pH
differences, progressive worsening of intestinal microcirculatory perfusion
occurred in the placebo group but not in the recombinant hirudin group.
CONCLUSION: Infusion of thrombin inhibitor recombinant hirudin during
reperfusion was associated with attenuated postischemia left ventricular
dysfunction and decreased vascular resistance. Consequently microvascular flow
was improved during ischemia-reperfusion injury. Control of thrombin formation
during reperfusion may be a feasible approach to improve oxygen delivery to
reperfused vascular beds.

Anesthesiology.  2004 Aug;101(2):327-39.  

Hemofiltration but not steroids results in earlier tracheal extubation following
cardiopulmonary bypass: a prospective, randomized double-blind trial.

Oliver WC Jr, Nuttall GA, Orszulak TA, Bamlet WR, Abel MD, Ereth MH, Schaff HV.

Mayo Medical School, Rochester, Minnesota, USA. oliver.william@mayo.edu

BACKGROUND: Activation of the inflammatory cascade is thought to account for
some of the respiratory dysfunction and prolonged mechanical ventilation
associated with cardiopulmonary bypass. The objective of this investigation was
to identify whether perioperative steroids or hemofiltration during
cardiopulmonary bypass, by their attenuation of inflammation, would reduce
duration of mechanical ventilation after cardiac surgery. METHODS: After
Institutional Review Board approval and informed consent, 192 patients scheduled
to undergo elective primary coronary artery bypass grafting or valvular
replacement or repair were randomized in a double-blind prospective study into
three groups. One group (Control) received saline at induction and at 6-h
intervals for four doses. Another group (Hemofil) received saline and
hemofiltration to obtain 27 ml/kg of hemofiltrate. The final group (Steroid)
received 1 g methylprednisolone before anesthesia induction and then 4 mg of
dexamethasone at 6-h intervals for four doses. All patients underwent
normothermic cardiopulmonary bypass and received propofol for postoperative
sedation. Separate two-sample comparisons were performed to compare each
experimental group versus the control group using the Wilcoxon rank sum test for
continuous variables and Fisher exact test for categorical variables. In all
cases, two-tailed P values </= 0.05 were considered statistically significant.
RESULTS: The median time until the patient reached an intermittent mandatory
ventilation of 4/min (258.5 versus 385.0 min, respectively; P = 0.02) and
tracheal extubation (352.0 versus 518.0 min; P = 0.03) was significantly reduced
for group Hemofil but no different for Steroid compared to Control. CONCLUSIONS:
Hemofiltration and steroids are both previously reported to attenuate the
inflammatory response but only hemofiltration reduced time to tracheal
extubation for adults after cardiopulmonary bypass in this study.

Anesthesiology.  2004 Aug;101(2):299-310.  

Cardioprotective properties of sevoflurane in patients undergoing coronary
surgery with cardiopulmonary bypass are related to the modalities of its
administration.

De Hert SG, Van der Linden PJ, Cromheecke S, Meeus R, Nelis A, Van Reeth V, ten
Broecke PW, De Blier IG, Stockman BA, Rodrigus IE.

Division of Cardiothoracic and Vascular Anesthesia, University Hospital Antwerp.
stefan.dehert@ua.ac.be

BACKGROUND: Experimental studies have related the cardioprotective effects of
sevoflurane both to preconditioning properties and to beneficial effects during
reperfusion. In clinical studies, the cardioprotective effects of volatile
agents seem more important when administered throughout the procedure than when
used only in the preconditioning period. The authors hypothesized that the
cardioprotective effects of sevoflurane observed in patients undergoing coronary
surgery with cardiopulmonary bypass are related to timing and duration of its
administration. METHODS: Elective coronary surgery patients were randomly
assigned to four different anesthetic protocols (n = 50 each). In a first group,
patients received a propofol based intravenous regimen (propofol group). In a
second group, propofol was replaced by sevoflurane from sternotomy until the
start of cardiopulmonary bypass (SEVO pre group). In a third group, propofol was
replaced by sevoflurane after completion of the coronary anastomoses (SEVO post
group). In a fourth group, propofol was administered until sternotomy and then
replaced by sevoflurane for the remaining of the operation (SEVO all group).
Postoperative concentrations of cardiac troponin I were followed during 48 h.
Cardiac function was assessed perioperatively and during 24 h postoperatively.
RESULTS: Postoperative troponin I concentrations in the SEVO all group were
lower than in the propofol group. Stroke volume decreased transiently after
cardiopulmonary bypass in the propofol group but remained unchanged throughout
in the SEVO all group. In the SEVO pre and SEVO post groups, stroke volume also
decreased after cardiopulmonary bypass but returned earlier to baseline values
than in the propofol group. Duration of stay in the intensive care unit was
lower in the SEVO all group than in the propofol group. CONCLUSION: In patients
undergoing coronary artery surgery with cardiopulmonary bypass, the
cardioprotective effects of sevoflurane were clinically most apparent when it
was administered throughout the operation.

Ann Thorac Surg.  2004 Aug;78(2):596-601.  

Nonneurologic morbidity and profound hypothermia in aortic surgery.

Harrington DK, Lilley JP, Rooney SJ, Bonser RS.

Cardiothoracic Surgical Unit, University Hospital Birmingham, Queen Elizabeth
Medical Centre, Birmingham, United Kingdom.

BACKGROUND: Use of profoundly hypothermic cardiopulmonary bypass may increase
the risk of postoperative bleeding and lung and renal dysfunction. The aim of
this study was to analyze postoperative blood loss and indices of pulmonary and
renal dysfunction in patients undergoing proximal aortic surgery with and
without the use of profound hypothermia to determine risk factors for
nonneurologic morbidity. METHODS: Risk factors for blood loss, transfusion
requirement, and pulmonary and renal dysfunction were studied in 116 patients
undergoing thoracic aortic surgery with profoundly or moderately hypothermic
cardiopulmonary bypass. RESULTS: Overall mortality was 8.6%. Mean (+/- standard
deviation) cardiopulmonary bypass times were 191 +/- 53 minutes (profoundly
hypothermic group) and 131 +/- 48 minutes (moderately hypothermic group; p <
0.0001). The incidence of blood loss more than 1 L or resternotomy for bleeding
was 25% (29 patients). Fifteen patients (12.9%) experienced postoperative
pulmonary dysfunction, and 25 patients (21.6%) had postoperative renal
dysfunction. Forty-one patients (35.3%) had a prolonged intensive therapy unit
length of stay. Multivariate analysis demonstrated that prolonged
cardiopulmonary bypass time was the only predictor of postoperative hemorrhage
and resternotomy for bleeding (p = 0.03). Increased intensive therapy unit
length of stay was predicted by total arch replacement (p = 0.01) and low 6-hour
ratio of partial pressure of arterial oxygen to inspired fraction of oxygen (p =
0.05). Increased preoperative creatinine (p = 0.002) and emergency status (p =
0.015) predicted postoperative renal dysfunction. Low 6-hour ratio of partial
pressure of arterial oxygen to inspired fraction of oxygen was predicted by
increased preoperative creatinine (p = 0.03) and prolonged cardiopulmonary
bypass time (p = 0.03). CONCLUSIONS: Profound hypothermia may cause a
coagulopathy, but procedure extent is the primary determinant of postoperative
bleeding. Profoundly hypothermic cardiopulmonary bypass does not appear to be a
risk factor for renal or early pulmonary dysfunction or intensive therapy unit
length of stay.