Ann Thorac Surg  2002 Sep;74(3):660-3; discussion 663-4 

Minimally invasive mitral valve surgery: a 6-year experience with 714 patients.

Grossi EA, Galloway AC, LaPietra A, Ribakove GH, Ursomanno P, Delianides J,
Culliford AT, Bizekis C, Esposito RA, Baumann FG, Kanchuger MS, Colvin SB.

Department of Surgery, New York University School of Medicine, New York 10016,
USA. grossi@cv.med.nyu.edu

BACKGROUND: This study analyzes a single institutional experience with minimally
invasive mitral valve operations of 6 years, reviewing short-term morbidity and
mortality and long-term echocardiographic follow-up data. METHODS: Seven hundred
fourteen consecutive patients had minimally invasive mitral valve procedures
between November 1995 and November 2001; concomitant procedures included 91
multiple valves and 18 coronary artery bypass grafts. Of these 714 patients, 561
patients had isolated mitral valve operations (375 repairs, 186 replacements).
Mean age was 58.3 years (range, 14 to 96 years; 30.1% > 70 years), and 15.4% of
patients had previous cardiac operations. Arterial cannulation was femoral in
79.0% and central in 21%, with the port access balloon endo-occlusion used in
82.3%. Cardioplegia was transjugular retrograde (54.1%) or antegrade (29.4%).
Right anterior minithoracotomy was used in 96.6% and left posterior
minithoracotomy in 2.2%. RESULTS: Hospital mortality for primary isolated mitral
valve repair was 1.1% and 5.8% for isolated mitral valve replacement. Overall
hospital mortality was 4.2% (30 of 714). Mean cross-clamp time was 92 minutes
and mean cardiopulmonary bypass time was 127 minutes. Postoperatively, median
ventilation time was 11 hours, intensive care unit time was 19 hours, and total
hospital stay was 6 days. Complications for all patients included permanent
neurologic deficit (2.9%), aortic dissection (0.3%); there was no mediastinal
infection (0.0%). Follow-up echocardiography demonstrated 89.1% of the repair
patients had only trace or no residual mitral insufficiency. CONCLUSIONS: This
study demonstrates that the minimally invasive port access approach to mitral
valve operations is reproducible with low perioperative morbidity and mortality
and with late outcomes that are equivalent to conventional operations.

AORN J  2002 Sep;76(3):467-76, 481-6, 488-9 

Monitoring bladder temperatures in the OR.

Fallis WM.

School of Nursing, University of Washington, Seattle, USA.

Temperature monitoring via the urinary bladder has become common in the OR,
often replacing monitoring at the rectal site. A systematic, integrated review
and synthesis of the literature was undertaken to assess the validity of using
the urinary bladder as a site for temperature measurement in the OR. During
steady thermal states, bladder temperature performed well, providing
temperatures similar to those of core sites. In contrast, poor performance was
demonstrated during rapid thermal changes, such as during the rapid cooling and
rewarming phases of cardiopulmonary bypass. At such times, a significant lag in
response rate at the bladder site was noted by multiple investigators. This
delayed responsiveness during thermally dynamic states, however, may provide
information regarding the adequacy of rewarming during bypass at sites
intermediate between the core and periphery. Limited research indicates that
urinary bladder temperature may be influenced by urine flow rate, and additional
research is required in this area. The cost effectiveness of this method of
temperature measurement requires investigation as well.

Chest  2002 Sep;122(3):1061-6 

Catastrophic cardiovascular adverse reactions to protamine are nitric
oxide/cyclic guanosine monophosphate dependent and endothelium mediated(*) :
should methylene blue be the treatment of choice?

Viaro F, Dalio MB, Evora MD PR.

Division of Experimental Surgery, Ribeirao Preto School of Medicine, University
of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil.

Clinical and experimental observations prove that heparin-neutralizing doses of
protamine increase pulmonary artery pressures and decrease systemic BP.
Protamine also increases myocardial oxygen consumption, cardiac output, and
heart rate, and decreases systemic vascular resistance. These cardiovascular
effects have clinical consequences that have justified studies in this area.
Protamine adverse reactions usually have three different categories: systemic
hypotension, anaphylactoid reactions, and catastrophic pulmonary
vasoconstriction. The precise mechanism that explains protamine-mediated
systemic hypotension is unknown. Four experimental protocols performed at Mayo
Clinic, Rochester, MN, studied the intrinsic mechanism of protamine
vasodilation. The first study reported in vitro systemic and coronary
vasodilation after protamine infusion. The second in vitro study suggested that
the pulmonary circulation is extensively involved in the protamine-mediated
effects on endothelial function. The third study, carried out in anesthetized
dogs, reported the methylene blue and nitric oxide synthase blockers
neutralization of the protamine vasodilatatory effects. The fourth study
suggested that protamine also causes endothelium-dependent vasodilation in heart
microvessels and conductance arteries by different mechanisms including
hyperpolarization. Reviewing these experimental results and our clinical
experience, we suggest methylene blue as a novel approach to prevent and treat
hemodynamic complications caused by the use of protamine after cardiopulmonary
bypass. In the absence of prospective clinical trials, a growing body of
cumulative clinical evidence suggests that methylene blue may be strongly
considered as a therapeutic approach in the treatment of distributive shock.

Arch Neurol  2002 Sep;59(9):1422-8 

Encephalopathy and stroke after coronary artery bypass grafting: incidence,
consequences, and prediction.

McKhann GM, Grega MA, Borowicz LM Jr, Bechamps M, Selnes OA, Baumgartner WA,
Royall RM.

Zanvyl Krieger Mind/Brain Institute, The Johns Hopkins University, 338 Krieger
Hall, 3400 N Charles St, Baltimore, MD 21218-2685. Guy.Mckhann@jhu.edu

BACKGROUND: In contrast to perioperative stroke, much less attention has been
paid to those with evidence of diffuse brain encephalopathy, presenting as
delirium, confusion, coma, and seizures in the immediate postoperative period.
OBJECTIVE: To determine the incidence, consequences, and predictive factors for
encephalopathy and stroke following coronary artery bypass grafting. METHODS: In
a prospective evaluation of 2711 patients operated on between January 1, 1997,
and December 31, 2000, preoperative risk factors were obtained before surgery
and postoperative outcomes, encephalopathy and stroke, were determined on a
daily basis. All strokes were confirmed by neurologic consultation and, in most
instances, by imaging. Logistic regression analyses were performed to determine
risk factors for these outcomes. RESULTS: The incidence of encephalopathy was
6.9% and of stroke, 2.7%. For patients without either of these outcomes, the
average length of stay in the hospital was 6.6 days and the mortality was 1.4%.
In contrast, patients with encephalopathy had a length of stay of 15.2 days and
a mortality of 7.5%, and those with stroke, a length of stay of 17.5 days and a
mortality of 22.0%. Predictive models were developed for encephalopathy
involving 5 preoperative factors (age, past stroke, carotid bruit, hypertension,
and diabetes) and 1 perioperative factor (time on cardiopulmonary bypass). The
model for stroke involved only 3 preoperative risk factors (past stroke,
hypertension, and diabetes). CONCLUSIONS: Encephalopathy or stroke is associated
with significant increases in length of stay and mortality after coronary artery
bypass grafting. Patients at higher risk for these outcomes can be identified
before surgery.

Anesthesiology  2002 Sep;97(3):585-91 

Clinical trial of the neuroprotectant clomethiazole in coronary artery bypass
graft surgery: a randomized controlled trial.

Kong RS, Butterworth J, Aveling W, Stump DA, Harrison MJ, Hammon J, Stygall J,
Rorie KD, Newman SP.

Health Psychology Unit, Academic Department of Psychiatry & Behavioural
Sciences, Reta Lila Weston Institute of Neurological Studies, Royal Free and
University College London Medical School, United Kingdom.

BACKGROUND: The neuroprotective property of clomethiazole has been demonstrated
in several animal models of global and focal brain ischemia. In this study the
authors investigated the effect of clomethiazole on cerebral outcome in patients
undergoing coronary artery bypass surgery. METHODS: Two hundred forty-five
patients scheduled for coronary artery bypass surgery were recruited at two
centers and prospectively randomized to clomethiazole edisilate (0.8%), 225 ml
(1.8 mg) loading dose followed by a maintenance dose of 100 ml/h (0.8 mg/h)
during surgery, or 0.9% NaCl (placebo) in a double-blind trial. Coronary artery
grafting was completed during moderate hypothermic (28-32 degrees C)
cardiopulmonary bypass. Plasma clomethiazole was measured at several intervals
during and up to 24 h after the end of infusion. A battery of eight
neuropsychological tests was administered preoperatively and repeated 4-7 weeks
after surgery. Analysis of the change in neuropsychological test scores from
baseline was used to determine the effect of treatment. RESULTS:
Neuropsychological assessments were completed in 219 patients (110
clomethiazole; 109 placebo). The mean plasma concentration of clomethiazole
during surgery was 66.2 microm. There was no difference between the
clomethiazole and placebo group in the postoperative change in
neuropsychological test scores. CONCLUSION: Clomethiazole did not improve
cerebral outcome following coronary artery bypass surgery.

World J Urol  2002 Sep;20(4):227-31 

The impact of extracorporal circulation on therapy-related mortality and
long-term survival of patients with renal cell cancer and intracaval neoplastic
extension.

Kuczyk MA, Munch T, Machtens S, Grunewald V, Jonas U.

Department of Urology, Hanover University Medical School, Carl-Neuberg-Str. 1,
30625 Hanover, Germany, kuczyk.markus@mh-hannover.de

In approximately 4%-10% of patients presenting with renal cell cancer, the
transluminal propagation of a tumour thrombus into the vena cava inferior or the
right atrium comes to diagnosis. Recent investigations have indicated that the
presence of neoplastic extension into the venous system does not reveal
independent prognostic value regarding the clinical course of the disease.
Although the complete surgical removal of vena cava thrombosis in patients
without simultaneously occurring regional lymph node or distant metastases has
become a well established treatment modality, several questions concerning this
surgical strategy still remain the subject of ongoing discussions. In the
present investigation that included 92 patients with renal cell cancer and
intracaval neoplastic extension, it was clearly demonstrated that using
cardiopulmonary bypass, deep hypothermia and circulatory arrest - preferably,
during the removal of intracaval thrombosis extending into the right atrium -
does not result in a substantially increased treatment-related intra- or
postoperative mortality. However, in contrast to a previously reported
observation, this treatment option did not reveal any substantial impact on the
long-term survival of the patients following surgical therapy. Accordingly, the
cranial extension of intracaval thrombosis was not identified as a biological
variable of any prognostic importance for renal cell cancer patients.

Vet Surg  2002 Sep-Oct;31(5):412-7 

Cardiopulmonary bypass in the cat.

Brourman JD, Schertel ER, Holt DW, Olshove VA.

Ohio State University College of Veterinary Medicine; MedVet Associates, Inc;
the Department of Circulation Technology, The Ohio State University; and
Children's Hospital, Columbus, OH.

OBJECTIVE-To assess the physiologic response to, and acute survival of, cats
undergoing cardiopulmonary bypass (CPB) and to evaluate the efficacy of a
commercial human pediatric oxygenator system on cats weighing less than 6 kg.
Study Design-Experimental study. ANIMALS-Six intact male cats METHODS-Cats were
placed on cardiopulmonary bypass by cannulating the cranial and caudal vena
cavae and the carotid artery. The pediatric CPB circuit was primed with 150 mL
of a balanced crystalloid solution. Venous drainage was enhanced by a
controlled, vacuum-assist system. A cross-clamp was placed on the ascending
aorta and cardiac arrest was induced by antegrade infusion of a cold
cardioplegia solution. After 45 minutes of arrest time, the cross-clamp was
removed and the cats were weaned off bypass and decannulated. No blood products
were administered. Heart rate, mean arterial pressure (MAP), central venous
pressure, arterial blood gas, hematocrit (HCT), total plasma protein
concentration (TP), serum electrolyte concentrations, and activated clotting
time (ACT) were measured at baseline period (BL), during CPB, 60 minutes after
CPB (CPB 60) and 90 minutes after CPB (CPB 90). A complete blood count (CBC),
blood chemistry profile, and urinalysis were performed at BL, during CPB, and
CPB 90. Cats were euthanatized after CPB 90. RESULTS-Cardiopulmonary bypass
resulted in a significant (P <.05) decrease in mean HCT (18.0%) and TP (2.3
gm/dL) at CPB 90 when compared to BL (30.5% and 6.0 gm/dL, respectively). The
MAP at CPB 90 (54 mm Hg) was decreased from BL (94 mm Hg). The ACT increased
from a mean of 124 seconds to > 400 seconds with heparinization and was reversed
to 300 seconds with protamine. Mean platelet counts decreased from BL (369,000
/uL) to CPB 90 (94,500 /uL). Mean white blood cell counts decreased from 13,200
/uL at BL to 2,200 /uL at CPB 90. Upon reperfusion, 1 cat fibrillated but was
successfully defibrillated. CONCLUSIONS-Cardiopulmonary bypass was performed
successfully in 6 cats weighing less than 6 kg. Acute survival to 90 minutes
after CPB was achieved in all 6 cats CLINICAL RELEVANCE-The ability to perform
CPB in the cat may allow intracardiac repair of various heart defects in this
species. Copyright 2002 by The American College of Veterinary Surgeons

Eur J Cardiothorac Surg  2002 Sep;22(3):402 

Warm retrograde blood cardioplegia saves more ischemic myocardium but may cause
a functional impairment compared to cold crystalloid.

Elvenes O, Korvald C, Myklebust R, Sorlie D.

Department of Cardiothoracic and Vascular Surgery, Faculty of Medicine,
University of Tromso, N-9038, Tromso, Norway

OBJECTIVES: Ongoing ischemia, or even ischemia in progress, is regularly
encountered in today's patients amenable to cardiac surgery. We set out to
assess the effect of 'active resuscitation' during cardioplegia with warm
continuous retrograde blood cardioplegia (WB) in a protocol simulating a
clinical situation. METHODS: After 60min with a regional ischemic injury to the
left ventricle, 21 pigs were randomized to receive no treatment (control), cold
retrograde intermittent crystalloid cardioplegia (CC) or WB. All animals were
put on cardiopulmonary bypass. After 1h of cardioplegia and 1h of reperfusion
the perfused left ventricle was colored with methylene blue. After excision of
the hearts a standard planimetri technique was used to determine the area at
risk and amount of necrosis (triphenyltetrazolium). Heart rate, mean arterial
pressure (MAP), cardiac output and myocardial blood flow were recorded as well
as myocardial oxygen consumption, plasma levels of free fatty acids, glucose,
lactate and Troponin T from the coronary sinus. RESULTS: The area at risk of the
left ventricle was 13.6+/-1.2%. We found 71+/-2, 61+/-3 and 30+/-2% necrosis of
the area at risk in the controls, CC and WB, respectively (P<0.001, CC versus
control and P<0.0001, WB against CC and control). Troponin T release was highest
in the CC group in the reperfusion period. Glucose levels increased
significantly after ischemia in the controls and WB. In accordance with the
amount of saved myocardium in the WB group which also had a normal coronary
sinus lactate level as opposed to the fourfold increase in the CC group after
ischemia. After standstill cardiac output and MAP were significantly lower than
baseline values in the WB group only (P<0.05). CONCLUSIONS: CC did reduce the
size of the infarction by about 10% compared to control animals, whereas WB
reduced the infarction by more than 50% of that seen after CC. Both modalities
are, however, associated with a functional reduction during the first 60min of
reperfusion, WB being the worst.

J Thorac Cardiovasc Surg  2002 Sep;124(3):448-58 

Long-term neurodevelopmental outcomes in school-aged children after neonatal
arterial switch operation.

Hovels-Gurich HH, Seghaye MC, Schnitker R, Wiesner M, Huber W, Minkenberg R,
Kotlarek F, Messmer BJ, Von Bernuth G.

Departments of Pediatric Cardiology, Neurolinguistics, Pediatric Neurology, and
Thoracic and Cardiovascular Surgery, Aachen University of Technology, and the
Institute for Medical Research and Information Processing, Repges & Partner,
Aachen, Germany.

OBJECTIVE: Neurodevelopmental status of children between 8 and 14 years of age
after neonatal arterial switch operation for transposition of the great arteries
has not previously been systematically evaluated. METHODS: Within a longitudinal
study, 60 unselected children operated on as neonates with combined deep
hypothermic circulatory arrest and low-flow cardiopulmonary bypass were
reevaluated at the age of 7.9 to 14.3 years (mean +/- SD 10.5 +/- 1.6 years).
Clinical neurologic status and standardized tests to assess gross motor
function, intelligence, acquired abilities, language, and speech were carried
out, and the results were related to preoperative, perioperative, and
postoperative status, to management, and to neurodevelopmental status at a mean
age of 5.4 years. RESULTS: Neurologic and speech impairments were evidently more
frequent (27% and 40%, respectively) than in the general population.
Intelligence and socioeconomic status were not different (P =.29 and P =.11),
whereas motor function, acquired abilities, and language were reduced (P </=.04
for each). Overall rate of developmental impairment in one or more domains was
55%, compared with 26% at age 5.4 years. Multivariable analysis showed that
severe preoperative acidosis and hypoxia predicted reduced motor function (mean
deficit 52.7 points, P <.001), whereas longer bypass duration predicted both
neurologic (odds ratio per 10 minutes of bypass duration 1.8, P =.04) and speech
(odds ratio per 10 minutes of bypass duration 1.9, P =.02) dysfunction, and
perioperative and postoperative cardiocirculatory insufficiency predicted
neurologic (odds ratio 6.5, P =.04) and motor (mean deficit 6.8 points, P =.03)
dysfunction. CONCLUSIONS: The neonatal arterial switch operation with combined
circulatory arrest and low-flow bypass is associated increasingly with age, with
reduced neurodevelopmental outcome but not with cognitive dysfunction. In our
experience, the risk of long-term neurodevelopmental impairment after neonatal
corrective cardiac surgery is related to deleterious effects of the global
perioperative management and to special adverse effects of prolonged bypass
duration. Severe preoperative acidosis and hypoxia and postoperative hemodynamic
instability must be considered as important additional risk factors.