Am Heart J.  2004 Sep;148(3):393-8.  

The Triiodothyronine for Infants and Children Undergoing Cardiopulmonary Bypass
(TRICC) study: design and rationale.

Portman MA, Fearneyhough C, Karl TR, Tong E, Seidel K, Mott A, Cohen G, Tacy T,
Lewin M, Permut L, Schlater M, Azakie A.

Division of Cardiology, Department of Pediatrics, Children's Hospital and
Regional Medical Center, Seattle, Wash 98105, USA.
Michael.Portman@seattlechildrens.org

BACKGROUND: Cardiopulmonary bypass induces marked and persistent depression of
circulating thyroid hormones in infants and children, possibly contributing to
postoperative morbidity. Clinical studies have evaluated parenteral
triiodothyronine supplementation after cardiopulmonary bypass in children.
However, these investigations had relatively small subject numbers as well as
age and diagnosis heterogeneity, thereby limiting ability to determine clinical
effect. A double-blind, randomized, placebo-controlled trial is needed to define
clinical safety and efficacy of triiodothyronine supplementation in infants.
METHODS AND RESULTS: The Triiodothyronine for Infants and Children Undergoing
Cardiopulmonary Bypass (TRICC) study is a multicenter, randomized, clinical
trial designed to determine safety and efficacy of triiodothyronine
supplementation in children <2 years of age undergoing surgical procedures for
congenital heart disease. Duration of mechanical ventilation after completion of
cardiopulmonary bypass is the primary clinical outcome parameter with multiple
secondary clinical and hemodynamic parameters. Nearly 200 patients will be
randomly assigned to receive either triiodothyronine or placebo. Patient
assignment will be performed using a stratified block randomization according to
specific preoperative diagnosis. CONCLUSIONS: The TRICC study will provide
important data regarding the efficacy and safety of triiodothyronine in this
age-specific population undergoing surgery for congenital heart disease.

Curr Med Res Opin.  2004 Sep;20(9):1429-35.  

The effect of preoperative antiplatelet therapy in coronary artery surgery:
blood transfusion requirements for patients on cardiopulmonary bypass.

Hekmat K, Menzel C, Kroener A, Schwinger RH, Kampe S, Fischer UM, Geissler HJ,
Mehlhorn U.

Department of Thoracic and Cardiovascular Surgery, University of Cologne,
Germany.

INTRODUCTION: Bleeding after heart operations remains a common complication and
contributes to morbidity and death. Recent studies have suggested that
antiplatelet therapy (APT) may not increase homologous blood requirements in
coronary bypass surgery. The purpose of this study was to examine the influence
of APT therapy on haemorrhage and transfusion requirements in patients
undergoing coronary artery bypass (CABG) on cardiopulmonary bypass (CPB).
MATERIALS AND METHODS: Records from 290 consecutive patients who underwent CABG
with CPB were retrospectively reviewed, including 145 patients who received APT
within 5 days prior to surgery and 145 control patients (CON). Blood loss was
measured up to 24 h. Demographic and clinical patient data were collected until
hospital discharge. RESULTS: Both groups were well matched with respect to
demographic and intra-operative data. There was significantly (p < 0.0005) more
mediastinal tube drainage at 24 h in the APT group (1123 mL +/- 537 mL) compared
to CON patients (874 mL +/- 351 mL). In addition, the APT group received
significantly more units of blood (APT: 2.6 +/- 2.5 vs CON: 1.6 +/- 1.8; p <
0.0005), platelet units (APT: 1.2 +/- 1.8 vs CON: 0.2 +/- 0.8; p < 0.0005), and
fresh frozen plasma units (APT: 2.0 +/- 2.2 vs CON: 1.3 +/- 2.0; p = 0.01).
CONCLUSION: This study suggests consideration should be given to delaying
elective CABG for patients who have received APT treatment until APT is
discontinued for at least 5 days.

Br J Anaesth. 2004 Sep 17   [Epub ahead of print] 

Effect of dexamethasone on perioperative renal function impairment during
cardiac surgery with cardiopulmonary bypass.

Loef BG, Henning RH, Epema AH, Rietman GW, Van Oeveren W, Navis GJ, Ebels T.

Cardiothoracic Intensive Care Unit, University Hospital Groningen, Groningen,
The Netherlands.

BACKGROUND: In cardiac surgery with cardiopulmonary bypass (CPB),
corticosteroids are administered to attenuate the physiological changes caused
by the systemic inflammatory response. The effects of corticosteroids on
CPB-associated renal damage have not been documented. The purpose of this study
was to evaluate the effects of dexamethasone on perioperative renal dysfunction
in patients undergoing cardiac surgery with CPB. METHODS: Renal damage was
prospectively studied in 20 patients without concomitant morbidity undergoing
coronary artery surgery with CPB. Patients were randomized in a double-blind
fashion to receive dexamethasone or placebo. Markers of glomerular function
(creatinine clearance) and damage (microalbuminuria), and markers of tubular
function (fractional excretion of sodium and free water clearance) and damage
(N-acetyl-beta-D glucosaminidase (NAG)) were evaluated in addition to plasma and
urinary glucose levels. Plasma and urinary specimens were obtained at the
following time periods: (1) baseline, during the 12 h before surgery; (2) skin
incision before heparinization; (3) from heparinization until the end of CPB;
(4) during the 2 h following weaning from CPB; (5) in the intensive care unit
from 2 to 6 h after weaning of CBP; (6) and from 36 to 60 h after weaning of
CPB. RESULTS: CPB was associated with an increase in markers in the placebo
group, which returned to baseline during the second postoperative day,
demonstrating a transient impairment of glomerular and tubular renal function.
Similar patterns were observed in patients treated with dexamethasone. While
postoperative glycosuria was significantly higher in the dexamethasone-treated
group, no other differences between groups were observed. CONCLUSION:
Dexamethasone administration before CPB has no protective effect on
perioperative renal dysfunction in low-risk cardiac surgical patients.

Heart Vessels.  2004 Sep;19(5):225-9.  

Which patients can be weaned from inotropic support within 24 hours after
cardiac surgery?

Tsukui H, Koh E, Yokoyama S, Ogawa M.

Department of Cardiovascular Surgery, Kyoto Second Red Cross Hospital, Kyoto,
Japan, htsukui@wf7.so-net.ne.jp

Inotropic support after cardiac surgery is sometimes employed for a long period
without any definite criteria to wean patients from it. There are few reports
describing factors influencing the inotropic support period. This study was
undertaken to clarify the proper inotropic support period, especially to judge
which patients can be weaned from it within 24 h. From January 2000 to December
2001, 151 patients, 88 (58.2%) with ischemic heart disease, 51 (33.8%) with
valvular disease, 7 (4.6%) with congenital heart disease, and 5 (3.4%) with
other heart disease, underwent cardiac surgery. The mean age was 66.2 +/- 10.1
years (range 30-95); 98 patients (65%) were male. The data were analyzed
retrospectively. Eighty patients (53%) were weaned from inotropic support within
24 h after cardiac surgery. Univariate analysis showed that intra-aortic balloon
pumping, blood transfusion, operation time, cardiopulmonary bypass time, and
aortic cross-clamping time significantly influenced the inotropic support
period. Multivariate analysis indicated that intra-aortic balloon pumping, blood
transfusion, and cardiopulmonary bypass time significantly influenced the
inotropic support period. Intra-aortic balloon pumping, blood transfusion, and
cardiopulmonary bypass time might determine the inotropic support period.
Appropriate surgical procedure and methods both reducing cardiopulmonary bypass
time (<75 min) and minimizing blood loss are the keys to weaning patients from
inotropic support within 24 h.

Circulation.  2004 Sep 14;110(11 Suppl 1):II274-9.  

Soluble human complement receptor 1 limits ischemic damage in cardiac surgery
patients at high risk requiring cardiopulmonary bypass.

Lazar HL, Bokesch PM, van Lenta F, Fitzgerald C, Emmett C, Marsh HC Jr, Ryan U;
OBE and the TP10 Cardiac Surgery Study Group.

Department of Cardiothoracic Surgery, Boston University School of Medicine and
Boston Medical Center, Boston, Mass 02118, USA. harold.lazar@bmc.org

BACKGROUND: This study was undertaken to determine whether soluble human
complement receptor type 1 (TP10), a potent inhibitor of complement activation,
would reduce morbidity and mortality in high-risk patients undergoing cardiac
surgery on cardiopulmonary bypass (CPB). METHODS: This was a randomized
multicenter, prospective, placebo-controlled, double-blind study in which 564
high-risk patients undergoing cardiac surgery on CPB received an intravenous
bolus of TP10 (1, 3, 5, 10 mg/kg) or placebo immediately before CPB. The primary
endpoint was the composite events of death, myocardial infarction (MI),
prolonged (> or =24 hours) intra-aortic balloon pump support (IABP), and
prolonged intubation. RESULTS: TP10 significantly inhibited complement activity
after 10 to 15 minutes of CPB and this inhibition persisted for 3 days
postoperatively. However, there was no difference in the primary endpoint
between the 2 groups (33.7% placebo versus 31.4% TP10; P=0.31). The primary
composite endpoint was, however, reduced in all male TP10 patients by 30%
(P=0.025). TP10 reduced the incidence of death or MI in males by 36% (P=0.026),
the incidence of death or MI in CABG males by 43% (P=0.043) and the need for
prolonged IABP support in male CABG and valve patients by 100% (P=0.019). There
was, however, no improvement seen in female TP10 patients. There were no
significant differences in adverse events between the groups. CONCLUSIONS: TP10
effectively inhibits complement activation during CPB; however, this was not
associated with an improvement in the primary endpoint of the study.
Nevertheless, TP10 did significantly decrease the incidence of mortality and MI
in male patients.

J Am Coll Cardiol.  2004 Sep 15;44(6):1248-53.  

Clinical prediction rule for atrial fibrillation after coronary artery bypass
grafting.

Amar D, Shi W, Hogue CW Jr, Zhang H, Passman RS, Thomas B, Bach PB, Damiano R,
Thaler HT.

Department of Anesthesiology and Critical Care Medicine, Memorial
Sloan-Kettering Cancer Center and Weill Medical College of Cornell University,
New York, New York 10021, USA. amard@mskcc.org

OBJECTIVES: This study was designed to devise and validate a practical
prediction rule for atrial fibrillation/atrial flutter (AF) after coronary
artery bypass grafting (CABG) using easily available clinical and standard
electrocardiographic (ECG) criteria. BACKGROUND: Reported prediction rules for
postoperative AF have suffered from inconsistent results and controversy
surrounding the added predictive value of a prolonged P-wave duration. METHODS:
In 1,851 consecutive patients undergoing CABG with cardiopulmonary bypass,
preoperative clinical characteristics and standard 12-lead ECG data were
examined. Patients were continuously monitored for the occurrence of sustained
postoperative AF while hospitalized. Multiple logistic regression was used to
determine significant predictors of AF and to develop a prediction rule that was
evaluated through jackknifing. RESULTS: Atrial fibrillation occurred in 508 of
1,553 patients (33%). Multivariate analysis showed that greater age (odds ratio
[OR] 1.1 per year [95% confidence intervals (CI) 1.0 to 1.1], p < 0.0001), prior
history of AF (OR 3.7 [95% CI 2.3 to 6.0], p < 0.0001), P-wave duration >110 ms
(OR 1.3 [95% CI 1.1 to 1.7], p = 0.02), and postoperative low cardiac output (OR
3.0 [95% CI 1.7 to 5.2], p = 0.0001) were independently associated with AF risk.
Using the prediction rule we defined three risk categories for AF: <60 points,
61 of 446 (14%); 60 to 79 points, 330 of 908 (36%); and >or=80 points, 117 of
199 (59%). The area under the receiver-operator characteristic curve for the
model was 0.69. CONCLUSIONS: These data show that post-CABG AF can be predicted
with moderate accuracy using easily available patient characteristics and may
prove useful in prognostic and risk stratification of patients after CABG. The
presence of intraatrial conduction delay on ECG contributed least to the
prediction model.

Hepatogastroenterology.  2004 Sep-Oct;51(59):1326-9.  

Aggressive surgical resection for hepatocellular carcinoma with tumor thrombus
extending to inferior vena cava and synchronous pulmonary metastasis.

Kitayama D, Yoshidome H, Mitsuhashi N, Ito H, Kimura F, Shimizu H, Ohtsuka M,
Miyazaki M.

Department of General Surgery, Chiba University Graduate School of Medicine,
Japan.

We describe a 66-year-old man having hepatocellular carcinoma with tumor
thrombus extending into the inferior vena cava and synchronous pulmonary
metastasis. He was referred to Chiba University Hospital on May, 2000,
complaining of emaciation. Radiological findings showed a huge hepatocellular
carcinoma in the entire right lobe and tumor thrombus extended into the
intrapericardial inferior vena cava. He also had a solitary pulmonary metastasis
in the left pulmonary lobe (stage IVB). Right hemihepatomy was performed under
total hepatic vascular exclusion without cardiopulmonary bypass, and tumor
thrombus was completely removed. Thoracoscopic wedge resection of pulmonary
metastasis was also performed. The patient had an uneventful postoperative
course. Histopathological examination revealed that the tumor was moderately
differentiated hepatocellular carcinoma The patient is still alive after 26
months with pulmonary recurrence, but without hepatic recurrence. To our
knowledge, there has been no reported case of resection for both hepatocellular
carcinoma invading the inferior vena cava and synchronous pulmonary metastasis.
In conclusion, aggressive surgical resection for advanced hepatocellular
carcinoma concomitant with pulmonary resection may bring about better prognosis
in highly selected patients.

J Intensive Care Med.  2004 Sep-Oct;19(5):243-58.  

Extracorporeal life support in pediatric and neonatal critical care: a review.

Lequier L.

Stollery Children's Hospital,3A3.02 WMC, 8440-112 Street, Edmonton, Alberta T6G
2B7, Canada. llequier@cha.ab.ca

Extracorporeal life support (ECLS) is a modified form of cardiopulmonary bypass
used to provide prolonged tissue oxygen delivery in patients with respiratory
and/or cardiac failure. The first large-scale success of ECLS was achieved in
the management of term newborns with respiratory failure. ECLS has become an
accepted therapeutic modality for neonates, children, and adults who have failed
conventional therapy and in whom cardiac and/or respiratory insufficiency is
potentially reversible. The use of ECLS allows one to reduce other
cardiopulmonary supports and apply a gentle ventilation strategy in a population
of severely compromised critical care patients. ECLS has now been employed in
more than 26,000 neonatal and pediatric patients with an overall survival rate
of 68%. ECLS has evolved significantly over 25 years of clinical practice;
patient selection for this complex and highly invasive therapy, as well as how
ECLS is employed in different patient groups, is constantly changing. Generally,
ECLS is used more liberally now than in the past. The number of patients
requiring this support, however, is declining yearly, and those patients who
receive ECLS compose a more severe subset of an intensive care population. This
review provides an overview of the development of ECLS and the equipment and
techniques employed. The use of ECLS for neonatal respiratory failure, pediatric
respiratory failure, and cardiac support are outlined. Management of the ECLS
patient is discussed in detail, and outcome of these patients is reviewed.
Finally, current trends and future implications of ECLS in neonatal and
pediatric critical care are addressed.

J Thorac Cardiovasc Surg.  2004 Sep;128(3):436-41.  

Aortic valve replacement with the minimal extracorporeal circulation (Jostra
MECC System) versus standard cardiopulmonary bypass: a randomized prospective
trial.

Remadi JP, Rakotoarivello Z, Marticho P, Trojette F, Benamar A, Poulain H,
Tribouilloy C.

Cardiovascular Surgery Unit and Anaesthesiology Department, South Hospital,
Amiens, France. remadi.jean-paul@chu-amiens.fr

BACKGROUND: We prospectively evaluated a newly introduced minimal extracorporeal
circulation system (Jostra MECC System; Jostra AG, Hirrlingen, Germany) for
aortic valve surgery. METHOD: In a prospective, randomized study, 100 patients
underwent aortic valve replacement either with standard cardiopulmonary bypass
(n = 50, group B) or with the MECC System (n = 50, group B). The myocardial
protection and the left vent were identical for the two groups. The
intrapericardial suction device was never used (only the cell salvage device was
used) to reduce the air-blood contact area. RESULTS: No significant differences
were noted in patient characteristics and operative data between groups.
Operative mortality (<30 days) was 2% for group A and 4% for group B (difference
not significant). From the preoperative period to the postoperative period, the
increase in C-reactive protein was significantly higher for group B (P <.001).
The postoperative troponin I level was significantly lower in group A (mean 4.65
+/- 2.9 microg/L at 24 hours) than in group B (8.2 +/- 4.4 microg/L, P <.03). On
the other hand, the MECC System was associated with platelet preservation. Renal
function was better preserved and the neurologic event rate was significantly
lower for the MECC group (P <.02). CONCLUSION: The MECC System is safe and
allows aortic valve replacement under the most favorable conditions. The system
is more biocompatible than standard cardiopulmonary bypass and provides a good
postoperative biologic profile and good clinical results, particularly for
high-risk patients.