Eur J Cardiothorac Surg. 2006 Sep 27; [Epub ahead of print] 

Normothermic cardiopulmonary bypass and myocardial cardioplegic protection for
neonatal arterial switch operation.

Pouard P, Mauriat P, Ek F, Haydar A, Gioanni S, Laquay N, Vaccaroni L, Vouhe PR.

Department of Anesthesiology, Hopital Necker Enfants Malades, 149 rue de Sevres,
Paris, France.

Objective: Hypothermic cardiopulmonary bypass (CPB) associated with cold
myocardial protection is commonly used to perform neonatal cardiac surgery.
Hypothermia is usually chosen to preserve the brain in case of failure of oxygen
delivery whatever it may result from. Nowadays, there is a growing number of
evidence demonstrating that hypothermia induces deleterious effects, which may
culminate in organ dysfunctions. In 2001, we started a protocol where the heart
and the body were no longer cooled, in all the procedures, including the
arterial switch operation (ASO), except those with aortic arch reconstruction.
Methods: Because data on the neonatal arterial switch operation were
prospectively gathered in our unit (and included fine biochemical analysis of
myocardial damage), we have compared two consecutive populations of arterial
switch operation to sort out the impact of normothermic CPB and normothermic
cardioplegia. Results: The results show that warm cardiopulmonary bypass
associated with warm cardioplegia is feasible for ASO, and that most of the
operative data are similar to hypothermic bypass, none are worse. Among the
postoperative data, the cardiac troponin I (cTnI) time course showed
significantly lower values in the normothermic group after 24h (4.46ngml(-1) vs
6.17ngml(-1) (p=0.027)), time to extubation is improved (32+/-26h vs 70+/-69h
(p=0.02)) and there is a trend to reduce the ICU length of stay (3.5+/-1.5 days
vs 5.6+/-3.9 days (p=0.08)), and consequently the cost of surgery. Conclusion:
Normothermic cardiopulmonary bypass is feasible for ASO and seems to allow a
faster recovery time.

Mt Sinai J Med. 2006 Sep;73(5):777-83. 

Decrease of total antioxidant capacity during coronary artery bypass surgery.

Kunt AS, Selek S, Celik H, Demir D, Erel O, Andac MH.

Department of Cardiovascular Surgery, Harran University, Research Hospital,
TR-63100 Sanliurfa, Turkey. dralper@msn.com

OBJECTIVE: Cardiac surgery induces an oxidative stress, which may lead to
impairment of cardiac function. In this study, we aimed to measure the changes
of oxidative and antioxidative status of patients undergoing coronary artery
bypass surgery (CABG). MATERIALS AND METHODS: We studied 79 patients who
underwent CABG with and without cardiopulmonary bypass (CPB). Of the 79
patients, 39 had CPB and 40 did not. Blood samples were drawn before, during,
and after the surgery. Antioxidant status was evaluated by measuring total
antioxidant capacity (TAC), and oxidative status was evaluated by measuring
total peroxide (TP) levels and oxidative stress index (OSI). RESULTS: TP and OSI
levels increased, while TAC decreased progressively after the beginning of
surgery, for all patients. There were negative correlations between TAC levels
and aortic cross-clamping period and anastomosis time ( r = -0.553, p < 0.001
and r = -0.500, p < 0.001, respectively). In addition, there was a positive
correlation between TAC and ejection fraction (r = 0.647, p < 0.001).
CONCLUSIONS: During CABG, oxidant and OSI levels significantly increase and TAC
significantly decreases. This situation is influenced by long CPB and
anastomosis time, and also by low ventricular ejection fraction. We concluded
that the patients who undergo CABG are exposed to potent oxidative stress that
impairs their TAC. We speculate that supplementation with antioxidant vitamins
such as vitamins C and E may be beneficial for patients undergoing CABG.

Thorac Cardiovasc Surg. 2006 Sep;54(6):404-7. 

The effects of a neutrophil elastase inhibitor on the postoperative respiratory
failure of acute aortic dissection.

Furusawa T, Tsukioka K, Fukui D, Sakaguchi M, Seto T, Terasaki T, Wada Y, Amano
J.

Department of Surgery, Division of Cardiovascular Surgery, Shinshu University
School of Medicine, Matsumoto, Japan.

BACKGROUND: Postoperative respiratory failure is often encountered in patients
suffering from acute aortic dissection (AAD) and is believed to be influenced by
release of neutrophil elastase after cardiopulmonary bypass. Sivelestat is a
specific neutrophil elastase inhibitor, and this study aims to evaluate the
effects of sivelestat on postoperative respiratory failure due to AAD. METHODS
AND RESULTS: Patients who were operated for AAD from January 2000 to April 2005
and who had less than 300 mmHg initial postoperative PaO (2)/FiO (2) were
investigated retrospectively and divided into two groups. Group 1 (n = 9)
received intravenous administration of sivelestat immediately after the
operation, while Group II (n = 9) received no sivelestat. There were no
significant differences between Group I and II with respect to patients'
characteristics or background (age, body weight, operating time, cardiopulmonary
bypass time, amount of bleeding, preoperative WBC number and initial PaO (2)/FiO
(2)). Though patients in Group I showed a subtle improvement in certain
parameters such as PaO (2)/FiO (2), A-aDO (2) and respiratory index (RI) over a
3-day observation period compared to those of Group II, there were no
significant differences. Neither postoperative mechanical ventilation time nor
ICU stay differed between Group I and II. However, Group I showed a
significantly greater improvement in the ratio of RI to initial RI on the 3POD
compared to that of Group II (61.6 +/- 44.2 % vs. 111.9 +/- 40.9 %, P = 0.02).
CONCLUSION: Inhibiting the activity of the neutrophil elastase may attenuate the
postoperative respiratory complications of patients with AAD.

ASAIO J. 2006 September/October;52(5):595-597. 

Comparison of Coronary Artery Blood Flow and Hemodynamic Energy in a Pulsatile
Pump Versus a Combined Nonpulsatile Pump and an Intra-aortic Balloon Pump.

Lim CH, Son HS, Baek KJ, Lee JJ, Ahn CB, Moon KC, Khi W, Lee H, Sun K.

*Anesthesiology and Pain Medicine, daggerThoracic and Cardiovascular Surgery,
Korea University, Seoul, Korea; double daggerEmergency Medicine, Konkuk
University, Seoul, Korea; and  section signKorea Artificial Organ Center, Korea
University, Seoul, Korea.

We compared the coronary artery blood flow and hemodynamic energy between
pulsatile extracorporeal life support (ECLS) and a centrifugal pump
(CP)/intra-aortic balloon pump (IABP) combination in cardiac arrest.A total
cardiopulmonary bypass circuit was constructed for six Yorkshire swine weighing
30 to 40 kg. The outflow cannula of the CP or a pulsatile ECLS (T-PLS) was
inserted into the ascending aorta, and the inflow cannula of the CP or T-PLS was
placed into the right atrium. A 30-ml IABP was subsequently placed in the
descending aorta. Extracorporeal circulation was maintained for 30 minutes with
a pump flow of 75 ml/kg per minute by a CP with an IABP or T-PLS. Pressure and
flow were measured in the right internal carotid artery. The energy equivalent
pressure (EEP) and surplus plus hemodynamic energy (SHE) were recorded. The left
anterior descending coronary artery flow was measured with an ultrasonic
coronary artery flow measurement system.The percent change of the mean arterial
pressure to EEP was effective in both groups (23.3 +/- 6.1 in CP plus IABP vs.
19.8 +/- 6.2% in T-PLS, p = NS). The SHE was high enough in the CP/IABP and the
T-PLS (20,219.8 +/- 5824.7 vs. 13,160.2 +/- 4028.2 erg/cm, respectively, p =
NS). The difference in the coronary artery flow was not statistically
significant at 30 minutes after bypass was initiated (28.2 +/- 9.79 ml/min in CP
plus IABP vs. 27.7 +/- 9.35 ml/min in T-PLS, p = NS).

Crit Care. 2006 Sep 11;10(5):R127 [Epub ahead of print] 

Follow-up of newborns treated with Extracorporeal Membrane Oxygenation; a
nation-wide evaluation at 5 years of age.

Hanekamp MN, Mazer P, van der Cammen MH, van Kessel-Feddema BJ, Nijhuis van der
Sanden RW, Knuijt S, Zegers-Verstraeten JL, Gischler SJ, Tibboel D, Kollee LA.

ABSTRACT: INTRODUCTION: Extracorporeal membrane oxygenation (ECMO) is a
supportive cardiopulmonary bypass technique for babies with acute reversible
cardiorespiratory failure. We assessed morbidity in ECMO survivors at the age of
5 years, when they start primary school and major decisions for their school
careers must be made. Materials and Methods 5-year-old neonatal
venoarterial-ECMO survivors from the two designated ECMO centres in the
Netherlands (Erasmus MC - Sophia Childrens Hospital in Rotterdam, and University
Medical Center Nijmegen) were assessed within the framework of an extensive
follow-up program. The protocol included medical assessment, neuromotor
assessment, and psychological assessment by means of parent and teacher
questionnaires. RESULTS: Seventeen of the 98 children included in the analysis
(17%) were found to have neurological deficits. Six of those 17 (6%) showed
major disability. Two of those six had a chromosomal abnormality. Three were
mentally retarded and profoundly impaired. The sixth had a right-sided
hemiplegia. These six children did not undergo neuromotor assessment.
Twenty-four of the remaining 92 (26%) showed motor difficulties: 15% actually
had a motor problem and 11% were at risk for this. Cognitive delay was
identified in eleven children (14%). The mean IQ score was within the normal
range (IQ=100.5). CONCLUSION: Neonatal ECMO in the Netherlands was found to be
associated with considerable morbidity at 5 years of age. It appeared feasible
to have as many as 87% of survivors participate in follow-up assessment, due to
co-operation between two centres and small travelling distances. Objective
evaluation of the long-term morbidity associated with the application of this
highly invasive technology in the immediate neonatal period requires an
interdisciplinary follow-up program with nation-wide consensus on timing and
actual testing protocol.

Can J Anaesth. 2006 Sep;53(9):919-25. 

Continuous positive airway pressure does not improve lung function after cardiac
surgery.

Altmay E, Karaca P, Yurtseven N, Ozkul V, Aksoy T, Ozler A, Canik S.

Department of Anesthesiology and Reanimation, Dr Siyami Ersek Thoracic and
Cardiovascular Surgery Center, Istanbul, Turkey.

PURPOSE: Despite the well-documented impairment of pulmonary function after
cardiopulmonary bypass, effective precautions and ideal management strategies
for this problem are still under debate. This study aimed to evaluate the
effects of continuous positive airway pressure (CPAP) applied during
cardiopulmonary bypass on respiratory and hemodynamic variables. METHODS: In
this randomized, prospective, controlled trial, 120 male patients, aged 45 to 70
yr undergoing first-time elective bypass surgery, were randomly assigned to
receive either 10 cm H2O of CPAP (Group I; n = 60) during cardiopulmonary
bypass, or serve as control (Group II; n = 60), where the patient's lungs were
vented to atmosphere during the bypass period. RESULTS: Alveolar-arterial oxygen
partial pressure difference and shunt fraction were significantly higher in the
control group compared with the CPAP group after cardiopulmonary bypass (T2) and
after closure of sternum (T3), (P < 0.05). No differences between groups with
respect to hemodynamic variables were observed at any time. Postoperative
pulmonary function variables were lower in both groups compared to baseline
values. CONCLUSIONS: Continuous positive airway pressure administered during
cardiopulmonary bypass decreased shunt fraction and alveolar-arterial oxygen
partial pressure difference during surgery, but had no sustained effect on
either variable postoperatively. We conclude that, in patients with normal
preoperative pulmonary function, application of 10 cm H2O CPAP does not improve
lung function after cardiac surgery.

Exp Biol Med (Maywood). 2006 Sep;231(8):1300-5. 

Sodium pump reduction correlates with aortic clamp time in pediatric heart
surgery.

Pavlovic M, Schaller A, Ammann RA, Pfammatter JP, Berdat P, Carrel T, Gallati S.

Division of Pediatric Cardiology, University Children's Hospital,
Freiburgstrasse 23, 3010 Berne, Switzerland. mladen.pavlovic@insel.ch

Myocardial depression after cardiac surgery is modulated by cardiopulmonary
bypass (CPB) and the underlying heart disease. The sodium pump is a key
component for myocardial function. We hypothesized that the change in sodium
pump expression during CPB correlates with intraoperative and postoperative
laboratory and clinical parameters in neonates and children with various
congenital heart defects. Sodium pump isoforms alpha1 (ATP1A1) and alpha3
(ATP1A3) mRNA expression in right atrial myocardium, excised before and after
CPB, was quantified. Groups were assigned according to presence (VO group, n =
8) or absence (NO group, n = 8) of right atrial volume overload. CPB and aortic
clamp time correlated with postoperative troponin-I values and ICU stay. ATP1A1
(P = 0.008) and ATP1A3 (P = 0.038) mRNA expression were significantly reduced
during CPB. Longer aortic clamp times were associated with lower postoperative
ATP1A1 (P = 0.045) and ATP1A3 (P = 0.002) mRNA expression. Low postoperative
ATP1A1 (P = 0.043) and ATP1A3 (P = 0.002) expressions were associated with high
troponin-I values. These results were restricted to the VO group. No correlation
of sodium pump mRNA expression was found with the duration of ICU stay or
ventilation. The postoperative troponin-I and clinical parameters correlated
with the length of CPB, regardless of volume overload. In contrast, only dilated
right atrium seemed to be susceptible to CPB in terms of sodium pump expression,
showing a reduction during the operation and a correlation of sodium pump with
postoperative troponin-I values.

J Thorac Cardiovasc Surg. 2006 Sep;132(3):675-80. 

Failure of surface-modified bypass circuits to improve platelet function during
pediatric cardiac surgery.

Kirshbom PM, Miller BE, Spitzer K, Easley KA, Spainhour CE, Kogon BE, Kanter KR.

Division of Cardiac Surgery, Emory University School of Medicine, Atlanta, GA,
USA. paul.kirshbom@emoryhealthcare.org

OBJECTIVE: Surface-modified cardiopulmonary bypass circuits have been shown to
improve platelet function and decrease postoperative bleeding after heart
surgery in adults. Two surface-modified cardiopulmonary bypass circuits are
approved and commercially available for pediatric cardiac surgery. There have
been few studies demonstrating the efficacy of these modifications for children.
We performed a prospective, randomized trial comparing surface-modified
cardiopulmonary bypass circuits to a standard unmodified circuit in pediatric
cardiac surgery. METHODS: Sixty-nine children (median 6 months old) undergoing
first-time cardiac surgery were enrolled and randomized to an uncoated circuit
or one of the two commercially available surface modified circuits for their
operation. Blood samples were collected at baseline, on cardiopulmonary bypass,
at the end of rewarming, after protamine, and at 18 to 24 postoperative hours.
Platelet count, beta-thromboglobulin, and thromboelastography with and without
abciximab were measured. Postoperative chest tube outputs and blood product
utilization were also analyzed. RESULTS: The platelet counts,
beta-thromboglobulin levels, thromboelastographic measures of platelet function,
and postoperative bleeding were not significantly different between the
surface-modified cardiopulmonary bypass circuit groups and the control group.
CONCLUSION: Currently available surface-modified cardiopulmonary bypass circuits
do not significantly improve platelet function or clinical outcomes after
routine pediatric cardiac surgery.

Crit Care Med. 2006 Oct;34(10):2658-65. 

Interleukin-10 and its role in clinical immunoparalysis following pediatric
cardiac surgery.

Allen ML, Hoschtitzky JA, Peters MJ, Elliott M, Goldman A, James I, Klein NJ.

Critical Care Group-Portex Unit, Institute of Child Health, University College
London, UK.

OBJECTIVE: A systemic insult is associated with subsequent hyporesponsiveness to
endotoxin (as measured by ex vivo tumor necrosis factor [TNF]-alpha production)
and an increased risk of late nosocomial infection in some patients. When
combined with low monocyte surface major histocompatibility complex class II
expression, this state of altered host defense is now commonly referred to as
immunoparalysis. This study was undertaken to delineate the relationship between
observed levels of the anti-inflammatory cytokine interleukin-10, common genetic
polymorphisms that influence these levels, and the occurrence and severity of
endotoxin hyporesponsiveness in children following elective cardiac surgery
requiring cardiopulmonary bypass. DESIGN: A prospective observational clinical
study. SETTING: A tertiary pediatric cardiac center. PATIENTS: Thirty-six
infants and children <2 yrs of age undergoing elective cardiac surgery requiring
cardiopulmonary bypass. INTERVENTIONS: None. MEASUREMENTS AND MAIN RESULTS: We
investigated the production of TNF-alpha, interleukin-6, interleukin-8,
interleukin-1 receptor antagonist, and interleukin-10 in whole blood in response
to lipopolysaccharide (Neisseria meningitides 10 ng/mL) in samples drawn before,
during, and up to 48 hrs after surgery. Patients were genotyped for the -1082,
-819, and -592 interleukin-10 promoter polymorphisms. Whole blood cytokine
response to lipopolysaccharide was reduced postoperatively to </=50% of
preoperative levels for all cytokines measured. Stimulated cytokine production
was lowest in cases with the highest postoperative plasma interleukin-10 levels,
which were in turn associated with the GCC haplotype. Those patients in whom the
whole blood response to endotoxin was maintained (TNF-alpha >100 pg/mL) over the
first 48 hrs were more likely to have an uncomplicated short stay (odds ratio
4.7, 95% confidence interval 1-22). CONCLUSIONS: Immediately following cardiac
surgery, many children become relatively refractory to lipopolysaccharide
stimulation. This immunoparalysis appears to be related in part to high
circulating levels of interleukin-10 and places these patients at increased risk
of postoperative complications. Interleukin-10 genotype may be a risk factor for
immunoparalysis.

Ann Thorac Surg. 2006 Sep;82(3):964-72. 

Use of partial cardiopulmonary bypass for coarctation repair through a left
thoracotomy in children without collaterals.

Backer CL, Stewart RD, Kelle AM, Mavroudis C.

Division of Cardiovascular-Thoracic Surgery, Children's Memorial Hospital,
Northwestern University Feinberg School of Medicine, Chicago, Illinois 60614,
USA. cbacker@childrensmemorial.org

BACKGROUND: Paraplegia is a devastating complication of coarctation of the aorta
(COA) repair. Since 1990 we have used left atrium-to-descending aorta
cardiopulmonary bypass (CPB) for COA repair in patients with inadequate
collaterals. We reviewed the results with that strategy and compared this CPB
group with COA repairs in which CPB was not used to see whether there was any
increase in morbidity or delay in recovery. METHODS: From 1990 to 2006, 11
patients with COA were identified to have inadequate collaterals based on
preoperative examination and intraoperative arterial monitoring and test clamp.
Left thoracotomy with left atrium-to-descending aorta CPB was used in all. Age
ranged from 4.2 to 17.4 years (mean, 8.7 +/- 4.6 years). Two were reoperations
for recurrent COA, 3 patients had four prior transcatheter balloon dilatations.
One patient had aberrant origin of the right subclavian artery. Operative
techniques included resection with extended end-to-end anastomosis (n = 6),
interposition graft (n = 4), and patch repair (n = 1). During the same period 71
patients older than 1 year of age had COA repair without CPB. Age ranged from
1.1 to 46.1 years (mean, 7.6 +/- 7.1 years; p = 0.6). RESULTS: Preoperative
imaging of CPB patients demonstrated absence of collaterals (n = 7), possible
collaterals (n = 2), small collaterals (n = 1), and anomalous origin of the
right subclavian artery (n = 1). Preoperative arm leg gradient in CPB patients
was 36.0 +/- 9.0 mm Hg versus 49.9 +/- 15 mm Hg in non-CPB patients (p < 0.01).
Mean distal femoral artery pressure with aortic test clamp was 34.3 +/- 4.8 mm
Hg in CPB patients versus 49.8 +/- 12.4 mm Hg in non-CPB patients (p < 0.01).
Mean CPB flow was 53% +/- 7.3% of calculated total flow. Cardiopulmonary bypass
time ranged from 17 to 46 minutes (mean, 27.5 +/- 9.7 minutes). Aortic clamp
time in CPB patients ranged from 15 to 33 minutes (mean, 21.6 +/- 6.3 minutes).
In the non-CPB group aortic clamp time ranged from 10 to 50 minutes (mean, 23.4
+/- 7.5 minutes; p = 0.5). In the CPB group length of stay ranged from 3 to 7
days (mean, 4.9 +/- 1.3 days), and in the non-CPB group length of stay ranged
from 3 to 12 days (mean, 4.7 +/- 1.4 days; p = 0.5). No patient had a neurologic
complication. There were no other major complications in the CPB group (eg,
bleeding, recurrent laryngeal nerve injury, re-COA). CONCLUSIONS: Preoperative
imaging and a lower arm-to-leg gradient in this series of COA patients suggested
inadequate collateral circulation with the potential need for CPB. A femoral
artery pressure of less than 45 mm Hg during test clamp was used as an
indication for partial CPB. The use of left atrium-to-descending aorta CPB with
just over 50% calculated total flow protected the spinal cord in a safe and
expeditious fashion. Use of left heart bypass did not affect morbidity or
recovery time as compared with COA repair in non-CPB patients.