Rev Esp Cardiol. 2007 Sep;60(9):984-7.

[Initial experience with the impella left ventricular assist device for
postcardiotomy cardiogenic shock and unprotected left coronary artery angioplasty
in patients with a low left ventricular ejection fraction]

[Article in Spanish]

Bautista-Hernández V, Gutiérrez F, Pinar E, Gimeno JR, Arribas JM, García-Puente 
J, Ray VG, Arcas R, Valdés M.

Servicio de Cirugía Cardiovascular. Hospital Universitario Virgen de la Arrixaca,
El Palmar, Murcia, España. vbautista_hernandez@hotmail.com

Low-output syndrome is one of the leading causes of death following open-heart
surgery or high-risk angioplasty. Ventricular assist devices have been used to
treat patients who suffer from postoperative cardiogenic shock despite use of an 
intraaortic balloon pump and maximum inotropic support. The Impella pump (Impella
Cardiosystems AG, Aachen, Germany) is a newly introduced left ventricular assist 
device that has been shown to reduce infarct size and to accelerate recovery of
stunned myocardium. We report our initial experience using the Impella device for
the treatment of cardiogenic shock following cardiopulmonary bypass and for
maintaining hemodynamic stability in high-surgical-risk patients undergoing
unprotected left coronary artery angioplasty.

Eur J Cardiothorac Surg. 2007 Sep 27; [Epub ahead of print]

Pulmonary lactate release following cardiopulmonary bypass.

Gasparovic H, Plestina S, Sutlic Z, Husedzinovic I, Coric V, Ivancan V, Jelic I.

Department of Cardiac Surgery, University Hospital Rebro Zagreb, Zagreb, Croatia.

Objective: The etiology of lung injury following cardiopulmonary bypass (CPB) is 
multifactorial. Our study focused on quantifying the lactate release from the
lungs precipitated by extracorporeal circulation at different time points after
the insult. This was complemented by an evaluation of the gas exchange at the
level of the alveolar-capillary membrane. Methods: Forty consecutive patients
(age 61+/-11 years, EuroScore 4.7+/-2.7) undergoing CABG were prospectively
analyzed. The data are presented as medians and the interquartile range. Results:
The pulmonary lactate release (PLR) increased from a baseline value of 0.033
(range -0.077 to 0.170) to 0.465mmol/min/m(2) (range 0.113-0.922), which was seen
6h postoperatively (P<0.001). The A-a O(2) gradient increased from 12.7 (range
8.8-15) to 39.1kPa (range 30.3-46.5) upon discontinuation of CPB (P<0.001). The
systemic arterial lactate (L(S)) concentration increased from 1.22 (range 1-1.44)
to 3.03mmol/l (range 2.29-4.76) 6h after surgery (P<0.001). The veno-arterial
pCO(2) difference (V-A dpCO(2)) rose from 0.6 (range 0.5-0.9) to 0.9kPa (range
0.7-1) (P=0.014). The mortality in the studied group was 5% (2/40). Conclusions: 
The lungs were found to be a significant source of lactate, and this pulmonary
lactate flux was accentuated by CPB. The PLR correlated with systemic
hyperlactatemia as well as the A-a O(2) gradient, and was found to be higher in
patients requiring prolonged mechanical ventilatory support. The duration of CPB 
had a significant impact on the systemic lactate concentrations, V-A dpCO(2) and 
the A-a O(2) gradient, but not on the PLR.

Scand Cardiovasc J. 2007 Sep 25;:1-8 [Epub ahead of print]

Fluid overload during cardiopulmonary bypass is effectively reduced by a
continuous infusion of hypertonic saline/dextran (HSD).

Kvalheim VL, Rynning SE, Farstad M, Haugen O, Nygreen E, Mongstad A, Husby P.

Section for Cardiothoracic Surgery, Department for Heart Disease, University of
Bergen, Haukeland University Hospital, Bergen, Norway.

Objective. Cardiopulmonary bypass (CPB) is associated with fluid overload. We
examined how a continuous infusion of hypertonic saline/dextran (HSD) influenced 
fluid shifts during CPB. Materials and methods. Fourteen animals were randomized 
to a control-group (CT-group) or a hypertonic saline/dextran-group (HSD-group).
Ringer's solution was used as CPB-prime and as maintenance fluid at a rate of 5
ml/kg/h. In the HSD group, 1 ml/kg/h of the maintenance fluid was substituted
with HSD. After 60 min of normothermic CPB, hypothermic CPB was initiated and
continued for 90 min. Fluid was added to the CPB-circuit as needed to maintain a 
constant level in the venous reservoir. Fluid balance, plasma volume, total
tissue water (TTW), intracranial pressure (ICP) and fluid extravasation rates
(FER) were measured/calculated. Results. In the HSD-group the fluid need was
reduced with 60% during CPB compared with the CT-group. FER was 0.38(0.06)
ml/kg/min in the HSD-group and 0.74 (0.16) ml/kg/min in the CT-group. TTW was
significantly lower in the heart and some of the visceral organs in the
HSD-group. In this group ICP remained stable during CPB, whereas an increase was 
observed in the CT-group (p<0.01). Conclusions. A continuous infusion of HSD
reduced the fluid extravasation rate and total fluid gain during CPB. TTW was
reduced in the heart and some visceral organs. During CPB ICP remained normal in 
the HSD-group, whereas an increase was present in the CT-group. No adverse
effects were observed.

Crit Care Med. 2007 Sep 19; [Epub ahead of print]

Influence of volume therapy with a modern hydroxyethylstarch preparation on
kidney function in cardiac surgery patients with compromised renal function: A
comparison with human albumin*

Boldt J, Brosch C, Ducke M, Papsdorf M, Lehmann A.

From the Department of Anesthesiology and Intensive Care Medicine, Klinikum der
Stadt Ludwigshafen, Ludwigshafen, Germany.

OBJECTIVE:: There is continuing concern about the influence of hydroxyethylstarch
on renal function in patients with compromised kidney function. DESIGN::
Prospective, randomized, single-center study. SETTING:: University-affiliated
hospital. PATIENTS:: Fifty patients undergoing elective, first-time coronary
artery bypass grafting using cardiopulmonary bypass with a preoperative serum
creatinine between 1.5 and 2.5 mmol/L. INTERVENTIONS:: According to a
prospective, randomized sequence, the patients received either hydroxyethylstarch
with a low molecular weight (mean molecular weight 130 kD) and a low molar
substitution (0.4) (6% hydroxyethylstarch 130/0.4) (n = 25) or 5% human albumin
(n = 25). Volume was added to the priming (500 mL) and given perioperatively
until the second postoperative day to keep pulmonary artery occlusion pressure or
central venous pressure between 12 and 14 mm Hg. MEASUREMENTS AND MAIN RESULTS:: 
Serum creatinine and cystatin plasma levels were measured from arterial blood
samples. From urine specimens, N-acetyl-beta-D-glucosaminidase, glutathione
transferase-alpha, and neutrophil gelatinase-associated lipocalin were measured. 
Measurements were performed after induction of anesthesia, at the end of surgery,
5 hrs after surgery, and on the first and second postoperative days. A follow-up 
after discharge from the hospital (60 days) was also done. Similar amounts of
hydroxyethylstarch and albumin were infused. Serum creatinine, glomerular
filtration rate, and cystatin C plasma levels were without significant
differences between the groups. Concentrations of kidney-specific proteins were
elevated at baseline and increased significantly after surgery without showing
group differences. Urinary levels of neutrophil gelatinase-associated lipocalin
increased more in the albumin- than in the hydroxyethylstarch-treated patients.
None of the patients developed acute renal failure requiring renal replacement
therapy during the hospital stay and thereafter. CONCLUSIONS:: A
hydroxyethylstarch preparation with a low molecular weight and a low molar
substitution given in cardiac surgery patients with preoperative compromised
kidney function did not negatively influence kidney integrity compared with a
human albumin-based volume replacement strategy.

Crit Care. 2007 Sep 21;11(5):R106 [Epub ahead of print]

Determination of the threshold of cardiac troponin I associated with an adverse
postoperative outcome after cardiac surgery: a comparative study between coronary
artery bypass graft, valve, and combined cardiac surgery.

Fellahi JL, Hedoire F, Le Manach Y, Monier E, Guillou L, Riou B.

ABSTRACT: BACKGROUND: To compare postoperative cardiac troponin I (cTnI) release 
and the thresholds of cTnI that predict adverse outcome after elective coronary
artery bypass graft (CABG), valve, and combined cardiac surgery. METHODS: Six
hundred and seventy five adult patients undergoing conventional cardiac surgery
with cardiopulmonary bypass were retrospectively analyzed. Patients in the CABG
(n=225) and valve surgery groups (n=225) were selected after matching (age, sex) 
with those in the combined surgery group (n=225). cTnI was measured
preoperatively and 24 h after the end of surgery. The main endpoint was a severe 
postoperative cardiac event (sustained ventricular arrhythmias requiring
treatment, need for inotropic support or intra-aortic balloon pump for at least
24 h, postoperative myocardial infarction) and/or death. Data are medians and
odds ratio [95% confidence interval]. RESULTS: Postoperative cTnI levels were
significantly different among the three groups (Combined 11.0 [9.5-13.1] vs. CABG
5.2 [4.7-5.7] and Valve 7.8 [7.6-8.0] ng.mL-1, respectively, P<0.05). The
thresholds of cTnI predicting severe cardiac event and/or death were also
significantly different among the three groups (Combined 11.8 [11.5-14.8] vs.
CABG 7.8 [6.7-8.8] and Valve 9.3 [8.0-14.0] ng.mL-1 respectively, P<0.05 level). 
An elevated cTnI above the threshold in each group was significantly associated
with severe cardiac event and/or death (odds ratio, 4.33 [2.82-6.64]).
CONCLUSIONS: The magnitude of postoperative cTnI release is related to the type
of cardiac surgical procedure. Different thresholds of cTnI must be considered
according to the procedure type to predict early an adverse postoperative
outcome.

Br J Anaesth. 2007 Sep 13; [Epub ahead of print]

Cardiac surgery with cardiopulmonary bypass: does aprotinin affect outcome?

Van der Linden PJ, Hardy JF, Daper A, Trenchant A, De Hert SG.

Department of Anaesthesiology, Centre Hospitalier Universitaire (CHU) Brugmann,
Hôpital Universitaire des Enfants Reine Fabiola, Brussels, Belgium.

BACKGROUND: /st> Aprotinin, a non-specific serine protease inhibitor, has been
used for two decades to reduce perioperative blood loss and the risk for
allogeneic transfusion in cardiac surgery. This study evaluated the effects of
aprotinin on outcome (mortality, cardiac events, renal failure, and
cerebrovascular events) in such patients undergoing cardiac surgery with
cardiopulmonary bypass. METHODS: /st> Data were obtained in patients who received
a strict blood conservation protocol: no antifibrinolytic therapy when at low
risk (n=854) and aprotinin (n=1210) when at high risk for blood transfusion.
Relative risk of different pre- and intra-operative variables was calculated for 
the different outcome variables. Backward stepwise logistic regression analysis
was used to identify the independent risk factors associated with the different
outcome variables. Statistical significance was accepted at P<0.01. RESULTS: /st>
Postoperative mortality and morbidity were higher in the aprotinin group but this
was related to an increased incidence of perioperative risk factors. Mortality
was similar to that predicted by the Euroscore. Complex surgery was the only
independent variable associated with postoperative cardiac events. Preoperative
heart failure, preoperative creatinine >1.5 mg dl(-1), urgent, and redo surgery
were the independent variables associated with postoperative haemodialysis. Age
>70 yr was identified as the only independent variable associated with neurologic
dysfunction. CONCLUSIONS: /st> In the present study, patients receiving aprotinin
as part of a strict blood conservation strategy represent a population at high
risk for postoperative complications. For the outcome variables studied,
aprotinin administration was not identified as an independent risk factor.

Circulation. 2007 Sep 11;116(11 Suppl):I89-97.

The cardiotomy trial: a randomized, double-blind study to assess the effect of
processing of shed blood during cardiopulmonary bypass on transfusion and
neurocognitive function.

Rubens FD, Boodhwani M, Mesana T, Wozny D, Wells G, Nathan HJ; Cardiotomy
Investigators.

Division of Cardiac Surgery, University of Ottawa Heart Institute, Ottawa,
Ontario, Canada. frubens@ottawaheart.ca

BACKGROUND: Reinfusion of unprocessed cardiotomy blood during cardiac surgery can
introduce particulate material into the cardiopulmonary bypass circuit, which may
contribute to postoperative cognitive dysfunction. On the other hand, processing 
of this blood by centrifugation and filtration removes coagulation factors and
may potentially contribute to coagulopathy. We sought to evaluate the effects of 
cardiotomy blood processing on blood product use and neurocognitive functioning
after cardiac surgery. METHODS AND RESULTS: Patients undergoing coronary and/or
aortic valve surgery using cardiopulmonary bypass were randomized to receive
unprocessed blood (control, n=134) or cardiotomy blood that had been processed by
centrifugal washing and lipid filtration (treatment, n=132). Patients and
treating physicians were blinded to treatment assignment. A strict transfusion
protocol was followed. Blood transfusion data were analyzed using Poisson
regression models. The treatment group received more intraoperative red blood
cell transfusions (0.23+/-0.69 U versus 0.08+/-0.34 U, P=0.004). Both red blood
cell and nonred blood cell blood product use was greater in the treatment group
and postoperative bleeding was greater in the treatment group. Patients were
monitored intraoperatively by transcranial Doppler and they underwent
neuropsychometric testing before surgery and at 5 days and 3 months after
surgery. There was no difference in the incidence of postoperative cognitive
dysfunction in the 2 groups (relative risk: 1.16, 95% CI: 0.86 to 1.57 at 5 days 
postoperatively; relative risk: 1.05, 95% CI: 0.58 to 1.90 at 3 months). There
was no difference in the quality of life nor was there a difference in the number
of emboli detected in the 2 groups. CONCLUSIONS: Contrary to expectations,
processing of cardiotomy blood before reinfusion results in greater blood product
use with greater postoperative bleeding in patients undergoing cardiac surgery.
There is no clinical evidence of any neurologic benefit with this approach in
terms of postoperative cognitive function.

Circulation. 2007 Sep 11;116(11 Suppl):I179-87.

Comparison of the profiles of postoperative systemic hemodynamics and oxygen
transport in neonates after the hybrid or the Norwood procedure: a pilot study.

Li J, Zhang G, Benson L, Holtby H, Cai S, Humpl T, Van Arsdell GS, Redington AN, 
Caldarone CA.

Division of Cardiology, The Hospital for Sick Children, 555 University Avenue,
Toronto, Ontario, Canada, M5G 1X8. jia.li@sickkids.ca

BACKGROUND: After the Norwood procedure, early postoperative neonatal physiology 
is characterized by hemodynamic instability and imbalance of oxygen transport
that is commonly attributed to surgical myocardial injury and a systemic
inflammatory response to cardiopulmonary bypass (CPB). Because the Hybrid
procedure (arterial duct stenting and bilateral pulmonary artery banding) avoids 
CPB, cardioplegic arrest, and circulatory arrest, we hypothesized that the Hybrid
procedure is associated with superior postoperative hemodynamics and oxygen
transport. METHODS AND RESULTS: Oxygen consumption (VO2) was continuously
measured using respiratory mass spectrometry for 72 hours after Hybrid (n=6) and 
Norwood (n=13) procedures. Arterial, superior vena cava, and pulmonary venous
blood gases and pressures were measured at 2- to 4-hour intervals to calculate
systemic and pulmonary blood flows (Qs, Qp), and systemic vascular resistance
(SVR), total pulmonary vascular resistance including pulmonary arterial band or
B-T shunt (tPVR), cardiac output (CO), oxygen delivery (DO2), and oxygen
extraction ratio (ERO2). Rate-pressure product was calculated as heart rate x
systolic arterial pressure. When compared with the Norwood procedure, the early
postoperative Hybrid patients had lower CO, higher SVR, and higher Qp:Qs ratios. 
In addition, the DO2 and VO2 were both lower in the Hybrids with higher ERO2 and 
lactate levels. This early postoperative pattern reversed after 48 hours.
CONCLUSIONS: Although Hybrid procedure avoids CPB and cardioplegic arrest, the
early hemodynamic profile is not superior to the Norwood in terms of cardiac
output and control of pulmonary blood flow. These data strongly suggest that a
"hands off" approach to postoperative care in Hybrid patients may not be
appropriate in patients with preoperative diminished myocardial function; and in 
such patients a Norwood-derived management strategy (afterload reduction and
inotropic support) should be considered.

Interact Cardiovasc Thorac Surg. 2007 Sep 10; [Epub ahead of print]

Mid-term results of peripheric cannulation after port-access surgery.

Sagbas E, Caynak B, Duran C, Sen O, Kabakci B, Sanisoglu I, Akpinar B.

Istanbul Science University Florence Nightingale Hospital, Turkey.

Several minimally invasive approaches, avoiding median sternotomy, have been
described within the last few years for cardiac surgery. Femoral arterial and
venous cannulation for extracorporeal perfusion are required for many of these
operations. The aim of this report is to assess the long-term outcomes of femoral
cannulations in patients who underwent minimally invasive procedures. One hundred
and sixty patients underwent operations by the port-access method between January
2002 and October 2006. Cardiopulmonary bypass was established by femoral
artery-vein cannulation, and a transthoracic clamp was used for the aortic
occlusion. One hundred and twenty-one patients were under follow-up in the
outpatient clinic and 85 patients underwent Doppler ultrasonography (US) for
femoral arterial and venous stenosis. The mean follow-up was 27.9 months (range
1-57 months). There were 3 hospital mortalities (1.86%), and 5 late mortalities
in this series. The mean follow-up for the Doppler examination was 20.54 months
(range 1-56 months). There were 2 seromas and 3 wound complications (2.48%), all 
of which healed after outpatient treatment. All of the flow patterns of the
common femoral arteries (CFA) were triphasic except in 3 of the patients. Three
patients (2.48%) were found to have arterial stenosis. One patient with
intermittant claudication underwent percutaneous dilatation and stenting of the
CFA. Doppler US detected luminal narrowing in 2 patients who had been having no
symptoms, and they are beeing followed in the outpatient clinic without any
complaints. We found a chronic recanalized thrombotic changes in the common
femoral vein (CFV) in one patient (0.63%). Our study demonstrates vessel patency 
and/or stenosis in patients without complaints. In conclusion, femoral artery and
vein cannulation for port- access surgery with transthoracic clamping can be
performed successfully with excellent results in the mid-term. Keywords:
Minimally invasive surgery; Complications; Ultrasound; Vascular disease.

Can J Anaesth. 2007 Sep;54(9):718-27.

Effect of intravenous nitroglycerin on cerebral saturation in high-risk cardiac
surgery.

Piquette D, Deschamps A, Bélisle S, Pellerin M, Levesque S, Tardif JC, Denault
AY.

Department of Anesthesiology and Research Center, Montreal Heart Institute and
Université de Montréal, 5000 Bélanger Street, Montréal, Québec H1T 1C8, Canada.

PURPOSE: To determine whether or not intravenous nitroglycerin (IV NTG) can
prevent a decrease in near-infrared spectroscopy (NIRS) values during
cardiopulmonary bypass (CPB). METHODS: We conducted a randomized double-blinded
study in a tertiary academic center including 30 patients with a Parsonnet
score>or=15 scheduled for a high-risk cardiac surgery. The patients were
randomized to receive either IV NTG (initial dose of 0.05 microg.kg(-1).min(-1), 
followed by 0.1 microg.kg(-1).min(-1)) or placebo after anesthetic induction
until the end of CPB. The primary outcome was a decrease of 10% in NIRS values
during CPB. RESULTS: Despite the absence of between-group difference in the mean 
cerebral oxygen saturation during CPB, there was a significant decrease in NIRS
values during CPB in the placebo group, whereas mean NIRS values were maintained 
in the IV NTG group (-16.7% vs 2.3% in the NTG, P=0.019). Major hemodynamic
variables were similar at corresponding time periods in both groups, while
patients in the IV NTG group had higher CK-MB values and experienced greater
blood loss during the first 24 hr postoperatively. CONCLUSION: Intravenous
nitroglycerin administration before and during CPB may prevent a decrease in NIRS
values associated with CPB in high-risk cardiac surgery. Further studies are
warranted to determine the efficacy and the risks associated with IV NTG infusion
for this indication during CPB in high-risk patients.