J Cardiovasc Surg (Torino)  2002 Oct;43(5):633-41 

Optimization of mechanical ventilation support following cardiac surgery.

Simeone F, Biagioli B, Scolletta S, Marullo AC, Marchet- Ti L, Caciorgna M,
Giomarelli P.

Institute of Thoracic and Cardiovascular Surgery, University of Siena, Siena,
Italy.

BACKGROUND: Mechanical ventilation (MV) is essential in the management of
patients that underwent cardiac surgery and cardiopulmonary bypass. It has been
demonstrated that MV dependence is directly related to morbidity incidence and
ICU length of stay, with a strong impact on economic cost. Therefore
identification of measures that can reduce MV interval, may reduce the incidence
of respiratory complications and length of hospitalization. The aim of this
study was to identify weaning indexes and adopt a weaning algorithm in order to
optimize ventilatory support after cardiac surgery. METHODS: Forty-nine patients
with low and medium Higgins risk score, who underwent, between Februa-ry and
November 1999, elective surgery at our Institution, were enrolled in this study.
All patients were randomized into 2 groups: Group I (weaning group - 24
patients), extubated with the aid of a weaning protocol, and Group II (control
group - 25 patients), extubated with conservative weaning, dependent on the
physician's subjective clinical judgment. All patients were successfully weaned
from mechanical support. RESULTS: Intubation time was significantly lower in
Group I than Group II and "Fast Track Recovery" group (p=0.05). ICU length of
stay was also significantly lower in Group I (p=0.03). Analysis of weaning
indexes did not show cut-off points predictive of successful weaning, except for
PaO2/FiO2 ratio, which was higher in Group I (p=0.02). CONCLUSIONS: These
results confirm that the use of a weaning algorithm enables the MV interval and
hospital length of stay to be shortened, suggesting that it should be used in
the management following cardiac surgery.

Cardiovasc Surg  2002 Oct;10(5):470 

Leukocyte activation and phagocytotic activity in cardiac surgery and infection.

Rothenburger M, Trosch F, Markewitz A, Berendes E, Schmid C, Scheld H, Tjan T.

Department of Thoracic and Cardiovascular Surgery, University Hospital of
Muenster, Albert-Schweitzer Str. 33, 48129, Muenster, Germany

BACKGROUND: Cardiac surgery (CS) using cardiopulmonary bypass (CPB) is
associated with cellular and humoral defense reactions termed the systemic
inflammatory response syndrome. Leukocyte activation is one of its causative
mechanisms which may be aggravated by additional infection. METHODS AND RESULTS:
Eighty-five patients undergoing CS with CPB were prospectively investigated.
Leukocyte counts, elastase, and phagocytotic activity were measured from 24 h
preoperatively up to 7 days postoperatively. Seventy-nine patients had an
uneventful course (group 1) while six patients developed a systemic infection
(group 2). Leukocytes and elastase levels increased postoperatively (p<0.01) and
were significantly higher in group 2 (p<0.01). In both groups a decrease of
leukocyte/elastase ratio occurred (p<0.002), no differences between groups were
observed. The phagocytotic activity, representing the circulating cells of the
reticuloendothelial system (RES), dropped on day 1 (p<0.05), and increased
thereafter above baseline levels (p<0.001). No differences of RES function
between groups was observed, the initial drop on day 1 in both groups was
compensated by the quality of phagocytotic ability of each cells. CONCLUSION:
Leukocyte activation after CS with CPB occurs. It is associated with a regular
RES function and similarly leukocyte/elastase ratios in both groups, suggesting
an adequate immune response. Therapeutic interventions resulting in depletion of
leukocytes to alleviate reperfusion injury might impair the immune response of
those patients acquiring perioperative infection and should be approached with
caution. Leukocyte depletion maybe effective in patients for whom an extended
period of CPB was required. Further investigations to prove this hypothesis
awaits confirmation.

Ann Surg  2002 Oct;236(4):465-9; discussion 469-70 

Management of traumatic aortic rupture: a 30-year experience.

Cardarelli MG, McLaughlin JS, Downing SW, Brown JM, Attar S, Griffith BP.

Department of Surgery, Division of Cardiac Surgery, University of Maryland
Medical System, Baltimore, Maryland 21201, USA. mcard001@umaryland.edu

OBJECTIVE: To present the authors' 30-year experience with traumatic aortic
rupture (TAR). SUMMARY BACKGROUND DATA: TAR is a highly lethal injury. Most
institutions manage a small number of cases, and most surgeons receive only
modest exposure during training. METHODS: Between 1971 and 2001, the authors
operated on 219 patients with a diagnosis of TAR. Diagnosis of TAR since 1994
has been based exclusively on the use of contrast-enhanced spiral computed
tomography, with angiography reserved for equivocal cases (periaortic
mediastinal hematoma without aortic wall abnormalities). Patients were divided
according to surgical technique. Eighty-two patients (group A) were operated on
with a clamp-and-sew technique. Sixty-four patients (group B) underwent surgery
with the use of a passive shunt, and 73 patients (group C) were treated using
heparin-less partial cardiopulmonary bypass. RESULTS: Mortality was 18 patients
for group A (21.9%), 23 patients for group B (35.9%), and 13 patients for group
C (17.8%) (P =.03). Paraplegia occurred in 15 of 64 survivors in group A
(23.4%), 7 of 41 survivors in group B (17%), and 0 of 60 survivors in group C (
P=.0005). Aortic occlusion without lower body perfusion for longer than 30
minutes (P =.004) and surgical technique without lower body bypass support (P
=.0005) were associated with paraplegia. CONCLUSIONS: Surgery for TAR based on
spiral computed tomography screening and diagnosis is reliable. The use of
heparin-less distal cardiopulmonary bypass in the authors' hands is safe and is
associated with a reduced incidence of paraplegia.

Anesthesiology  2002 Oct;97(4):837-41 

Hemostatic activation and inflammatory response during cardiopulmonary bypass:
impact of heparin management.

Koster A, Fischer T, Praus M, Haberzettl H, Kuebler WM, Hetzer R, Kuppe H.

Department of Anesthesia, Deutsches Herzzentrum, and Institute of Physiology,
Freie Universitat, Berlin, Germany. Koster@dhzb.de

BACKGROUND: Cardiac surgery involving cardiopulmonary bypass (CPB) leads to
fulminant activation of the hemostatic-inflammatory system. The authors
hypothesized that heparin concentration-based anticoagulation management
compared with activated clotting time-based heparin management during CPB leads
to more effective attenuation of hemostatic activation and inflammatory
response. In a randomized prospective study, the authors compared the influence
of anticoagulation with a heparin concentration-based system (Hepcon HMS;
Medtronic, Minneapolis, MN) to that of activated clotting time-based management
on the activation of the hemostatic-inflammatory system during CPB. METHODS: Two
hundred elective patients (100 in each group) undergoing standard cardiac
surgery in normothermia were enrolled. No antifibrinolytic agents or aprotinin
and no heparin-coated CPB systems were used. Samples were collected after
administration of the heparin bolus before initiation of CPB and after
conclusion of CPB before protamine infusion. RESULTS: There were no differences
in the pre-CPB values between both groups. After CPB there were significantly
higher concentrations ( < 0.05) for heparin and a significant reduction in
thrombin generation (25.2 +/- 21.0 SD vs. 34.6 +/- 25.1), d-dimers (1.94 +/-
1.74 SD vs. 2.58 +/- 2.1 SD), and neutrophil elastase (715.5 +/- 412 SD vs.
856.8 +/- 428 SD), and a trend toward lower beta-thromboglobulin, C5b-9, and
soluble P-selectin in the Hepcon HMS group. There were no differences in the
post-CPB values for platelet count, adenosine diphosphate-stimulated platelet
aggregation, antithrombin III, soluble fibrin, Factor XIIa, or postoperative
blood loss. CONCLUSION: Compared with heparin management with the activated
clotting time, heparin concentration-based anticoagulation management during CPB
leads to a significant reduction of thrombin generation, fibrinolysis, and
neutrophil activation, whereas there is no difference in the effect on platelet
activation. The generation of fibrin even in the presence of high heparin
concentrations most likely has to be attributed to the reduced antithrombin III
concentrations or reduced inhibition of clot-bound thrombin. Therefore, in
addition to maintenance of higher heparin concentrations, monitoring and
substitution of antithrombin III should be considered to ensure more efficient
antithrombin activity during CPB.

Circulation  2002 Oct 1;106(14):1764-70 

Effectiveness of coronary artery bypass grafting with or without cardiopulmonary
bypass in overweight patients.

Ascione R, Reeves BC, Rees K, Angelini GD.

Bristol Heart Institute, University of Bristol, Bristol, UK.

BACKGROUND: Off-pump coronary artery bypass surgery has been demonstrated to
reduce morbidity in elective patients. However, high-risk patients might benefit
the most from this surgical procedure. Our goal was to investigate the
effectiveness of on-pump and off-pump coronary artery bypass surgery on early
clinical outcome in a consecutive series of overweight patients. METHODS AND
RESULTS: From April 1996 to April 2001, data on 4321 patients undergoing
coronary surgery (mortality 1.4%) were prospectively entered into the Patient
Analysis and Tracking System. Data were extracted for all patients with a body
mass index > or =25 kg/m(2). A risk-adjusted analysis was performed to assess
the effect of surgical technique in the whole overweight cohort. 2844 patients
were identified (2261 male, median age 63, interquartile range 56 to 68).
Patients undergoing on-pump surgery (2170, 76.3%) were less likely than those
undergoing off-pump surgery to have hypercholesterolemia or left main stem
disease and were, on average, less obese. However, they were more likely to have
unstable angina and to have had a previous myocardial infarction, and they had
more extensive coronary disease and received more grafts (all P<0.05).
Unadjusted analyses, taking account only of consultant team, showed significant
benefits of off-pump surgery in terms of hospital deaths, arrhythmias, inotropic
use, use of intra-aortic balloon pump, blood loss, transfusion requirement,
postoperative hemoglobin, chest infections, neurological complications,
intensive care unit and hospital stay (all P<0.05). After adjustment for
confounding prognostic factors, the benefits of off-pump surgery were still
significant for death in hospital, transfusion requirement, postoperative
hemoglobin, neurological complications, intensive care unit and hospital stay
(ORs 0.35 to 0.79, P<0.05). CONCLUSIONS: These results suggest that off-pump
surgery is safe and effective and is associated with a reduced in-hospital
mortality and morbidity in overweight patients when compared with conventional
coronary surgery with cardiopulmonary bypass and cardioplegic arrest.

J Urol  2002 Oct;168(4 Pt 1):1374-7 

Management of renal cell carcinoma with level III thrombus in the inferior vena
cava.

Ciancio G, Vaidya A, Savoie M, Soloway M.

Department of Surgery, Division of Transpalntation, University of Miami School
of Medicine, Floria, USA.

PURPOSE: Level III thrombus in the inferior vena cava poses a challenge to the
surgeon due to its relative inaccessibility. We introduce a new system to
redefine level III thrombus in anatomical relation to the hepatic veins and
describe a technique of safe resection of these tumors through a transabdominal
approach without recourse to cardiopulmonary bypass. MATERIALS AND METHODS: From
August 1997 to July 2001, 23 patients underwent resection of renal cell
carcinoma with a level III thrombus. Intraoperative as well as postoperative
variables such as operative time, estimated blood loss, number of transfusions,
cardiopulmonary bypass, postoperative complications, pathological findings and
survival were recorded. RESULTS: A total of 15 male and 8 female patients with a
mean age of 62 years (range 25 to 83) underwent resection of a level III
thrombus emanating from renal cell carcinoma. Patients were divided into groups
IIIa-9 with an infrahepatic thrombus, IIIb-6 with a hepatic thrombus, IIIc-5
with a suprahepatic, infradiaphragmatic thrombus and IIId-3 with a suprahepatic,
supradiaphragmatic, infra-atrial thrombus. Mean operative time was 5 hours 42
minutes (range 4 to 7.5 hours). The number of transfusions was 0 to 4. Estimated
blood loss was 100 to 5,000 cc (mean 500). Neither cardiopulmonary bypass nor
veno-venous bypass was required. Median followup was 25 months. Two patients
(9%) died, including 1 in the immediate postoperative period and the other from
metastasis 15 months after surgery. At the last followup 3 patients (13%) had
metastasis and 18 (78%) were disease-free for overall and disease-free survival
rates of 91% and 78%, respectively. CONCLUSIONS: An aggressive surgical approach
remains the mainstay of treatment to achieve cure. We believe that the extent of
dissection is different in each subgroup and, therefore, the need exists to
redefine level III thrombus of the inferior vena cava. The application of liver
transplant techniques for mobilizing the liver off of the inferior vena cava as
well as the inferior vena cava off of the posterior abdominal wall contributes
to excellent exposure and enables adequate vascular control of the inferior vena
cava.

Anesth Analg  2002 Oct;95(4):889-92 

A Glial-Derived Protein, S100B, in Neonates and Infants with Congenital Heart
Disease: Evidence for Preexisting Neurologic Injury.

Bokesch PM, Appachi E, Cavaglia M, Mossad E, Mee RB.

Departments of Cardiothoracic Anesthesia, Pediatric Critical Care, and the
Center for Congenital Heart Disease and Surgery, The Cleveland Clinic
Foundation, Ohio.

The glial-derived protein S100B is a serum marker of cerebral ischemia and
correlates with negative neurological outcome after cardiopulmonary bypass (CPB)
in adults. We sought to characterize the S100B release pattern before and after
CPB in neonates and infants with congenital heart disease and correlate it with
surgical mortality. Serum was collected before surgery and at 24 postoperative h
from 109 neonates and infants with congenital heart disease. All patients had
presurgical transthoracic echocardiograms and CPB with or without hypothermic
circulatory arrest. S100B concentrations were determined using a two-site
immunoluminometric assay (Sangtec 100(TM)). Thirty-day surgical mortality was
observed. All neonates had significantly increased S100B concentrations before
surgery that decreased by 24 postoperative h. Preoperative S100B concentrations
in 32 neonates with hypoplastic left heart syndrome correlated inversely with
the forward flow and size of the ascending aorta and postoperative mortality
(r(2) = -0.63; P = 0.03). Among infants, increased pulmonary blood flow was
associated with higher S100B levels before surgery than cyanosis. There was no
correlation with postoperative S100B and time on CPB, hypothermic circulatory
arrest, or 30-day surgical mortality. In conclusion, preoperative S100B
concentrations correlate inversely with the size of the ascending aorta in
hypoplastic left heart syndrome and may serve as a marker for preexisting brain
injury and mortality. IMPLICATIONS: Neonates with hypoplastic left heart
syndrome and no forward flow in the ascending aorta may have brain injury at
birth before heart surgery.

Anesth Analg  2002 Oct;95(4):828-34 

Correction of ionized plasma magnesium during cardiopulmonary bypass reduces the
risk of postoperative cardiac arrhythmia.

Wilkes NJ, Mallett SV, Peachey T, Di Salvo C, Walesby R.

Departments of Anaesthesia and Cardiothoracic Surgery, Royal Free Hospital,
London, United Kingdom.

We conducted this randomized controlled trial to determine whether the
intraoperative measurement and correction of ionized plasma magnesium can reduce
the risk of cardiac arrhythmia after cardiopulmonary bypass. Eighty-five
patients presenting for coronary artery bypass grafting were randomly assigned
either to the magnesium-corrected group, which received magnesium sulfate on the
basis of measured levels of ionized plasma magnesium (n = 43), or to the control
group, in which magnesium levels were identified but not corrected (n = 42).
Ionized magnesium was determined with an ion-selective electrode with minimal
delay, and further samples were taken for laboratory analysis of total plasma
magnesium. All patients had Holter electrocardiogram monitoring for 72 h after
surgery. Total hypomagnesemia (45 patients; 53% of all patients) was more common
than ionized hypomagnesemia (11 patients; 13%) before cardiopulmonary bypass.
Both total and ionized magnesium levels declined further during the course of
cardiopulmonary bypass in the control group. The incidence of ventricular
tachycardia in the first 24 h was less frequent in the magnesium-corrected group
(3 patients; 7%) than the control group (12 patients, 30%; P < 0.01). Patients
in the magnesium-corrected group were more likely to display continuous sinus
rhythm (Lown Grade 0) in the first 24 h (14 patients; 34%) than patients in the
control group (2 patients, 5%; P < 0.001). Our results suggest that the
intraoperative correction of ionized magnesium is associated with a reduction in
postoperative ventricular arrhythmia in cardiac surgical patients. IMPLICATIONS:
In this study the correction of ionized plasma magnesium during cardiopulmonary
bypass was guided by measurements from an ion-selective electrode. This
intervention resulted in a reduction in the incidence of postoperative
ventricular tachycardia and an increased frequency of continuous sinus rhythm.
Ion-selective electrodes constitute a convenient near-patient test, providing a
basis for the targeted replacement of ionized plasma magnesium.

J Thorac Cardiovasc Surg  2002 Oct;124(4):811-20 

Production of proinflammatory cytokines and myocardial dysfunction after
arterial switch operation in neonates with transposition of the great arteries.

Hovels-Gurich HH, Vazquez-Jimenez JF, Silvestri A, Schumacher K, Minkenberg R,
Duchateau J, Messmer BJ, Von Bernuth G, Seghaye MC.

Departments of Pediatric Cardiology and Thoracic and Cardiovascular Surgery and
the Institute of Biomedical Statistics, Aachen University of Technology, Aachen,
Germany, and the Department of Immunology, Hoxopital Brugman, Brussels, Belgium.

OBJECTIVE: Neonates undergoing cardiac surgery have a systemic inflammatory
reaction with release of proinflammatory cytokines, which could be responsible
for myocardial dysfunction as a result of myocardial cell damage. The purpose of
this study was to test the hypothesis that the production of proinflammatory
cytokines during cardiac surgery would be associated with myocardial dysfunction
after the arterial switch operation in neonates. METHODS: A total of 63 neonates
with transposition of the great arteries were operated on with combined deep
hypothermic circulatory arrest and low-flow cardiopulmonary bypass at a median
age of 7 days. Perioperative plasma concentrations of interleukins 6 and 8 were
correlated with myocardial dysfunction, as assessed clinically and by
echocardiography within 24 hours after the operation, and with perioperative
cardiac troponin T blood levels as a marker of myocardial cell damage. RESULTS:
Myocardial dysfunction was observed in 11 patients (17.5%), and 2 of them died.
Durations of cardiopulmonary bypass and aortic crossclamping, but not of
circulatory arrest, were correlated with myocardial dysfunction. Patients with
myocardial dysfunction had significantly higher cardiac troponin T blood levels
at the end of cardiopulmonary bypass and 4 and 24 hours after the operation than
did patients without myocardial dysfunction. Patients with myocardial
dysfunction also had higher interleukin 6 plasma concentrations after
cardiopulmonary bypass and 4 hours after the operation, as well as higher
interleukin 8 plasma concentrations 4 and 24 hours after the operation, than did
those without myocardial dysfunction. Postoperative interleukin 6 and 8 plasma
concentrations were significantly correlated with postoperative cardiac troponin
T blood levels. Multivariable analysis of independent risk factors for
myocardial dysfunction comprising cytokine and troponin levels and bypass
duration revealed interleukin 6 levels 4 hours after the operation as
significant (P =.047). CONCLUSIONS: Cardiac operations in neonates stimulate the
production of proinflammatory cytokines, which may contribute to myocardial cell
damage and myocardial dysfunction.