J Thorac Cardiovasc Surg. 2005 Nov;130(5):1278-86. Epub 2005 Oct 13. 

Increasing duration of deep hypothermic circulatory arrest is associated with an
increased incidence of postoperative electroencephalographic seizures.

Gaynor JW, Nicolson SC, Jarvik GP, Wernovsky G, Montenegro LM, Burnham NB,
Hartman DM, Louie A, Spray TL, Clancy RR.

Division of Cardiothoracic Surgery, The Cardiac Center at The Children's
Hospital of Philadelphia, Philadelphia, Pa 19104, USA. gaynor@email.chop.edu

OBJECTIVE: Electroencephalographic seizures have been shown to occur in 5% to
20% of neonates and infants after biventricular repair of a variety of cardiac
defects. Occurrence of a seizure is a predictor of adverse long-term
neurodevelopmental sequelae. The contemporary incidence of postoperative
seizures after repair of cardiac defects such as hypoplastic left heart syndrome
and other forms of single ventricle is not known. METHODS: A prospective study
of 178 patients less than 6 months of age undergoing cardiopulmonary bypass with
or without deep hypothermic circulatory arrest (DHCA) was conducted at a single
institution from September 2001 through March 2003 to identify postoperative
seizures assessed by 48-hour continuous video electroencephalographic
monitoring. RESULTS: Cardiac defects included transposition of the great
arteries with or without a ventricular septal defect (n = 12), ventricular
septal defect with or without coarctation (n = 28), tetralogy of Fallot (n =
24), hypoplastic left heart syndrome or variant (n = 60), other functional
single ventricle (n = 14), and other defects suitable for biventricular repair
(n = 40). Median age at the time of the operation was 7 days (range, 1-188 days)
and was 30 days or less in 110 (62%) patients. DHCA was used in 117 (66%)
patients, with multiple episodes in 9 patients. Median total duration of DHCA
was 40 minutes (range, 1-90 minutes). Electroencephalographic seizures were
identified in 20 (11.2%) patients. Seizures occurred in 15 (14%) of 110 neonates
and 5 (7%) of 68 older infants. Seizures occurred in 1 (4%) of 24 patients with
tetralogy of Fallot, 1 (8%) of 12 with transposition of the great arteries, and
11 (18%) of 60 with hypoplastic left heart syndrome or variant. By stepwise
logistic regression analysis, once increasing duration of total DHCA (P = .001)
was considered, no other variable improved prediction of occurrence of a
seizure. Patients with DHCA duration of more than 40 minutes had an increased
incidence of seizures (14/58 [24.1%]) compared with those with a DHCA duration
of 40 minutes or less (4/59 [6.8%], P = .04). The incidence of seizures for
patients with a DHCA duration of 40 minutes or less was not significantly
different from those in whom DHCA was not used (2/61 [3.3%], P = .38).
CONCLUSIONS: In the current era, continuous electroencephalographic monitoring
demonstrates early postoperative seizures in 11.2% of a heterogeneous cohort of
neonates and infants with complex congenital heart defects. Increasing duration
of DHCA was identified as a predictor of seizures. However, the incidence of
seizures in children with limited duration of DHCA was similar to that in
infants undergoing continuous cardiopulmonary bypass alone.

Acta Neuropathol (Berl). 2005 Oct 22; [Epub ahead of print] 

Hypoxic-ischemic brain injury in infants with congenital heart disease dying
after cardiac surgery.

Kinney HC, Panigrahy A, Newburger JW, Jonas RA, Sleeper LA.

Department of Pathology, Children's Hospital and Harvard Medical School, Enders
1112, 300 Longwood Avenue, Boston, MA, 02115, USA.

Cardiac surgery for congenital heart disease is performed increasingly earlier
in infancy, including in the neonatal period. With increased survival of
infants, there is growing concern about the long-term neurological sequelae of
hypoxic-ischemic injury due to congenital heart disease itself prior to surgery,
corrective surgery with the use of low-flow cardiopulmonary bypass (CPB) and/or
deep hypothermic circulatory arrest (DHCA), and/or unstable hemodynamic factors
postoperatively. In analyzing the neuropathology of 38 infants dying after
cardiac surgery, we tested a set of questions related to the severity and
patterns of brain injury, CPB, DHCA, and age of the infants at the time of
surgery. In all infants dying after cardiac surgery, irrespective of the
modality, cerebral white matter damage [periventricular leukomalacia (PVL) or
diffuse white matter gliosis] was the most significant lesion in terms of
severity and incidence, followed by a spectrum of gray matter lesions. There was
no significant association between the duration of deep hypothermic circulatory
arrest and the degree of severity of overall brain injury, and the pattern of
brain injury was similar irrespective of the modality of cardiac surgery. There
was no significant association between the age at the time of surgery (neonatal
versus postneonatal) and the severity of overall brain injury. The patterns of
brain injury were not age-related in the limited time-frame analyzed, except
that infants who developed acute PVL after both closed and DHCA/CPB surgery
(14/38 infants, 34%) were significantly younger at death (median age 13.0 days)
compared to unaffected infants (median age at death 42.5 days) (P=0.031). This
observation suggests that neonatal (<30 postnatal days), but not postneonatal
(>30 postnatal days), brains are at risk for acute PVL, and likely reflects the
vulnerability of immature (pre-myelinating) white matter to hypoxia-ischemia.

Chest. 2005 Oct;128(4):2910-7. 

Effects of inhaled nitric oxide on inflammation and apoptosis after
cardiopulmonary bypass.

El Kebir D, Hubert B, Taha R, Troncy E, Wang T, Gauvin D, Gangal M, Blaise G.

Laboratory of Anesthesia, Department of Anesthesia and Research Center, Center
Hospitalier de Universitie de Montreal, Hopital Notre-Dame, Deschamps Pavilion,
Room FS-1136, 1560 Sherbrooke St East, Montreal, QC, Canada, H2L 4M1.

BACKGROUND: Cardiopulmonary bypass (CPB), a procedure often used during cardiac
surgery, is associated with an inflammatory process that leads to lung injury.
We hypothesized that inhaled nitric oxide (INO), which has anti-inflammatory
properties, possesses the ability to modulate lung cell apoptosis and prevent
CPB-induced inflammation. METHODS: Twenty male pigs were randomly classified
into four groups: sham, sham plus INO, CPB, and CPB plus INO. INO (20 ppm) was
administered for 24 h after anesthesia. CPB was performed 90 min into INO
treatment. BAL fluid and blood were collected at time 0 (before CPB), at 4 h
after beginning CPB, and 24 h after beginning CPB (T24). RESULTS: At T(24), BAL
interleukin (IL)-8 levels and neutrophil percentages were elevated significantly
in the CPB group. At T(24), INO reduced IL-8 concentrations and attenuated the
increase of neutrophil percentage in the CPB-plus-INO group.
Nitrite-plus-nitrate (NOx) concentrations were decreased significantly in groups
without INO. Moreover, animals treated with INO showed higher rates of pulmonary
apoptosis compared to their respective control groups except for the
sham-plus-INO group, in which they were diminished. CONCLUSION: These results
demonstrate that NOx production is reduced after CPB, and that INO acts as an
anti-inflammatory agent by decreasing neutrophil numbers and their major
chemoattractant, IL-8. INO also increases cell apoptosis in the lungs during
inflammatory conditions, which may explain, in part, how it resolves pulmonary
inflammation.

Chest. 2005 Oct;128(4):2677-87. 

Dexamethasone: benefit and prejudice for patients undergoing on-pump coronary
artery bypass grafting: a study on myocardial, pulmonary, renal, intestinal, and
hepatic injury.

Morariu AM, Loef BG, Aarts LP, Rietman GW, Rakhorst G, van Oeveren W, Epema AH.

Department of BioMedical Engineering/Artificial Organs, University Medical
Center Groningen, Antonius Deusinglaan 1, 9713 AV Groningen, Netherlands.

STUDY OBJECTIVES: Cardiac surgery with cardiopulmonary bypass (CPB) results in
perioperative organ damage caused by the systemic inflammatory response syndrome
(SIRS) and ischemia/reperfusion injury. Administration of corticosteroids before
CPB has been demonstrated to inhibit the activation of the systemic inflammatory
response. However, the clinical benefits of corticosteroid therapy are
controversial. This study was designed to document the effects of dexamethasone
on cytokine release and perioperative myocardial, pulmonary, renal, intestinal,
and hepatic damage, as assessed by specific and sensitive biomarkers. DESIGN AND
PATIENTS: A prospective, double-blind, placebo-controlled, randomized trial for
dexamethasone was conducted in 20 patients receiving either dexamethasone (1
mg/kg before anesthesia induction and 0.5 mg/kg after 8 h; n = 10) or placebo (n
= 10). Different markers were used to assess the SIRS: interleukin (IL)-6, IL-8,
IL-10, C-reactive protein (CRP), and tryptase; and organ damage: heart (plasma
heart-type fatty acid binding protein, cardiac troponin I [cTnI], creatine
kinase-MB), kidneys (N-acetyl-glucosaminidase [NAG], microalbuminuria),
intestine (intestinal-type fatty acid binding protein [I-FABP]/liver-type fatty
acid binding protein [L-FABP]), and liver (alpha-glutathione S-transferase).
RESULTS: Dexamethasone modulated the SIRS with lower proinflammatory (IL-6,
IL-8) and higher antiinflammatory (IL-10) IL levels. CRP and tryptase were lower
in the dexamethasone group. cTnI values were lower in the dexamethasone group at
6 h in the ICU (p = 0.009). Patients in the dexamethasone group had a longer
time to tracheal extubation (18.86 +/- 1.13 h vs 15.01 +/- 0.99 h, p = 0.02
[mean +/- SEM]), with a lower oxygenation index at that time: Pa(O2)/fraction of
inspired oxygen ratio, 37.17 +/- 1.8 kPa vs 29.95 +/- 2.1 kPa (p = 0.009). The
postoperative glucose level (10.7 +/- 0.6 mmol/L vs 7.4 +/- 0.5 mmol/L, p =
0.005) was higher in the dexamethasone group. Serum glucose was independently
associated with intestinal injury (urine I-FABP peak, R2 = 42.5%, beta = 114.4
+/- 31.4, significant at p = 0.002; urine L-FABP peak, R2 = 47.3%, beta =
7,714.1 +/- 1,920.9, significant at p = 0.001) and renal injury (urine NAG, R2 =
32.1%, beta = 0.21 +/- 0.07, significant at p = 0.009). Tryptase peaks
correlated negatively with peaks of intestinal and renal injury biomarkers.
CONCLUSION: Even while inhibiting SIRS, dexamethasone treatment offered no
protection against transient, subclinical, perioperative abdominal organ damage.
Tryptase release could have a preconditioning effect, offering protection
against perioperative intestinal and renal damage. Dexamethasone treatment
resulted in more pronounced postoperative pulmonary dysfunction, prolonged time
to tracheal extubation, and initiated postoperative hyperglycemia in patients
undergoing elective on-pump coronary artery bypass graft surgery.

Eur J Cardiothorac Surg. 2005 Nov;28(5):701-4. Epub 2005 Oct 10. 

Minimal versus conventional cardiopulmonary bypass: assessment of intraoperative
myocardial damage in coronary bypass surgery.

Immer FF, Pirovino C, Gygax E, Englberger L, Tevaearai H, Carrel TP.

Department of Cardiovascular Surgery, University Hospital, 3010 Berne,
Switzerland.

OBJECTIVE: Minimal extracorporeal circulation (mini-ECC) is a new technology,
consisting of a centrifugal pump, an oxygenator, and a modified suction system.
The main advantage of mini-ECC is the reduction of tubing length (reduction of
the priming volume). Additional beneficial effects are a decrease of coagulation
cascade and a reduction of blood transfusion in patients undergoing coronary
artery bypass grafting (CABG) surgery. We compared the intraoperative and early
postoperative myocardial damage and outcome of patients who underwent CABG
surgery with conventional cardiopulmonary bypass (CPB) or mini-ECC. METHODS: One
hundred and thirty-six consecutive patients who underwent isolated CABG surgery
at our institution were prospectively studied. Fifty-four patients (39.7%) were
operated with mini-ECC. Patient characteristics were similar in both groups. The
most interesting intraoperative details as well as in-hospital outcome were
assessed. RESULTS: There was no difference in mortality between the two groups.
Cross-clamping time was similar in both groups (p=0.07). Defibrillation was
required in one patient in the mini-ECC group (1.9%) and in 38 patients (46.3%)
in the CPB group (p<0.001). In the mini-ECC group, the requirement of inotropic
support and incidence of atrial fibrillation was significantly lower than in the
CPB group. Postoperative creatine kinase isoenzyme MB (CK-MB) and cardiac
Troponin I (cTnI) were significantly lower in the mini-ECC group (p<0.05).
Duration of ventilation, length of stay in the intensive care unit and total
hospitalization time were significantly shorter in patients operated with
mini-ECC (p<0.05). CONCLUSION: Mini-ECC is a safe procedure and is followed by a
diminished release of CK-MB and cTnI than after CPB. Postoperative recovery is
accelerated following mini-ECC and there is a significantly lower incidence of
postoperative atrial fibrillation.

J Thorac Cardiovasc Surg. 2005 Oct;130(4):1144. 

Hyperglycemia during cardiopulmonary bypass is an independent risk factor for
mortality in patients undergoing cardiac surgery.

Doenst T, Wijeysundera D, Karkouti K, Zechner C, Maganti M, Rao V, Borger MA.

Division of Cardiovascular Surgery, Toronto General Hospital and University of
Toronto, Toronto, Ontario, Canada.

BACKGROUND: Hyperglycemia is commonly present in the perioperative period in
patients undergoing cardiac surgery, even during administration of insulin. A
direct relationship between postoperative hyperglycemia and mortality has been
established in diabetic patients undergoing cardiac surgery. However, this
relationship might be confounded because patients with poor outcome receive more
glucogenic drugs postoperatively. We assessed the influence of hyperglycemia
(highest glucose level) during cardiopulmonary bypass on perioperative morbidity
and mortality in diabetic and nondiabetic patients. METHODS: We performed a
multivariate logistic regression analysis on all diabetic (n = 1579) and
nondiabetic (n = 4701) patients undergoing cardiac surgery at the Toronto
General Hospital between 1999 and 2001. Boluses of insulin were given during
cardiopulmonary bypass when the glucose level exceeded 15 mmol/L, when the serum
potassium level exceeded 6.0 mmol/L, or both. RESULTS: Overall mortality was
1.8% (n = 115). A high glucose level during cardiopulmonary bypass was an
independent predictor of mortality in both diabetic (odds ratio, 1.20;
confidence interval, 1.08-1.32) and nondiabetic (odds ratio, 1.12; confidence
interval, 1.06-1.19; per millimole per liter increase in glucose) patients. A
high glucose level during cardiopulmonary bypass was also an independent
predictor of all major adverse events in both patient groups (odds ratio, 1.06;
confidence interval, 1.03-1.09). A high glucose level was not closely related to
cardiopulmonary bypass (r = 0.3) or aortic crossclamp times (r = 0.4).
CONCLUSIONS: A high peak serum glucose level during cardiopulmonary bypass is an
independent risk factor for death and morbidity in diabetic patients and
unexpectedly also in nondiabetic patients.

J Thorac Cardiovasc Surg. 2005 Oct;130(4):1054-61. 

Protein oxidation injury occurs during pediatric cardiopulmonary bypass.

Sheil ML, Luxford C, Davies MJ, Peat JK, Nunn G, Celermajer DS.

Adolph Basser Cardiac Institute, The Children's Hospital at Westmead, Sydney,
Australia. Meredits@chw.edu.au

OBJECTIVE: Proteins are the major effectors of biological structure and
function. Oxidation-induced changes to protein structure can critically impair
protein function, with important pathologic consequences. This study was
undertaken to examine whether oxidation-induced changes to protein structure
occur during pediatric cardiopulmonary bypass and to examine the association
with postoperative outcome. METHODS: Elevation of the 3,4-dihydroxyphenylalanine
content of a protein relative to its native tyrosine content indicates
structural damage due to oxidation. Protein 3,4-dihydroxyphenylalanine/native
tyrosine ratios were measured before surgery and up to 6 hours after institution
of cardiopulmonary bypass in 24 children undergoing repair of congenital heart
disease, who were prospectively selected to form a cyanotic and comparable
acyanotic control group. Results were correlated with perioperative variables
and postoperative outcomes. RESULTS: Elevation of protein
3,4-dihydroxyphenylalanine/tyrosine ratios above baseline (0.48 mmol/mol [SD,
0.11 mmol/mol] vs 0.36 mmol/mol [SD, 0.13 mmol/mol]; P = .001) occurred within
30 minutes of initiating cardiopulmonary bypass in cyanotic but not in acyanotic
children and correlated inversely with preoperative arterial oxygen saturation
(R = -0.52; P = .03). Protein 3,4-dihydroxyphenylalanine/tyrosine ratios were
also increased above baseline at 120 minutes (0.44 mmol/mol [SD, 0.12 mmol/mol];
P = .007) and 180 minutes (0.40 mmol/mol [SD, 0.14 mmol/mol]; P = .01) after the
institution of cardiopulmonary bypass in children who underwent prolonged
procedures. Elevation of 3,4-dihydroxyphenylalanine/tyrosine during prolonged
procedures was associated with postoperative arrhythmias and the need for
increased inotropic support (P = .001). CONCLUSIONS: Oxidative injury to
proteins occurs during pediatric cardiopulmonary bypass. Cyanotic children are
most at risk, particularly those undergoing prolonged procedures, in whom
elevation of the protein 3,4-dihydroxyphenylalanine/tyrosine ratio is associated
with increased postoperative morbidity.

Anesthesiology. 2005 Oct;103(4):687-694. 

Poor Intraoperative Blood Glucose Control Is Associated with a Worsened Hospital
Outcome after Cardiac Surgery in Diabetic Patients.

Ouattara A, Lecomte P, Le Manach Y, Landi M, Jacqueminet S, Platonov I, Bonnet
N, Riou B, Coriat P.

* Assistant Professor, dagger Staff Anesthesiologist, Department of
Anesthesiology, double dagger Assistant Professor, Department of Diabetology, 
section sign Assistant Professor, Department of Thoracic and Cardiovascular
Surgery,  parallel Professor of Anesthesiology and Critical Care and Chairman,
Department of Emergency Medicine and Surgery, # Professor of Anesthesiology and
Critical Care and Chairman, Department of Anesthesiology.

BACKGROUND:: Tight perioperative control of blood glucose improves the outcome
of diabetic patients undergoing cardiac surgery. Because stress response and
cardiopulmonary bypass can induce profound hyperglycemia, intraoperative
glycemic control may become difficult. The authors undertook a prospective
cohort study to determine whether poor intraoperative glycemic control is
associated with increased intrahospital morbidity. METHODS:: Two hundred
consecutive diabetic patients undergoing on-pump heart surgery were enrolled. A
standard insulin protocol based on subcutaneous intermediary insulin was given
the morning of the surgery. Intravenous insulin therapy was initiated
intraoperatively from blood glucose concentrations of 180 mg/dl or greater and
titrated according to a predefined protocol. Poor intraoperative glycemic
control was defined as four consecutive blood glucose concentrations greater
than 200 mg/dl without any decrease in despite insulin therapy. Postoperative
blood glucose concentrations were maintained below 140 mg/dl by using aggressive
insulin therapy. The main endpoints were severe cardiovascular, respiratory,
infectious, neurologic, and renal in-hospital morbidity. RESULTS:: Insulin
therapy was required intraoperatively in 36% of patients, and poor
intraoperative glycemic control was observed in 18% of patients. Poor
intraoperative glycemic control was significantly more frequent in patients with
severe postoperative morbidity (37% vs. 10%; P < 0.001). The adjusted odds ratio
for severe postoperative morbidity among patients with a poor intraoperative
glycemic control as compared with patients without was 7.2 (95% confidence
interval, 2.7-19.0). CONCLUSION:: Poor intraoperative control of blood glucose
concentrations in diabetic patients undergoing cardiac surgery is associated
with a worsened hospital outcome after surgery.

Ann Thorac Surg. 2005 Oct;80(4):1460-7. 

Specific bypass conditions determine safe minimum flow rate.

Anttila V, Hagino I, Zurakowski D, Iwata Y, Duebener L, Lidov HG, Jonas RA.

Department of Pathology, Children's Hospital Boston, Harvard Medical School,
Boston, Massachusetts, USA.

BACKGROUND: The purpose of this study is to define a safe minimum flow rate for
specific bypass conditions using continuous monitoring with near-infrared
spectroscopy and direct observation of the cerebral microcirculation. METHODS:
Two series of experiments (n = 72 in each) were conducted in which piglets were
cooled to a temperature of 15 degrees, 25 degrees, or 34 degrees C on
cardiopulmonary bypass with hematocrit 20% or 30%, pH-stat management in all,
followed by 1 or 2 hours of reduced flow (10, 25, or 50 mL.kg(-1).min(-1)).
Animals in series one had a cranial window placed over the parietal cortex to
evaluate the microcirculation with intravital microscopy. Plasma was labeled
with fluorescein-isothiocyanate-dextran for assessment of functional capillary
density (FCD) and microvascular diameter. In series two, near-infrared
spectroscopy was utilized to detect tissue oxygenation index (TOI). Outcome
measures included histologic and neurologic injury scores. RESULTS: The TOI
during low flow and FCD during rewarming and after weaning from cardiopulmonary
bypass were associated with neurologic injury. Failure of FCD to return to
baseline during rewarming predicted worse functional and histologic outcome (p <
0.001). Regression analysis indicated that temperature and low-flow rate were
multivariable predictors of TOI and FCD during rewarming (p < 0.001).
CONCLUSIONS: Tissue oxygen index derived from near-infrared spectroscopy is a
useful real-time monitor for detecting inadequate cerebral perfusion during
cardiopulmonary bypass. Minimal safe pump flow rate varies according to the
conditions of bypass: using pH stat management and with an hematocrit of either
20% or 30%, a flow rate as low as 10 mL.kg(-1).min(-1) is safe for as long as 2
hours at a temperature of 15 degrees C. However, under the same conditions at 34
degrees C, a flow rate of 10 mL.kg(-1).min(-1) is very likely to be associated
with neurologic injury.

Ann Thorac Surg. 2005 Oct;80(4):1388-93; discussion 1393. 

Does the combination of aprotinin and angiotensin-converting enzyme inhibitor
cause renal failure after cardiac surgery?

Kincaid EH, Ashburn DA, Hoyle JR, Reichert MG, Hammon JW, Kon ND.

Department of Cardiothoracic Surgery, Wake Forest University School of Medicine,
Winston-Salem, North Carolina 27157, USA. tkincaid@wfubmc.edu

BACKGROUND: Aprotinin use in cardiac surgery has been associated with mild
elevations in serum creatinine but generally has not been associated with an
increase in the risk of acute renal failure. In the presence of
angiotensin-converting enzyme (ACE) inhibitors, however, aprotinin may
contribute to significant reductions in glomerular perfusion pressure. The
purpose of this study was to test the hypothesis that the combination of ACE
inhibitors and aprotinin cause renal failure after cardiac surgery. METHODS: The
study consisted of a retrospective investigation of all adult patients
undergoing coronary artery bypass graft, valve, or combined procedures during
the years 2000 to 2002 at a single institution. Aprotinin was administered
selectively for reoperations, combined procedures, and other operations deemed
to be at higher risk for bleeding. Excluded from analysis were patients with
preoperative serum creatinine greater than 1.5 mg/dL, a history of renal
failure, emergent or salvage procedures, preoperative use of intraaortic balloon
pump, and off-pump procedures. Perioperative renal failure was defined as
creatinine greater than 2.0 mg/dL within 72 hours of surgery. Preoperative
demographic and intraoperative variables were analyzed with univariate and
logistic regression analysis with odds ratio (OR) and bootstrap validation.
RESULTS: A total of 1,209 patients were included. The incidence of perioperative
renal failure was 3.5%, and mortality in this group was 48%. Controlling for
other demographic and intraoperative variables that may affect renal function
(age, sex, diabetes mellitus, hypertension, New York Heart Association class,
prior cardiac surgery, valve procedures, cardiopulmonary bypass time, aortic
cross-clamp time, lowest hematocrit during cardiopulmonary bypass, transfusions)
the preoperative use of ACE inhibitors along with intraoperative use of
aprotinin was significantly associated with acute renal failure (OR 2.9, 95%
confidence interval [CI]: 1.4 to 5.8, p < 0.0001). The effect of either drug
alone was not significant. Other identified risk factors included age (OR 1.2
per year, CI: 1.01 to 1.5, p = 0.035), valve procedure (OR 2.7, CI: 1.3 to 5.7,
p = 0.016), lowest hematocrit on cardiopulmonary bypass (OR 2.2, CI: 1.6 to 3.2,
p < 0.0001), and transfusions of red blood cells (OR 1.04 per unit, CI: 1.02 to
1.06, p < 0.0001) and platelets (OR 1.7 per unit, CI: 1.2 to 2.4, p = 0.001).
CONCLUSIONS: The combination of preoperative use of ACE inhibitors and
intraoperative use of aprotinin should be avoided in cardiac surgery.