Crit Care Med  2001 Nov;29(11):2137-42

Influence of aminosteroid and glucocorticoid treatment on inflammation and
immune function during cardiopulmonary bypass.

Volk T, Schmutzler M, Engelhardt L, Docke WD, Volk HD, Konertz W, Kox WJ.

Department of Anesthesiology and Intensive Therapy, University Hospital Charite,
Campus Mitte, Humboldt-University, Berlin, Germany.

OBJECTIVE: During cardiopulmonary bypass, inflammation and immunosuppression is
present. We measured circulating mediators and monocyte-based functions and
tested the hypothesis that these variables are influenced by methylprednisolone
(MP) or tirilazad mesylate (TM) treatment. DESIGN: Randomized, controlled,
double-blind prospective trial. SETTING: A university hospital. PATIENTS:
Thirty-nine patients scheduled for conventional coronary surgery with
three-vessel disease. INTERVENTIONS: Preoperative application of MP (15 mg/kg)
or TM (10 mg/kg) compared with placebo (PL). MEASUREMENTS AND MAIN RESULTS:
Circulating proinflammatory markers including interleukin (IL)-6, IL-8, monocyte
chemoattractant protein 1, and C-reactive protein were all decreased by MP
treatment but not by TM treatment. Whereas rapid increases in circulating
anti-inflammatory IL-10 were superinduced by MP but not TM, plasma levels of
IL-1RA and transforming growth factor beta were not altered by either treatment.
Decreased ex vivo lipopolysaccharide-stimulated secretion of tumor necrosis
factor alpha was prolonged after MP treatment but not after TM treatment.
Perioperative stimulated secretion of IL-12 and interferon gamma was diminished
in all groups, whereas ex vivo IL-1RA secretion tended to increase in all
groups. Depression of monocyte surface expression of HLA-DR was significantly
greater in patients treated with MP, whereas CD14 expression did not change.
CONCLUSIONS: These data confirm that, during cardiopulmonary bypass, pro- and
anti-inflammatory systems are activated at the same time, whereas monocyte-based
immune functions are depressed. Treatment with MP abrogates proinflammatory
mediators and induces a shift toward anti-inflammation at the cost of further
functional monocyte deficits, whereas treatment with TM apparently has neither
anti-inflammatory nor immunosuppressive actions in this setting.

Can J Anaesth  2001 Nov;48(10):1011-4

Hepatosplanchnic oxygenation is better preserved during mild hypothermic than
during normothermic cardiopulmonary bypass : [L'oxygenation hepatosplanchnique
est mieux preservee pendant la circulation extracorporelle sous legere
hypothermie que sous normothermie].

Okano N, Hiraoka H, Owada R, Fujita N, Kadoi Y, Saito S, Goto F, Morita T.

Department of Anesthesiology, Saitama Cardiovascular and Pulmonary Center,
Saitama. the Department of Anesthesiology and Reanimatology, Gunma University,
School of Medicine, Gunma, Japan.

PURPOSE: To assess and compare the effects of normothermic and mild hypothermic
cardiopulmonary bypass (CPB) on hepatosplanchnic oxygenation. METHODS: We
studied 14 patients scheduled for elective coronary artery bypass graft surgery
who underwent normothermic (>35 degrees C; group I, n=7) or mild hypothermic (32
degrees C; group II, n=7) CPB. After induction of anesthesia, a hepatic venous
catheter was inserted into the right hepatic vein to monitor hepatic venous
oxygen saturation (ShvO(2)) and hepatosplanchnic blood flow by a constant
infusion technique that uses indocyanine green. RESULTS: The ShvO(2) decreased
from a baseline value in both groups during CPB and was significantly lower at
ten minutes and 60 min after the onset of CPB in group I (39.5 +/- 16.2% and
40.1 +/- 9.8%, respectively) than in group II (61.1 +/- 16.2% and 61.0 +/-
17.9%, respectively; P <0.05). During CPB, the hepatosplanchnic oxygen
extraction ratio was significantly higher in group I than in group II (44.0 +/-
7.2% vs 28.7 +/- 13.1%; P <0.05). CONCLUSION: Hepatosplanchnic oxygenation was
better preserved during mild hypothermic CPB than during normothermic CPB.

Paediatr Anaesth  2001 Nov;11(6):729-32

Life threatening cardiopulmonary failure in an infant following protamine
reversal of heparin after cardiopulmonary bypass.

Boigner H, Lechner E, Brock H, Golej J, Trittenwein G.

PICU, University Children's Hospital of Vienna, Vienna Department of Paediatric
Cardiology General Hospital of Linz, Linz, Austria Department of Anaesthetics,
General Hospital of Linz, Linz, Austria.

Life threatening cardiopulmonary failure following protamine reversal of heparin
after cardiopulmonary bypass (CPB) was reported to occur in adults but rarely in
children. Atrial septal defect closure was performed in a 6-week-old infant
erroneously suspected to suffer from right atrial thrombosis in addition.
Protamine administration after CPB led to critical pulmonary hypertension and
severe haemorrhagic pulmonary oedema resulting in severe hypoxia. Inhaled nitric
oxide, together with high frequency oscillation ventilation supplemented by
intravenous prostacycline, enabled complete recovery of cardiopulmonary and
neurological function. Life threatening cardiovascular compromise after
intravenous protamine can occur even in young infants which then require
challenging paediatric critical care.

J Am Coll Cardiol  2001 Nov 1;38(5):1456-62

The current practice of intra-aortic balloon counterpulsation: results from the
Benchmark Registry.

Ferguson JJ, Cohen M, Freedman RJ, Stone GW, Miller MF, Joseph DL, Ohman EM.

Texas Heart Institute, Houston, Texas, USA

OBJECTIVESThis study presents clinical data from the first large registry of
aortic counterpulsation, a computerized database that incorporates prospectively
gathered data on indications for intra-aortic balloon counterpulsation (IABP)
use, patient demographics, concomitant medication and in-hospital outcomes and
complications.BACKGROUNDThe intra-aortic balloon pump (IABP) is widely used to
provide circulatory support for patients experiencing hemodynamic instability
due to myocardial infarction, cardiogenic shock, or in very high risk patients
undergoing angioplasty or coronary artery bypass grafting.METHODSBetween June
1996 and August 2000, 203 hospitals worldwide (90% U.S., 10% non-U.S.) collected
16,909 patient case records (68.8% men, 31.2% women; mean age 65.9 +/- 11.7
years).RESULTSThe most frequent indications for use of IABP were as follows: to
provide hemodynamic support during or after cardiac catheterization (20.6%),
cardiogenic shock (18.8%), weaning from cardiopulmonary bypass (16.1%),
preoperative use in high risk patients (13.0%) and refractory unstable angina
(12.3%). Major IABP complications (major limb ischemia, severe bleeding, balloon
leak, death directly due to IABP insertion or failure) occurred in 2.6% of
cases; in-hospital mortality was 21.2% (11.6% with the balloon in place). Female
gender, high age and peripheral vascular disease were independent predictors of
a serious complication.CONCLUSIONSThis registry provides a useful tool for
monitoring the evolving practice of IABP. In the modern-day practice of IABP,
complication rates are generally low, although in-hospital mortality remains
high. There is an increased risk of major complications in women, older patients
and patients with peripheral vascular disease.

J Am Coll Cardiol  2001 Nov 1;38(5):1450-5

Decrease in jugular venous oxygen saturation during normothermic cardiopulmonary
bypass predicts short-term postoperative neurologic dysfunction in elderly
patients.

Kadoi Y, Saito S, Goto F, Fujita N.

Department of Anesthesiology and Reanimatology, Gunma University, School of
Medicine, Gunma, Japan

OBJECTIVESWe sought to examine whether the decrease in jugular venous oxygen
saturation (SjvO(2)) during cardiopulmonary bypass (CPB) can be used to predict
short-term and long-term postoperative cognitive disorders in elderly
patients.BACKGROUNDIt has been reported that elderly patients might be more
susceptible to hypoperfusion during CPB.METHODSOne hundred eighty-five patients
scheduled for elective coronary artery bypass graft surgery were studied. Group
1 (n = 56) was young (<50 years old), group 2 (n = 67) was middle-aged (50 to 69
years old) and group 3 (n = 62) was elderly (>70 years old). After induction of
anesthesia, a fiberoptic oximetry oxygen saturation catheter was inserted into
the right jugular bulb to monitor SjvO(2) continuously. Hemodynamic variables
and arterial and jugular venous blood gases were measured at seven time
points.RESULTSThe cerebral desaturation time (duration when SjvO(2) was <50%)
and the ratio of the cerebral desaturation time to the total CPB time in group 3
were significantly different from those in groups 1 and 2 (group 1: 20 +/- 6 min
and 16 +/- 5%; group 2: 19 +/- 7min and 14 +/- 6%; group 3: 34 +/- 9min and 24
+/- 7%, respectively; p < 0.05). Also, age (odds ratio [OR] 1.3, 95% confidence
interval [CI] 1.0 to 1.8, p = 0.02) and desaturation time (OR 1.3, 95% CI 1.0 to
1.4, p = 0.03) were perioperative factors in relation to short-term cognitive
impairment. However, age and desaturation time were not perioperative factors in
relation to long-term cognitive impairment.CONCLUSIONSReduced SjvO(2) was
associated with short-term cognitive dysfunction in elderly patients.

J Thorac Cardiovasc Surg  2001 Nov;122(5):935-45

Stroke in surgery of the thoracic aorta: Incidence, impact, etiology, and
prevention.

Goldstein LJ, Davies RR, Rizzo JA, Davila JJ, Cooperberg MR, Shaw RK, Kopf GS,
Elefteriades JA.

Department of Surgery, Section of Cardiothoracic Surgery, and Yale University
School of Medicine, New Haven, Conn.

OBJECTIVES: To determine the incidence, impact, etiology, and methods for
prevention of stroke after surgery of the thoracic aorta. METHODS: A total of
317 thoracic aortic operations on 303 patients (194 male, 109 female) aged 13 to
87 years (mean 61 years) were reviewed. There were 218 procedures on the
ascending aorta and arch and 99 on the descending aorta. Of the 218 procedures
on the ascending aorta and arch, 86 involved cardiopulmonary bypass, 122
involved deep hypothermic circulatory arrest, 2 involved antegrade cerebral
perfusion, and 8 involved "clamp and sew" or left heart bypass. Of the 99
procedures on the descending aorta, 20 involved "clamp and sew," 69 involved
left heart or full bypass, and 10 involved deep hypothermic circulatory arrest.
A total of 206 cases were elective and 97 were emergency operations. RESULTS:
Twenty-three (7.3%) of 317 patients had a stroke. Fifteen strokes occurred in
operations on the ascending aorta and 8 in operations on the descending aorta
(6.9% vs 8.1%; P =.703). Stroke occurred in 16 (16.5%) of 97 emergency
operations and 7 (3.4%) of 206 elective operations (P =.001). In the 300
patients surviving the operation, stroke was a significant predictor of
postoperative death (9/23 [39.1%] vs 23/277 [8.3%]; P =.001). Analysis of
operative reports, brain images, and neurologic consultations revealed 15 of the
23 strokes were embolic, 3 were ischemic, 3 hemorrhagic, and 2 indeterminate.
Patients with stroke had longer intensive care unit stays (18.4 vs 6.8 days; P
=.0001), longer times to extubation (12.7 vs 3.8 days; P <.0012), longer
postoperative stays (31.4 vs 14.3 days; P =.001), and decreased age-adjusted
survival (relative risk 2.775; P =.0013). After implementation of a rigorous
antiembolic regimen, both strokes and mortality trended downward. CONCLUSIONS:
(1) Stroke complicates surgery of both the ascending and descending thoracic
aorta and warrants consideration in decision making. (2) Strokes are largely
embolic. (3) Antiembolic measures for particles and air are essential, including
gentle aortic manipulation, thorough debridement, transesophageal
echocardiography to identify aortic atheromas, carbon dioxide flooding of the
field, and (in descending cases) proximal clamp application before initiating
femoral perfusion.

Anesthesiology  2001 Nov;95(5):1074-8

Cardiac and neurologic complications identify risks for mortality for both men
and women undergoing coronary artery bypass graft surgery.

Hogue CW Jr, Sundt T 3rd, Barzilai B, Schecthman KB, Davila-Roman VG.

Department of Anestesiology, Washigton University School of Medicine, St. Louis,
Missouri 63110, USA. hoguec@notes.wustl.edu

BACKGROUND: Despite a number of studies showing that women and men respond to
coronary artery bypass graft surgery differently, it is not known whether
variables associated with mortality are the same for women and men. The purpose
of this study was to identify variables independently associated with mortality
for women undergoing coronary artery bypass graft surgery. METHODS:
Single-institutional data were prospectively collected from 5,113 patients
(1,558 or 30.5% women) undergoing coronary artery bypass graft surgery. The
database was reviewed for patient characteristics and operative outcomes based
on sex. Complications evaluated included low cardiac output syndrome (cardiac
index < 2.0 l x min(-1) x m(-2) for > 8 h, regardless of treatment), stroke (new
permanent global or focal motor deficits), Q-wave myocardial infarction,
postoperative atrial fibrillation, and operative mortality. RESULTS: Women were
older than men, and they were more likely to have preexisting hypertension,
diabetes, and a history of stroke. Operative mortality for women was higher than
for men (3.5% vs. 2.5%, P < 0.05). Compared with men, women were more likely to
experience a postoperative myocardial infarction, stroke, and low cardiac output
syndrome. When performing analysis on data from both sexes separately, low
cardiac output syndrome, new stroke, myocardial infarction, and duration of
cardiopulmonary bypass were independently associated with mortality for women
and men both. Patient age was not independently associated with risk for
mortality for women, but it was for men. However, when the authors combined both
sexes in the logistic regression analysis, the age-sex interaction was not
significant (P = 0.266), indicating that there was insufficient evidence to
assert that age has a different effect on mortality for men and women.
CONCLUSIONS: These data confirm that women have higher perioperative mortality
after coronary artery bypass graft surgery compared with men. A higher frequency
of cardiac and neurologic complications seem to account to a large extent for
the higher operative mortality for women. Factors independently associated with
perioperative mortality are generally similar for women and men.

Eur J Cardiothorac Surg  2001 Nov;20(5):979-85

Arterial blood gas management in retrograde cerebral perfusion: the importance
of carbon dioxide.

Ueno K, Takamoto S, Miyairi T, Morota T, Shibata K, Murakami A, Kotsuka Y.

Department of Cardiothoracic Surgery, University of Tokyo, Tokyo, Japan

Objectives: Many interventional physiological assessments for retrograde
cerebral perfusion (RCP) have been explored. However, the appropriate arterial
gas management of carbon dioxide (CO(2)) remains controversial. The aim of this
study is to determine whether alpha-stat or pH-stat could be used for effective
brain protection under RCP in terms of cortical cerebral blood flow (CBF),
cerebral metabolic rate for oxygen (CMRO(2)), and distribution of regional
cerebral blood flow. Methods: Fifteen anesthetized dogs (25.1+/-1.1 kg) on
cardiopulmonary bypass (CPB) were cooled to 18 degrees C under alpha-stat
management and had RCP for 90 min under: (1), alpha-stat; (2), pH-stat; or (3),
deep hypothermic (18 degrees C) antegrade CPB (antegrade). RCP flow was
regulated for a sagittal sinus pressure of around 25 mmHg. CBF was monitored by
a laser tissue flowmeter. Serial analyses of blood gas were made. The regional
cerebral blood flow was measured with colored microspheres before
discontinuation of RCP. CBF and CMRO(2) were evaluated as the percentage of the
baseline level (%CBF, %CMRO(2)). Results: The oxygen content of arterial inflow
and oxygen extraction was not significantly different between the RCP groups.
The %CBF and %CMRO(2) were significantly higher for pH-stat RCP than for
alpha-stat RCP. The regional cerebral blood flow, measured with colored
microspheres, tended to be higher for pH-stat RCP than for alpha-stat RCP, at
every site in the brain. Irrespective of CO(2) management, regional differences
were not significant among any site in the brain. Conclusions: CO(2) management
is crucial for brain protection under deep hypothermic RCP. This study revealed
that pH-stat was considered to be better than alpha-stat in terms of CBF and
oxygen metabolism in the brain. The regional blood flow distribution was
considered to be unchanged irrespective of CO(2) management.

Eur J Cardiothorac Surg  2001 Nov;20(5):923-9

Off-pump versus on-pump coronary artery bypass grafting: oxidative stress and
renal function.

Gerritsen WB, van Boven WJ, Driessen AH, Haas FJ, Aarts LP.

Department of Clinical Chemistry, Sint Antonius Hospital, The, Nieuwegein,
Netherlands

Objectives: Oxidative stress and renal dysfunction occur in patients undergoing
coronary artery bypass grafting with cardiopulmonary bypass (on-pump CABG).
Whether the same adverse effects also occur during off-pump CABG is the question
in this study. Methods: Forty patients, 27 men and 13 women, undergoing elective
CABG were included; 20 patients underwent on-pump CABG and 20 patients underwent
off-pump CABG. Renal and ischemia/reperfusion injury parameters were studied, as
well as malondialdehyde as a parameter for oxidative stress. Results: The renal
function measured as the mean urinary creatinine excretion decreased
significantly during surgery for the on-pump CABG group from 7.62+/-4.74 before
surgery to 3.07+/-1.49 mmol/l after surgery, whereas no changes occurred in the
off-pump CABG group. The mean urinary concentrations of hypoxanthine, xanthine
and malondialdehyde expressed as creatinine ratios for the on-pump group
increased significantly from 1.92+/-1.36, 6.06+/-3.62 and 0.21+/-0.07 before
surgery to 11.88+/-5.77, 13.11+/-6.61 and 0.57+/-0.31 mmol/mol creatinine,
respectively at arrival to the intensive care unit (ICU). During the next
time-points, the purines and malondialdehyde decreased to 9.21+/-7.46,
7.55+/-3.95 and 0.32+/-0.13 mmol/mol creatinine, respectively after a 20 h stay
at the ICU. For the off-pump CABG group, the mean ratios also increased
significantly from 1.71+/-1.38, 2.01+/-0.96 and 0.16+/-0.10 before surgery to
4.73+/-3.19, 5.15+/-3.74 and 0.23+/-0.17 mmol/mol creatinine, respectively at
arrival to the ICU. During the next time-points, the ratios of xanthine and
malondialdehyde decreased to 3.80+/-2.92 and 0.24+/-0.13 mmol/mol creatinine,
respectively. The ratio for hypoxanthine reached the highest ratio (6.97+/-5.67
mmol/mol creatinine) after a 9 h stay at the ICU, after which the ratio
decreased to 5.98+/-5.56 mmol/mol creatinine after a 20 h stay at the ICU.
However, all ratios from the on- and off-pump CABG patients still remained
elevated compared with preoperative ratios. In addition, all ratios for the
on-pump CABG group were elevated significantly at all time-points for xanthine,
at time-points T2 and T4 for hypoxanthine and at time-point T2 for
malondialdehyde as compared with the off-pump CABG group. Conclusions: Only mild
signs of oxidative stress and no renal dysfunction were found during and after
off-pump CABG compared with on-pump CABG.