Acta Anaesthesiol Scand. 2007 Nov;51(10):1344-9.

Risk factors for acute renal failure requiring dialysis after surgery for
congenital heart disease in children.

Pedersen KR, Povlsen JV, Christensen S, Pedersen J, Hjortholm K, Larsen SH,
Hjortdal VE.

Department of Cardiothoracic and Vascular Surgery, Aarhus University Hospital,
Skejby, Denmark.

BACKGROUND: Limited data exist on the risk factors for acute renal failure (ARF) 
following cardiac surgery in children with congenital heart disease. This cohort 
study was conducted to examine this subject, as well as changes in the incidence 
of ARF from 1993 to 2002, the in-hospital mortality and the time spent in the
intensive care unit (ICU). METHODS: One thousand, one hundred and twenty-eight
children, operated on for congenital heart disease between 1993 and 2002, were
identified from our prospectively collected ICU database to obtain data on
potential risk factors. RESULTS: A total of 130 children (11.5%) developed ARF
after surgery. A young age [> or =1.0 vs. <0.1 year; odds ratio (OR), 0.23; 95%
confidence interval (CI), 0.12-0.46], high Risk Adjusted Classification of
Congenital Heart Surgery (RACHS-1) score (OR, 2.72; 95% CI, 1.66-4.45) and
cardiopulmonary bypass (CPB) (<90 min vs. none; OR, 2.68; 95% CI, 1.03-6.96; > or
=90 min vs. none; OR, 12.94; 95% CI, 5.46-30.67) were independent risk factors
for ARF. The risk of ARF decreased during the study period. Children with ARF
spent a significantly longer time in the ICU (2-7 days vs. <2 days, P = 0.002; > 
or =7 days vs. <2 days, P < 0.001) compared with non-ARF patients, and showed
increased in-hospital mortality (20% vs. 5%, P < 0.001). CONCLUSION: A young age,
high RACHS-1 score and CPB were independent risk factors for ARF after surgical
procedures for congenital heart disease in children. The risk of ARF decreased
during the study period. Children with severe ARF spent a longer time in the ICU,
and the mortality in ARF patients was higher than that in non-ARF patients.

Minerva Anestesiol. 2007 Nov;73(11):559-65.

Acute renal failure after isolated CABG surgery: six years of experience.

Landoni G, Bove T, Crivellari M, Poli D, Fochi O, Marchetti C, Romano A, Marino
G, Zangrillo A.

Department of Cardiothoracic Anesthesia and Intensive Care, Vita-Salute San
Raffaele University, San Raffaele Scientific Institute, Milan, Italy
landoni.giovanni@hsr.it.

BACKGROUND: A prospective observational study was carried out in a Cardiosurgical
Intensive Care Unit (ICU) in order to evaluate the incidence of Acute Renal
Failure (ARF) after coronary artery bypass graft surgery and identify its
predictors. The effects of ARF on outcome were also investigated. METHODS: The
study enrolled 3013 consecutive patients undergoing coronary artery bypass graft 
surgery. Baseline variables including age, sex, preoperative renal failure,
left-ventricular dysfunction, emergency surgery, neurological adverse events,
patient history of chronic obstructive pulmonary disease and diabetes mellitus
were collected. Intraoperative variables were: type of surgery (on- or off-pump),
intra-aortic balloon pump placement, and cardiopulmonary bypass duration. The
measured postoperative variables were: low cardiac output syndrome, hemorrhage,
transfusion of blood products, and surgical revision. RESULTS: Preoperative renal
dysfunction (creatinine >1.4 mg/dL), blood transfusion, low-output syndrome,
emergency surgery, low ejection fraction and age were independently associated
with ARF. The median (interquartile range) ICU stay was 5.5 (range 4-11.5) days
in patients who did and 1 (range 1-2) day in those who did not develop ARF
(P<0.001). The median (interquartile range) hospital length of stay was 10 (range
8-21) days in patients who did and 5 (range 4-7) days in those who did not
develop ARF (P<0.001). CONCLUSION: Preoperative renal dysfunction, blood
transfusion, low-output syndrome, emergency surgery, low ejection fraction and
age were independently associated with ARF. Length of ICU and hospital stay were 
reduced in patients not developing ARF.

Ann Thorac Surg. 2007 Nov;84(5):1496-502.

Comment in:
    Ann Thorac Surg. 2007 Nov;84(5):1502-3.

Does off-pump coronary surgery reduce postoperative acute renal failure? The
importance of preoperative renal function.

Di Mauro M, Gagliardi M, Iacò AL, Contini M, Bivona A, Bosco P, Gallina S,
Calafiore AM.

Department of Cardiac Surgery, University of Catania, Catania, Italy.

BACKGROUND: Off-pump was compared with on-pump coronary artery bypass graft
surgery to evaluate the impact of cardiopulmonary bypass on the incidence of
postoperative acute renal failure (ARF). METHODS: From November 1994 to December 
2001, 2,943 patients having multivessel surgical disease underwent myocardial
revascularization. Ninety patients were excluded because of incompleteness of
data, intraoperative death, or preoperative chronic dialysis. The analysis was
split: one analysis included 1,724 (862 each group) of 2,618 patients with normal
preoperative creatinine (<1.5 mg/dL), and the second analysis included 160 (80
each group) of 215 patients with preoperative abnormal renal function; in both
analyses matched groups were selected applying propensity score. RESULTS: In the 
group with normal preoperative creatinine, the incidence of 30-day ARF was 5.4%
(2.9% off-pump versus 7.9% on-pump; p < 0.001). Stepwise logistic regression
confirmed that cardiopulmonary bypass was an independent variable for increased
postoperative ARF incidence (odds ratio, 3.3), as well as age and reduced left
ventricular ejection fraction. Receiver operating characteristic curves showed
that cardiopulmonary bypass duration was a predictor of higher ARF incidence
(area under the curve, 0.79) with a cutoff value of 66 minutes. In the patients
with abnormal renal function preoperatively, the incidence of ARF was similar
between the groups (16.3% on-pump versus 12.5% off-pump; p = 0.499). Acute renal 
failure had an important impact on early (odds ratio, 3.6) and late mortality
(hazard ratio, 4.1). CONCLUSIONS: Off-pump surgery plays an important
renoprotective role and provides better early and late outcome in patients with
normal preoperative creatinine. When the preoperative creatinine is abnormal, the
surgical strategy does not seem to have any influence. The occurrence of ARF
significantly impairs early and long-term mortality, and the surgical strategy
does not improve outcomes.

Ann Thorac Surg. 2007 Nov;84(5):1515-20; discussion 1521.

Minimal extracorporeal circulation is a promising technique for coronary artery
bypass grafting.

Immer FF, Ackermann A, Gygax E, Stalder M, Englberger L, Eckstein FS, Tevaearai
HT, Schmidli J, Carrel TP.

Department of Cardiovascular Surgery, University Hospital, Berne, Switzerland.
franzimmer@yahoo.de

BACKGROUND: Minimal extracorporeal circulation (MECC) is a promising perfusion
technology, taking the advantage of an ECC while having a significantly reduced
priming volume. We analyzed the actual possible benefits of using MECC in
patients undergoing CABG procedures and compared the results with conventional
extracorporeal circulation (CECC). METHODS: One thousand fifty-three consecutive 
patients underwent CABG surgery using the MECC perfusion technique. Subgroup
analyses focused on perioperative myocardial markers (cardiac troponin I [cTnI]),
incidence of atrial fibrillation (AF), and perioperative evaluation of
inflammatory markers and data were compared with those of patients who underwent 
CABG using CECC. A propensity score analysis was performed. RESULTS: Patient
characteristics and distribution of EuroSCORE risk were similar in both groups.
Severity of coronary artery disease and extent of revascularization were also
comparable in both groups (number of distal anastomoses: 3.2 +/- 1.1 in CECC vs
3.2 +/- 0.9 in MECC; p = not significant [ns]). The cTnI was significantly lower 
in the MECC group (11.0 +/- 10.8 microg/L in MECC vs 24.7 +/- 25.3 microg/L in
CECC; p < 0.05). Incidence of AF was 11.1% in MECC and 39.0% in CECC (p < 0.05). 
Inflammatory markers (interleukin-6, SC5b-9) were lower in MECC patients (p <
0.05). Propensity score analysis confirmed faster recovery in MECC patients and
lower incidence of AF. CONCLUSIONS: Minimal extracorporeal circulation is a safe 
perfusion technique for CABG and may therefore concurrence OPCAB and traditional 
CABG under CECC.

Anesth Analg. 2007 Nov;105(5):1192-9, table of contents.

Intraoperative management of patients with carcinoid heart disease having
valvular surgery: a review of one hundred consecutive cases.

Weingarten TN, Abel MD, Connolly HM, Schroeder DR, Schaff HV.

Department of Anesthesiology, Mayo Clinic and Mayo Foundation, Rochester,
Minnesota 55905, USA.

BACKGROUND: Cardiac surgery for carcinoid heart disease is complicated by
hemodynamic instability secondary to carcinoid crises, cardiovascular
dysfunction, and blood loss. The safety of vasopressors and the benefit of
aprotinin during concomitant octreotide administration are uncertain. METHODS: We
reviewed the effects of vasopressors and aprotinin on octreotide administration
and mortality by univariate analysis in 100 consecutive cases of cardiac surgery 
for carcinoid heart disease from 1985 to 2003. Because mortality declines were
temporally related to the introduction of aprotinin, bivariate analyses were
performed to identify other factors associated with mortality. RESULTS: Carcinoid
symptoms and hypotension were treated with octreotide (n = 89) and/or
vasopressors (n = 93). Vasopressors were not associated with increased octreotide
administration. Patients requiring epinephrine had higher mortality but also had 
worse preoperative New York Heart Association class, higher urinary
5-hydroxyindoleacetic acid levels, and increased blood transfusion requirements. 
Aprotinin (n = 54) was associated with decreased blood transfusion requirements, 
increased octreotide administration, but not mortality. Overall mortality was
13%, declining from 28% between 1985 and 1994 to 6% between 1995 and 2003.
Mortality was associated with greater blood transfusion requirements and longer
duration of cardiopulmonary bypass. CONCLUSIONS: Vasopressors may be used in
conjunction with octreotide in carcinoid patients. The increased mortality
associated with epinephrine likely reflects selection bias rather than a primary 
adverse effect. The improved survival over time in carcinoid patients is
multifactorial and unrelated to aprotinin administration, suggesting further
inhibition of the kallikrein-kinin system has little added benefit for this
outcome in the presence of octreotide.

Acta Anaesthesiol Scand. 2007 Nov 1 [Epub ahead of print]

Inhaled iloprost to control pulmonary artery hypertension in patients undergoing 
mitral valve surgery: a prospective, randomized-controlled trial.

Rex S, Schaelte G, Metzelder S, Flier S, de Waal EE, Autschbach R, Rossaint R,
Buhre W.

Department of Anaesthesiology, University Hospital, Rheinisch-Westfälische
Technische Hochschule Aachen, Aachen, Germany.

Background: Pulmonary hypertension (PHT) is common in patients undergoing mitral 
valve surgery and is an independent risk factor for the development of acute
right ventricular (RV) failure. Inhaled iloprost was shown to improve RV function
and decrease RV afterload in patients with primary PHT. However, no
randomized-controlled trials on the intraoperative use of iloprost in cardiac
surgical patients are available. We therefore compared the effects of inhaled
iloprost vs. intravenous standard therapy in cardiac surgical patients with
chronic PHT. Methods: Twenty patients with chronic PHT undergoing mitral valve
repair were randomized to receive inhaled iloprost (25 mug) or intravenous
nitroglycerine. Iloprost was administered during weaning from cardiopulmonary
bypass (CPB). Systemic and pulmonary haemodynamics were assessed with pulmonary
artery catheterization and transoesophageal echocardiography. Milrinone and/or
inhaled nitric oxide were available as rescue medication in case of failure to
wean from CPB. Results: Inhaled iloprost selectively decreased the pulmonary
vascular resistance index after weaning from CPB (208 +/- 108 vs. 422 +/- 62
dyn.s/cm(5)/m(2), P<0.05), increased the RV-ejection fraction (29 +/- 3% vs. 22
+/- 5%, P<0.05), improved the stroke volume index (27 +/- 7 vs. 18 +/- 6 ml/m(2),
P<0.05) and reduced the transpulmonary gradient (10 +/- 4 vs. 16 +/- 3 mmHg,
P<0.05). In all patients receiving inhaled iloprost, weaning from CPB was
successful during the first attempt. In contrast, three patients in the control
group required re-institution of CPB and had to be weaned from CPB using rescue
medication. Conclusions: In patients with pre-existing PHT undergoing mitral
valve surgery, inhaled iloprost is superior to intravenous nitrogylycerine by
acting as a selective pulmonary vasodilator, reducing RV afterload and moderately
improving RV-pump performance.

J Thorac Cardiovasc Surg. 2007 Nov;134(5):1193-8.

Effect of cardiopulmonary bypass and aortic clamping on functional residual
capacity and ventilation distribution in children.

von Ungern-Sternberg BS, Petak F, Saudan S, Pellegrini M, Erb TO, Habre W; Swiss 
Paediatric Respiratory Research Group.

Pediatric Anesthesia Unit, Geneva Children's Hospital, Geneva, Switzerland.
britta.reglivonungern@hcuge.ch

OBJECTIVE: To characterize factors that contribute to lung function impairment
after cardiopulmonary bypass, we assessed functional residual capacity and
ventilation homogeneity during the perioperative period in children with
congenital heart disease who are to undergo surgical repair. METHODS: Functional 
residual capacity and lung clearance index were measured by using a sulfur
hexafluoride washout technique in 24 children (aged 0-10 years). Measurements of 
functional residual capacity and ventilation distribution were performed after
induction of anesthesia, at different stages of the surgical procedure, and up to
90 minutes after skin closure. Anesthesia was standardized, and ventilator
settings, including the fraction of inspired oxygen, were kept constant
throughout the study period. RESULTS: Sternotomy and retractor insertion led to a
significant increase in functional residual capacity (mean [SD], 24% [14%]),
followed by a similar percentage decrease in the resting volume after a
significant reduction in pulmonary blood flow during cardiopulmonary bypass with 
aortic clamping. Although reestablishing pulmonary blood flow increased
functional residual capacity (10% [6%]), chest closure led to a decrease in
functional residual capacity of 36% (14%) that only slightly improved during the 
first 90 minutes after surgical intervention. Changes in lung clearance index
were affected conversely compared with changes in functional residual capacity at
all assessment times. CONCLUSIONS: These results confirmed that chest wall
condition and pulmonary circulation affect lung volumes and ventilation
homogeneity. Although opening of the chest wall improved alveolar recruitment and
ventilation homogeneity, blood flow appeared essential for alveolar stability,
presumably by exerting a tethering force caused by the filled capillaries on the 
alveolar walls and therefore contributing to an increase in resting lung volume.

Crit Care. 2007 Nov 7;11(6):R117 [Epub ahead of print]

Tranexamic acid attenuates inflammatory response in cardiopulmonary bypass
surgery through blockade of fibrinolysis: a case control study followed by a
randomized double-blind controlled trial.

Jimenez JJ, Iribarren JL, Lorente L, Rodriguez JM, Hernandez D, Nassar MI, Perez 
R, Brouard M, Milena A, Martinez R, Mora ML.

ABSTRACT: INTRODUCTION: Extracorporeal circulation induces haemostatic
alterations which lead to inflammatory response (IR) and postoperative bleeding. 
Tranexamic acid (TA) reduces fibrinolysis and blood loss after cardiopulmonary
bypass (CPB). However, its effects on IR and vasoplegic shock (VS) are not well
known and this was the main objective of this study. METHODS: A case-control was 
carried out to determine factors associated with IR after CPB. Secondly, patients
undergoing elective CPB surgery were randomly assigned to receive 2g of TA or
placebo (0.9% saline) before and after intervention. We performed an
intention-to-treat analysis, comparing the incidence of IR and VS. We also
analyzed several biological parameters related with inflammation, coagulation and
fibrinolysis systems. We used SPSS-12.2 for statistical purposes. RESULTS: In the
case control study, 165 patients were studied, 20.6% fulfilled IR criteria and
the use of TA proved an independent protective variable (OR 0.38; 95%CI:
0.18-0.81; P<0.01). The clinical trial was interrupted. Fifty patients were
randomly assigned to receive TA (24) and placebo (26). Incidence of IR was 17% in
the TA group vs 42% in the placebo group (P=0.047). In the TA group, we observed 
a significant reduction in the incidence of vasoplegic shock (P=0.003), the use
of norepinephrine (P=0.029) and time on mechanical ventilation (P=0.018). These
patients showed a significantly lower D-dimer, PAI-1 and creatine-kinase levels, 
and a trend toward a lower levels of STNFR and IL-6, within the first 24-hr after
CPB. CONCLUSION: The use of tranexamic acid attenuates the development of
inflammatory response and vasoplegic shock after CPB. Trial registration number
ISRCTN05718824.

Resuscitation. 2007 Nov 5 [Epub ahead of print]

Full recovery of an avalanche victim with profound hypothermia and prolonged
cardiac arrest treated by extracorporeal re-warming.

Oberhammer R, Beikircher W, Hörmann C, Lorenz I, Pycha R, Adler-Kastner L,
Brugger H.

Department of Anaesthesiology and Critical Care Medicine, General Hospital
Innichen, Freisingstrasse 2, I-39038 Innichen, Italy.

Survival of hypothermic avalanche victims with cardiac arrest is rare. This
report describes full recovery of a 29-year-old backcountry skier completely
buried for 100min at 3.0m (9.8ft) depth. On extrication he was unconscious, but
breathing spontaneously into an air pocket; core body temperature measured 22.0
degrees C (71.6 degrees F). He was intubated and ventilated on site. Ventricular 
fibrillation commenced during helicopter transportation, whereby chest
compression was lacking for 15min. At the nearest hospital continuous
cardiopulmonary resuscitation was initiated, but defibrillation failed. Tympanic 
core body temperature measurement confirmed life-threatening hypothermia of 21.7 
degrees C (71.1 degrees F) and serum K(+) was 4.3mmol/l, necessitating
transferral to a hospital with cardiopulmonary bypass facilities. Defibrillation 
finally succeeded following re-warming, by femoral veno-arterial bypass, to 34.5 
degrees C (94.1 degrees F). Total duration of cardiac arrest was 150min. The
patient developed pulmonary oedema, treated by extracorporeal membrane
oxygenation, but progressed well and was discharged from hospital on day 17, fit 
to resume professional and social activities. Follow-up cerebral magnetic
resonance imaging 2 years after avalanche burial demonstrated only minimal
changes attributable to unrelated, prior cranial trauma. Extensive neurological
and psychological investigations gave excellent results. This report confirms
previous literature that an air pocket with patent airways is essential for
survival of a completely buried avalanche victim after 35min and endorses the
recommended management strategies of the International Commission for Mountain
Emergency Medicine ICAR MEDCOM. In particular, all hypothermic victims extricated
with an air pocket and free airways must be treated optimistically, even despite 
prolonged cardiac arrest. This remarkable case documents the fastest drop in core
temperature ever recorded during snow burial, namely 9.0 degrees C (16.2 degrees 
F)/h, and the second-lowest reversible core temperature in avalanche literature.

J Neurol. 2007 Nov 9 [Epub ahead of print]

Strokes after cardiac surgery: mostly right hemispheric ischemic with mild
residual damage.

Korn-Lubetzki I, Oren A, Asher E, Dano M, Bitran D, Fink D, Steiner-Birmanns B.

Dept. of Neurology, Shaare Zedek Medical Center, 3235, Jerusalem, 91031, Israel, 
ikl@md.huji.ac.il.

OBJECTIVE : Since cardiac surgery is now performed on patients with high risk for
cerebrovascular disease, we studied the clinical findings and medium term outcome
of patients with acute stroke/transient ischemic attack (TIA) after cardiac
surgery. METHODS : All consecutive patients with acute stroke/TIA after cardiac
surgery were prospectively observed during a 19 month period. Follow-up was
between 3 months and 21 months. Risk factors, type of stroke, anatomic
localization, initial neurological deficit and followup outcome were evaluated,
using standard assessment scores. RESULTS : Among 406 patients operated (mean age
64.3 +/- 12.7 years, 284 males), 18 developed stroke and 2 TIAs (mean age 65.7
years, 13 males). There were no cases of intracerebral hemorrhage. Most of the
strokes happened shortly after valve surgery (mean 1.3 days post operatively) and
were right hemispheric (right = 11, left = 3; p = 0.034).Vertebrobasilar stroke
appearance was delayed (mean: 8.25 days post operatively); they were attributed
mostly to cardiac arrhythmias. Stroke/TIA patients did not have a higher
preoperative risk than those without, but their cardiac functional score was
worse (p = 0.01), and the average cardiopulmonary bypass time during surgery was 
longer (p = 0.009). Two patients died in hospital, both with vertebrobasilar
stroke.Most of the hemispheric stroke patients became functionally independent
(mean modified Rankin Scale < 2), even those with initial severe deficit.
CONCLUSION : Strokes after cardiac surgery are mostly right hemispheric and
exclusively ischemic. Outcome is relatively fair. We suggest an embolic injury to
the right hemisphere, procedure related, as a possible mechanism.