J Thorac Cardiovasc Surg. 2007 Dec;134(6):1421-6; 
 
Aprotinin is safe in pediatric patients undergoing cardiac surgery.

Backer CL, Kelle AM, Stewart RD, Suresh SC, Ali FN, Cohn RA, Seshadri R,
Mavroudis C.

Division of Cardiovascular-Thoracic Surgery, Department of Surgery, Northwestern 
University Feinberg School of Medicine, Chicago, Ill, USA.

OBJECTIVE: Aprotinin, a serine protease inhibitor, decreases transfusion
requirements and inflammatory response after cardiopulmonary bypass. This study
was done to determine whether aprotinin is associated with adverse outcomes,
particularly mortality and acute kidney failure, in pediatric patients (<18 years
of age) undergoing cardiopulmonary bypass. METHODS: We compared a cohort of all
pediatric cardiopulmonary bypass operations from 1994-1999, when aprotinin was
not used (n = 1230), with a cohort from 2000-2006, when all patients received
high-dose aprotinin (n = 1251). Primary end points were operative and late
mortality, acute kidney failure, need for dialysis, and neurologic complications.
Association of aprotinin with primary end points was assessed by means of
univariate analysis, multivariate logistic regression, and Cox regression
analysis, where appropriate. RESULTS: The aprotinin group was younger (mean age, 
3.49 +/- 1.84 vs 3.64 +/- 4.75 years; P = .019) and had a higher Aristotle score 
(7.8 +/- 2.3 vs 7.2 +/- 2.6, P < .001). Univariate and multivariate analysis
showed no significant difference between the no-aprotinin and aprotinin groups
for operative mortality (55 [4.5%] vs 47 [3.8%], P = .508), acute kidney failure 
(68 [6.0%] vs 69 [5.7%], P = .77), need for temporary dialysis (6 [0.49%] vs 12
[0.96%], P = .17), or neurologic complications (14 [1.1%] vs 17 [1.4%], P = .62).
By means of Cox regression analysis, aprotinin had no influence on late mortality
(24 vs 10 deaths, P = .078). CONCLUSION: In this retrospective cohort study of
pediatric patients undergoing cardiopulmonary bypass, there was no association
between the use of aprotinin and acute kidney failure, need for dialysis,
neurologic complications, and operative or late mortality. We continue to use
aprotinin for all pediatric patients undergoing cardiopulmonary bypass.

ASAIO J. 2007 Nov-Dec;53(6):778-84.

Comparison of four different pediatric 10F aortic cannulae during pulsatile
versus nonpulsatile perfusion in a simulated neonatal model of cardiopulmonary
bypass.

Undar A, Ji B, Rider A, Lukic B, Kunselman AR, Weiss WJ, Myers JL.

Department of Pediatrics, Penn State Milton S. Hershey Medical Center, Penn State
College of Medicine, Hershey, Pennsylvania 17033-0850, USA.

We compared four commercially available 10F pediatric aortic cannulae with
different geometric designs (DLP-Long tip, DLP-Short tip, RMI-Long tip, and
Surgimedics-Short tip) during pulsatile versus nonpulsatile perfusion in terms of
pressure drops and surplus hemodynamic energy (SHE) levels in an in vitro
neonatal model of cardiopulmonary bypass. The pseudo patient was subjected to
seven pump flow rates at 100 ml/min increments in the 400-1,000 ml/min range. A
total of 44 experiments (n = 22, nonpulsatile; n = 22, pulsatile) were performed 
at each of the seven flow rates. Surgimedics had significantly higher pressure
drops than the other three cannulae at various flow rates during nonpulsatile and
pulsatile perfusion, respectively. When the perfusion mode was changed from
nonpulsatile to pulsatile flow, SHE levels at both precannula and postcannula
sites increased seven to nine times at all flow rates in all four cannulae.
Surgimedics generated a significant lower SHE level when compared with the other 
three cannulae at all flow rates at both precannula and postcannula sites. The
results suggest that different geometries of aortic cannulae have a significant
impact on pressure drops of the cannulae as well as hemodynamic energy generation
and delivery. Pulsatile perfusion generates more "extra" hemodynamic energy when 
compared with the nonpulsatile perfusion mode with all four cannulae used in this
study.

J Cardiothorac Vasc Anesth. 2007 Dec;21(6):843-6. 

Clinical and laboratory correlates of excessive and persistent blood glucose
elevation during cardiac surgery in nondiabetic patients: a retrospective study.

Prasad AA, Kline SM, Schuler HG, Sukernik MR.

Department of Anesthesiology, Pennsylvania State University College of Medicine, 
Hershey, PA.

Background: Hyperglycemia during cardiac surgery in nondiabetic patients is a
common finding associated with increased morbidity and mortality, but its
predictors have not been studied to date. Methods: To identify clinical and
laboratory correlates of excessive and persistent blood glucose (BG) elevation
during cardiopulmonary bypass (CPB) in nondiabetic patients, the authors reviewed
195 medical records. After exclusion of patients with preoperative BG >120 mg/dL 
and with missing preoperative BG data, 163 cases were included in the final
analysis. Patients with BG >/=200 mg/dL during CPB and remaining >/=200 mg/dL
either during or after CPB or at the first postoperative measurement formed the
study group (n = 35). One case had insufficient data to determine group
assignment and was not used in comparison. The remaining patients formed the
control group (n = 127). Results: BG was >/=200 mg/dL at least once
perioperatively in 114 of 163 (70%) patients. It occurred during CPB in 100 of
163 (61%) cases and persisted beyond CPB in 35 of 162 (22%) cases. Univariate
analysis revealed a significant difference between groups in preoperative use of 
angiotensin-converting enzyme (ACE) inhibitors (51% v 29%, p = 0.02), total dose 
of phenylephrine during CPB (14.1 mg +/- 10.6 mg v 10.3 +/- 9.6 mg, p = 0.003)
and pre-CPB BG (123 +/- 22 mg/dL v 113 +/- 18 mg/dL, p = 0.02). In multivariate
analysis, ACE inhibitors and pre-CPB BG remained statistically significant.
Conclusions: Nondiabetic patients with excessive and persistent BG elevation
during cardiac surgery are more likely to take ACE inhibitors preoperatively,
show relatively high pre-CPB BG, and possibly require higher doses of
vasoconstrictors during CPB.

J Cardiothorac Vasc Anesth. 2007 Dec;21(6):847-50. Epub 2007 Jun 15.

Fenoldopam infusion for renal protection in high-risk cardiac surgery patients: a
randomized clinical study.

Cogliati AA, Vellutini R, Nardini A, Urovi S, Hamdan M, Landoni G, Guelfi P.

Department of Anesthesia and Intensive Care, Villa Maria Cecilia Hospital,
Cotignola, Ravenna, Italy.

Objective: The purpose of this study was to evaluate the renoprotective effects
of fenoldopam in patients at high risk of postoperative acute kidney injury
undergoing elective cardiac surgery requiring cardiopulmonary bypass. Design: A
double-blind randomized clinical trial. Setting: Hospital. Participants: One
hundred ninety-three patients. Interventions: Patients undergoing cardiac surgery
were randomly assigned to receive a continuous infusion of fenoldopam, 0.1
mug/kg/min (95 patients), or placebo (98 patients) for 24 hours. Patients were
included if at least 1 of the following risk factors was present: preoperative
serum creatinine >/=1.5 mg/dL, age >70 years, diabetes mellitus, or prior cardiac
surgery. Serum creatinine and urinary output were measured at baseline (T1), 24
hours (T2), and 48 hours after surgery (T3). Acute kidney injury was defined as a
postoperative serum creatinine level of >/=2 mg/dL with an increase in serum
creatinine level of 0.7 mg/dL or greater from preoperative to maximum
postoperative values. Measurements and Main Results: Acute kidney injury
developed in 12 of 95 (12.6%) patients receiving fenoldopam and in 27 of 98
(27.6%) patients receiving placebo (p = 0.02), whereas renal replacement therapy 
was started in 0 of 95 and 8 of 98 (8.2%) patients, respectively (p = 0.004).
Serum creatinine was similar at baseline (1.8 +/- 0.4 mg/dL v 1.9 +/- 0.3 mg/dL) 
in the fenoldopam and placebo groups but differed significantly (p < 0.001 and p 
< 0.001) 24 hours (1.6 +/- 0.2 mg/dL v 2.5 +/- 0.6 mg/dL) and 48 hours (1.5 +/-
0.3 mg/dL v 2.8 +/- 0.4 mg/dL) after the operation. Conclusions: A 24-hour
infusion of 0.1 mug/kg/min of fenoldopam prevented acute kidney injury in a
high-risk population undergoing cardiac surgery.

Cardiovasc Diabetol. 2007 Dec 17;6(1):39 [Epub ahead of print]

The impact of a reduced dose of dexamethasone on glucose control after coronary
artery bypass surgery.

Vogelzang M, Hoekstra M, Drost JT, Janse M, van der Horst IC, Boonstra PW,
Zijlstra F, Loef BG, Nijsten MW.

ABSTRACT: BACKGROUND: Intensive insulin therapy to maintain normoglycemia after
cardiac surgery reduces morbidity and mortality. We investigated the magnitude
and duration of hyperglycemia caused by dexamethasone administered after
cardiopulmonary bypass. METHODS: A single-center before-after cohort study was
performed. All consecutive patients undergoing coronary artery bypass grafting
with cardiopulmonary bypass during a 6-month period were included. Insulin
administration was guided by a sliding scale protocol. Halfway the observation
period, the dexamethasone protocol was changed. The single dose (1D) group
received a pre-operative dose of dexamethasone of 1 mg/kg. The double dose group 
(2D) received an additional dose of 0.5 mg/kg of dexamethasone post-operatively
at ICU admission. RESULTS: We included 116 patients in the 1D group and 158
patients in the 2D group. There were no significant baseline differences between 
the groups. Median Euroscore was 5. In univariable analysis, the glucose level
was different between groups 1D and 2D at 4, 6, 9, 12 and 24 hours after ICU
admission (all p < 0.001). Insulin infusion was higher in the 1D group. Corrected
for insulin dose in multivariable linear analysis, the difference in glucose
between the 1D and 2D groups was 1.5 mmol/L (95% confidence interval 1.0-2.0, p <
0.001) 12 hours after ICU admission. CONCLUSIONS: Dexamethasone exerts a
hyperglycemic effect in cardiac surgery patients. Patients receiving high-dose
corticosteroid therapy should be monitored and treated more intensively for
hyperglycemic episodes.

Kidney Int. 2007 Dec 19 [Epub ahead of print]

Liver fatty acid-binding protein as a biomarker of acute kidney injury after
cardiac surgery.

Portilla D, Dent C, Sugaya T, Nagothu KK, Kundi I, Moore P, Noiri E, Devarajan P.

1Division of Nephrology, Department of Internal Medicine, University of Arkansas 
for Medical Sciences and Central Arkansas Veterans Healthcare System, Little
Rock, Arkansas, USA.

Acute kidney injury (AKI) is a major complication of cardiac bypass surgery. We
examined whether levels of liver fatty acid-binding protein (L-FABP) can be an
early biomarker for ischemic injury by measuring this protein in the urine of 40 
pediatric patients prior to and following cardiopulmonary bypass surgery. AKI was
defined as a 50% increase in the serum creatinine from baseline, which was
normally not seen until 24-72 h after surgery. Enzyme-linked immunosorbent assay 
analysis showed increased L-FABP levels (factored for creatinine excretion) of
about 94- and 45-fold at 4 and 12 h, respectively, following surgery in the 21
patients who developed AKI with western blot analysis, confirming L-FABP
identity. Univariate logistic regression analyses showed that both bypass time
and urinary L-FABP were significant independent risk indicators for AKI. After
excluding bypass time from the model and using a stepwise multivariate logistic
regression analysis, urinary L-FABP levels at 4 h after surgery were an
independent risk indicator with the area under the receiver-operating
characteristic curve 0.810, sensitivity 0.714, and specificity 0.684 for a
24-fold increase in urinary L-FABP. Our study shows that urinary L-FABP levels
represent a sensitive and predictive early biomarker of AKI after cardiac
surgery.Kidney International advance online publication, 19 December 2007;
doi:10.1038/sj.ki.5002721.

Clin Appl Thromb Hemost. 2007 Dec 26 [Epub ahead of print]

Inflammatory and Hemostatic Activation in Patients Undergoing Off-Pump Coronary
Artery Bypass Grafting.

Untch BR, Jeske WP, Schwartz J, Botkin S, Prechel M, Walenga JM, Bakhos M.

Loyola University Chicago.

To characterize hemostatic differences imposed by 2 common cardiac surgeries, the
authors studied patients undergoing coronary artery revascularization by off-pump
(n = 13) or cardiopulmonary bypass on-pump (n = 26) technique. Blood samples
collected to 4 days post-surgery were evaluated by flow cytometry and
enzyme-linked immunosorbent assay. A significant inflammatory response occurred
in both the groups after surgery shown by increased interleukin cytokines and
C-reactive protein; however, levels peaked lower and hours later in the off-pump 
group. Platelets (P-selectin; platelet-leukocyte complexes) and leukocytes
(CD11b) were activated only in on-pump patients. Thrombin generation was enhanced
in both groups after surgery. Only in the on-pump patients, the
thrombin-antithrombin complex, prothrombin fragment 1.2, and thrombomodulin
(vascular integrity) decreased intraoperatively. Tissue plasminogen activator and
plasminogen activator inhibitor-1 were greater in the on-pump patients. Off-pump 
surgery may place patients at higher risk of postoperative hypercoagulability
because of normal platelet function, intraoperative thrombin generation, less
fibrinolytic activity, and lack of vascular protection.

Int Heart J. 2007 Nov;48(6):743-54.

Factors for Successful Weaning From a Percutaneous Cardiopulmonary Support System
(PCPS) in Patients With Low Cardiac Output Syndrome After Cardiovascular Surgery.

Oshima K, Kunimoto F, Takahashi T, Mohara J, Takeyoshi I, Hinohara H, Hayashi Y, 
Tajima Y, Kuwano H.

Intensive Care Unit, Gunma University Hospital.

The objective of this study was to analyze the early predictive factors for
successful weaning from a percutaneous cardiopulmonary support system (PCPS) in
patients with low cardiac output syndrome after cardiovascular surgery. A total
of 938 patients underwent cardiovascular surgery with cardiopulmonary bypass
(CPB) from January 1991 to September 2006 at Gunma University Hospital. Of these 
938 patients, 13 (1.4%) required PCPS to maintain hemodynamics within 48 hours
after surgery. The mean age of the 13 patients was 66 years (range, 45 to 86
years). Nine patients underwent open-heart surgery, 3 repair of a thoracic aortic
aneurysm, and 1 a pericardiectomy. The patients were divided into 2 groups; group
A (n = 4) who were removed from PCPS and group B (n = 9) who were not removed
from PCPS. The conditions during the operation and after PCPS support were
compared between the 2 groups. The mean age was higher, and operation time, CPB
time, and aortic cross-clamping time were significantly (P < 0.05) longer in
patients with PCPS than in those without PCPS. The mean PCPS time in all 13
patients was 190 +/- 122 hours. The mean age was higher, and CPB time and the
aortic cross-clamping time were longer in group B than in group A (NS). The mean 
duration of PCPS support was significantly (P < 0.05) shorter in group A than in 
group B (117 +/- 42 hours versus 235 +/- 136 hours). PCPS flow in group A could
be reduced from 48 hours after PCPS induction. However, PCPC flow in group B
could not be reduced, and there were significant (P < 0.05) differences in PCPS
flow at 72 and 96 hours after starting PCPS. Significant (P < 0.05) differences
in the absolute values of the APACHE II score, serum lactate levels, administered
epinephrine dose, and levels of total bilirubin (T-Bil), serum creatinine (sCr), 
and lactate dehydrogenase (LDH) were found between the 2 groups within 96 hours
after PCPS induction. In addition, there were significant (P < 0.05) differences 
in the rate of change compared with the baseline control value obtained prior to 
PCPS use in PCPS flow, APACHE II score, and levels of T-Bil, sCr, and LDH within 
96 hours after PCPS induction. Significant differences in the rate of change of
sCr and LDH were found, especially from the early phase after PCPS use, compared 
with other parameters. In the patients removed from PCPS, PCPS flow could be
reduced within 48 hours after commencement of PCPS. Improvements in the APACHE II
score and biochemical variables within 96 hours appear to be reliable prognostic 
factors for PCPS patients.

Eur J Cardiothorac Surg. 2007 Dec 24 [Epub ahead of print]

Towards safer reoperations: special aspects in aortic dissection.

Schäfers HJ, Kunihara T.

Department of Thoracic and Cardiovascular Surgery, University Hospital of
Saarland, 66421 Homburg/Saar, Germany.

Surgical treatment of acute aortic dissection has been largely standardized, but 
some patients develop late complications that require repeat surgery. The 10-year
freedom from proximal and distal reoperation is approximately 70-80%, and the
risk of proximal reoperation is approximately 10%. Aggressive resection of the
aortic root has not been proven to eliminate the need for proximal reoperation,
but it appears reasonable for pre-existent root dilatation. The coronary button
technique has resulted in greater freedom from death and reoperation and thus
appears advisable. The risk of distal reoperations seems generally lower than
that of proximal operations (0-4%). Routine extension of replacement into the
total arch in the initial operation is associated with increased risk, and it
appears not to decrease the probability of reoperation. Aggressive replacement of
the total arch may be justified only for connective tissue disease. The choice of
thoracic incision is important for aortic reoperations. A median sternotomy
provides excellent exposure to the proximal aorta. A posterolateral thoracotomy
allows good exposure for distal arch or descending aorta but may be associated
with pain-related pulmonary impairment. A bilateral thoracotomy gives easy access
for arch and descending aorta but is associated with the highest degree of
respiratory impairment. We use a median sternotomy in most instances and choose a
bilateral thoracotomy for complex aortic pathology. A posterolateral thoracotomy 
seems preferable for most distal arch and/or descending aortic replacements.
Since femoral arterial cannulation can contribute to an increased incidence of
neurological complication, cannulation of the axillary artery appears advisable. 
We prefer implantation of a Dacron graft and to cannulate the graft. If the aorta
is adjacent to the sternum, the patient is placed on cardiopulmonary bypass (CPB)
before repeat sternotomy. The patient is cooled to a nasopharyngeal temperature
of 28-30 degrees C and at the time of sternotomy CPB is temporarily interrupted. 
We have not yet had to use transapical venting. Using these approaches we have
been able to maintain a procedure-related mortality of 4%, which is not different
from primary operations on an aneurysmatic aorta.

J Biomed Opt. 2007 Nov-Dec;12(6):062112.

Clinical evaluation of time-resolved spectroscopy by measuring cerebral
hemodynamics during cardiopulmonary bypass surgery.

Ohmae E, Oda M, Suzuki T, Yamashita Y, Kakihana Y, Matsunaga A, Kanmura Y, Tamura
M.

Hamamatsu Photonics K.K., Central Research Laboratory, 5000 Hirakuchi, Hamamatsu,
Shizuoka, 434-8601, Japan.

We developed a three-wavelength time-resolved spectroscopy (TRS) system, which
allows quantitative measurement of hemodynamics within relatively large living
tissue. We clinically evaluated this TRS system by monitoring cerebral
circulation during cardiopulmonary bypass surgery. Oxyhemoglobin,
deoxyhemoglobin, total hemoglobin and oxygen saturation (SO(2)) were determined
by TRS on the left forehead attached with an optode spacing of 4 cm. We also
simultaneously monitored jugular venous oxygen saturation (SjvO(2)) and arterial 
blood hematocrit (Hct) using conventional methods. The validity and usefulness of
the TRS system were assessed by comparing parameters obtained with the TRS and
conventional methods. Although the changes in SO(2) were lower than those in
SjvO(2), SO(2) obtained by TRS paralleled the fluctuations in SjvO(2), and a good
correlation between these values was observed. The only exceptions occurred
during the perfusion period. Moreover, there was a good correlation between tHb
and Hct values (r(2)=0.63). We concluded that time-resolved spectroscopy
reflected the conditions of cerebral hemodynamics of patients during surgical
operations.