Bernardo A. Vidne

Analyses of coronary graft patency after aprotinin use : results from the international multicenter aprotinin graft patency experience (IMAGE) trial

OBJECTIVE We examined the effects of aprotinin on graft patency, prevalence of myocardial infarction, and blood loss in patients undergoing primary coronary surgery with cardiopulmonary bypass. METHODS Patients from 13 international sites were randomized to receive intraoperative aprotinin (n = 436) or placebo (n = 434). Graft angiography was obtained a mean of 10.8 days after the operation. Electrocardiograms, cardiac enzymes, and blood loss and replacement were evaluated. RESULTS In 796 assessable patients, aprotinin reduced thoracic drainage volume by 43% (P < .0001) and requirement for red blood cell administration by 49% (P < .0001). Among 703 patients with assessable saphenous vein grafts, occlusions occurred in 15.4% of aprotinin-treated patients and 10.9% of patients receiving placebo (P = .03). After we had adjusted for risk factors associated with vein graft occlusion, the aprotinin versus placebo risk ratio decreased from 1.7 to 1.05 (90% confidence interval, 0.6 to 1.8). These factors included female gender, lack of prior aspirin therapy, small and poor distal vessel quality, and possibly use of aprotinin-treated blood as excised vein perfusate. At United States sites, patients had characteristics more favorable for graft patency, and occlusions occurred in 9.4% of the aprotinin group and 9.5% of the placebo group (P = .72). At Danish and Israeli sites, where patients had more adverse characteristics, occlusions occurred in 23.0% of aprotinin- and 12.4% of placebo-treated patients (P = .01). Aprotinin did not affect the occurrence of myocardial infarction (aprotinin: 2.9%; placebo: 3.8%) or mortality (aprotinin: 1.4%; placebo: 1.6%). CONCLUSIONS In this study, the probability of early vein graft occlusion was increased by aprotinin, but this outcome was promoted by multiple risk factors for graft occlusion.

Chlorhexidine-impregnated dressing for prevention of colonization of central venous catheters in infants and children: a randomized controlled study.

Background: Infections of short term, nontunneled, intravascular catheters are often caused by migration of organisms from the insertion site. The aim of this study was to evaluate the effectiveness and safety of a chlorhexidine gluconate-impregnated dressing for the reduction of central venous catheter (CVC) colonization and CVC-associated bloodstream infections in infants and children after cardiac surgery. Methods: This prospective, randomized, controlled study was conducted in the pediatric cardiac intensive care unit of a tertiary care pediatric medical center. Patients 0–18 years of age who were admitted to the pediatric cardiac intensive care unit during a 14-month period and required a CVC for >48 hours were randomized to receive a transparent polyurethane insertion site dressing (control group) or a chlorhexidine gluconate-impregnated sponge (Biopatch) dressing covered by a transparent polyurethane dressing (study group). The main outcome measures were rates of bacterial colonization, rates of CVC-associated bloodstream infections and adverse events. Results: Seventy-one patients were randomized to the control group and 74 to the study group. There were no significant between group differences in age, sex, Pediatric Risk of Mortality score or cardiac severity score. CVC colonization occurred in 21 control patients (29%) and 11 (14.8%) study patients (P = 0.0446; relative risk, 0.6166; 95% confidence interval, 0.3716–1.023). Bloodstream infection occurred in 3 patients (4.2%) in the control group and 4 patients (5.4%) in the study group. Local redness was noted in 1 control patient and 4 study group patients. Conclusions: The chlorhexidine gluconate-impregnated sponge is safe and significantly reduces the rates of CVC colonization in infants and children after cardiac surgery.

Role of anti-tumor necrosis factor-alpha in ischemia/reperfusion injury in isolated rat liver in a blood-free environment.

BACKGROUND Warm ischemia/reperfusion injury during liver transplantation is the most important cause of primary nonfunction of liver allografts. Tumor-necrosis factor (TNF)-alpha apparently mediates tissue damage by inducing apoptosis and/or necrosis in liver transplants. The aim of the study was to determine, using an isolated rat liver model, if pretreatment with anti-TNF-alpha monoclonal antibodies can attenuate ischemia/reperfusion liver injury. Specifically, its effect on liver cell apoptosis through the modulation of caspase activity was examined in a blood-free environment. METHODS Isolated rat livers were perfused with Krebs-Henseleit solution and randomly divided into three groups: (1) continuous perfusion for 165 min (control); (2) perfusion for 90 min, break for 60 min (ischemia), and reperfusion for 15 min; (3) as with group 2, but with administration of monoclonal mouse anti-rat TNF-alpha monoclonal antibodies before induction of ischemia. Caspase-3- and -9-like activity was measured by fluorometric assay, and apoptotic cells were identified by morphological criteria and application of the terminal deoxnucleotidyl transferase-mediated dUTP nick-end-labeling (Tunel) assay. RESULTS Portal pressure increased significantly in group 2 (14.8+/-2.3 mm Hg) compared to group 3, which showed no change (P<0.05). Significant amounts of TNF-alpha were detected in the effluent in group 2 at 1 min of reperfusion (147+/-8.9 pg/ml) compared to group 3 (30+/-6.7 pg/ml, P<0.05). Statistically significant reductions in liver enzyme levels were also noted in the animals pretreated with TNF-alpha antibodies (P<0.02). Caspase-3 and -9 activity was significantly decreased (270 and 160%, respectively) in group 3 compared to group 2 (P<0.005 and <0.05, respectively). A significant reduction in postischemic hepatic injury was noted on Tunel assay: many apoptotic hepatocyte cells were detected in group 2 but not in livers pretreated with monoclonal mouse anti-TNF-alpha antibodies (group 3). CONCLUSIONS Neutralization with specific monoclonal antibodies against TNF before ischemia induction can attenuate postischemic hepatic injury. Apoptotic injury seems to be ameliorated through modulation of caspase-3- and -9-like activity.

Is the heart a source for elevated circulating endothelin levels during aorta—coronary artery bypass grafting surgery in human beings?

Reports have shown increased systemic levels of endothelins during coronary artery bypass grafting in human beings. It was not known whether increased endothelin levels during coronary artery bypass grafting reflect a general systemic response to the surgical procedure or increased myocardial production of endothelins in response to ischemia and reperfusion. We therefore measured endothelin levels in the right atrium and proximal aorta of 15 patients undergoing coronary artery bypass grafting for anginal syndrome immediately before aortic crossclamping and again after cessation of cardiopulmonary bypass. In five patients, we also measured coronary sinus levels of endothelins during cardiopulmonary bypass circulation. We found that endothelin levels were elevated throughout the surgical procedure. Right atrial endothelin levels were significantly elevated after cessation of cardiopulmonary bypass circulation with respect to values immediately before aortic crossclamping (11.1 +/- 3.1 vs 14.2 +/- 3.7 pg/ml, p = 0.008), whereas endothelin levels in the proximal aorta did not rise significantly (10.5 +/- 2.3 vs 11.6 +/- 2.4 pg/ml, p > 0.5). Coronary sinus endothelin levels tended to decline temporarily during cardiopulmonary bypass circulation (11.1 +/- 2.1 pg/ml before aortic crossclamping, 7.9 +/- 1.9 1 minute after release of aortic crossclamp, and 9.9 +/- 2.1 pg/ml after release of partial aortic crossclamping, p = 0.06). We conclude that the rise in right atrial endothelin levels during coronary artery bypass grafting reflects systemic production and secretion of endothelins, probably by vasculature or organs distal to the proximal aorta, and is not the result of increased myocardial production and secretion of endothelins.

Anomalous origin of the pulmonary artery from the aorta: early diagnosis and repair leading to immediate physiological correction.

INTRODUCTION Anomalous origin of one pulmonary artery from the ascending aorta is a rare cardiac anomaly in which the pulmonary artery abnormally arises from the ascending aorta. Physiologically, most patients develop signs of cardiac failure due to high flow to both lungs, with systemic or supra-systemic pressures in the normally connected lung. The purpose of this study is to present our experience with this rare anomaly, in which early anatomic repair lead to rapid physiologic correction. MATERIALS AND METHODS Retrospective case review of all patients with anomalous origin of one pulmonary artery from the ascending aorta at Schneider Childrens Medical center of Israel between 1986 and 2007. All clinical operative and echocardiographic charts were analysed. RESULTS Twelve patients were diagnosed as anomalous origin of one pulmonary artery from the ascending aorta. In 10 patients, the right pulmonary artery rose from the ascending aorta, while in two an anomalous origin of the left pulmonary artery was associated with a right aortic arch. Initial diagnoses was made with two-dimensional echocardiography in all patients. In six patients, diagnostic cardiac catheterisation was performed in order to confirm the diagnosis. Age at diagnosis ranged from 5 to 180 days with a median of 15 days, and patient weight ranged from 780 grams to 5 kilograms, with a median of 3 kilograms. Initial echocardiographic evaluation showed systemic (four patients) or supra-systemic (seven patients) pressures in the right ventricle and normally connected lung. All underwent surgical repair. There was no operative mortality. All reconstructed patients achieved normal right ventricular pressures within days after surgery. The flow pattern in both pulmonary arteries was normalised. CONCLUSIONS Early surgical repair of anomalous origin of one pulmonary artery from the ascending aorta is feasible and safe even in newborn and premature babies with complete resolution of the pulmonary hypertension and normalisation of pulmonary vascular resistance.

Early oral analgesia after fast-track cardiac anesthesia.

Objectif L’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.

L’analgésie orale précoce après la technique accélérée d’anesthésie cardiaque

Objectif L’analgesie orale apres la technique acceleree d’anesthesie cardiaque n’a pas ete etudiee. Le but de cette etude etait de comparer deux regimes d’analgesie a l’oxycodone per os.PurposeOral analgesia after “fast-track” cardiac anesthesia has not been explored. The aim of this study was to compare two oral oxycodone analgesic regimens.MethodsOne hundred-twenty patients scheduled for coronary artery bypass grafting were randomly assigned postoperatively to receive immediate-release oxycodone 5 mg and acetaminophen 325 mg (Percocet-5) (group I)per os four times daily, or controlled-release oxycodone 10 mg (OxyContin) (group II)per os every 12 hr and placebo twice daily. Acetaminophen 500 mgper os was used as first-line rescue medication, and immediate-release oxycodone (syrup form) 5 mgper os as second-line rescue medication. Pain intensity was assessed with a visual analogue scale on the first postoperative day, the morning after extubation, and thereafter four times daily for four days. Use of rescue medication and adverse events were recorded.ResultsBaseline demographic and operation-related characteristics were similar in both groups. While pain control was good in both groups, the immediate-release group experienced less pain on all postoperative days (P = 0.003), required significantly less rescue medication, and had fewer adverse effects such as somnolence and nausea.ConclusionPeroral oxycodone is effective for early pain control after fast-track cardiac anesthesia. Immediate-release oxycodone/acetaminophen appears to provide better analgesia and fewer side effects compared to controlled-release oxycodone.RésuméObjectifL’analgésie orale après la technique accélérée d’anesthésie cardiaque n’a pas été étudiée. Le but de cette étude était de comparer deux régimes d’analgésie à l’oxycodone per os.MéthodesCent- vingt patients devant subir une chirurgie de revascularisation myocardique ont été aléatoirement répartis en deux groupes après l’opération : le groupe I a reçu 5 mg d’oxycodone à libération immédiate et 325 mg d’acétaminophène (Percocet- 5) per os quatre fois par jour, et le groupe II a reçu 10 mg d’oxycodone à libération contrôlée (OxyContin) per os chaque 12 h et un placebo deux fois par jour. L’acétaminophène (500 mg per os) a été utilisé comme médicament de sauvetage de première intention et l’oxycodone (5 mg per os à libération immédiate sous forme de sirop) comme médicament de sauvetage de seconde intention. L’intensité de la douleur a été évaluée à l’aide d’une échelle visuelle analogue le premier jour après l’opération, le matin suivant l’extubation, puis quatre fois par jour pendant quatre jours. L’utilisation de médicaments de sauvetage ainsi que les complications ont été enregistrées.RésultatsLes caractéristiques démographiques de base ainsi que celles en rapport avec l’opération furent similaires dans les deux groupes. Bien que le contrôle de la douleur ait été bon dans les deux groupes, les patients du groupe à libération immédiate ont ressenti moins de douleur durant les jours suivant l’opération (P = 0,003), ont eu besoin d’une dose significativement moindre de médicaments de sauvetage, et ont subi moins d’événements négatifs tels que la somnolence ou la nausée.ConclusionL’oxycodone peroral est efficace pour un contrôle de la douleur précoce après une technique accélérée d’anesthésie cardiaque. L’oxycodone / acétaminophène à libération immédiate semble fournir une meilleure analgésie et moins d’effets secondaires que l’oxycodone à libération contrôlée.

Septic emboli caused by vascular catheters after surgery for congenital heart disease

Objective: To review the incidence, diagnosis, and management of septic emboli caused by vascular catheters after surgery for congenital heart disease. Design: Retrospective clinical review. All patients were computer registered. Our database includes daily follow‐up and every sign of infection registered. Setting: Pediatric cardiac surgery intensive care unit in a university hospital. Patients: A total of 720 consecutive pediatric cardiac operations performed in 108 neonates and 612 older children from 1995 to 1997 are reviewed. Measurements and Main Results: Septic emboli were defined as erythematous non‐tender papulonodular hemorrhagic lesions restricted to the limb and distal to the monitoring catheter. Four patients (0.55%) with catheter‐related septic emboli after congenital heart surgery were identified, three neonates (0.41%) and one older infant (0.14%). The incidence of catheter‐related septic emboli in our patients was significantly higher in the neonatal group compared with older infants (p = .0076; odds ratio=17.45). All infants with catheter‐associated septic emboli were severely ill and required prolonged intensive care management postoperatively for periods ranging from 27 to 90 days (mean, 50 days). The catheters involved were in place for periods ranging from 5 to 7 days. All patients were treated by catheter removal and intravenous antibiotics without surgical intervention in the vascular access area. The affected limbs healed well without residual damage. Conclusions: Septic emboli are a rare complication of infected vascular catheters in neonates and small infants undergoing prolonged postoperative intensive care management (0.55%). They may indicate the source of unexplained sepsis involving mainly Gram‐negative bacilli. Generally, treatment consists of removal of the offending catheter and antibiotic administration with no need for surgical intervention.

Isoflurane and sodium nitroprusside reduce the depressant effects of protamine sulfate on isolated ischemic rat hearts

UNLABELLED The administration of protamine sulfate (protamine) to reverse the action of heparin is associated with adverse reactions. We studied the effects of protamine and isoflurane on isolated, perfused rat hearts previously subjected to cardioplegic ischemia. Hearts were perfused with oxygenated Krebs-Henseleit (KH) solution for 30 min, then subjected to cardioplegic ischemia for 30 min (KCl 16 mEq/L at 31 degrees C) and 5 min reperfusion. Drug exposure lasted 15 min, and the recovery period was 60 min. Test groups were control, protamine (10 microg/mL), isoflurane (1.5%), protamine +/- isoflurane, sodium nitroprusside (SNP) (2.5 ng/mL), and SNP +/- protamine. Left ventricular developed pressure (LVP), coronary flow, and myocardial oxygen consumption were depressed by protamine to 30% +/- 4%, 47% +/- 4%, and 39% +/- 4% of baseline (P < 0.001 versus control), respectively. Isoflurane and SNP afforded partial protection from the effects of protamine: LVP was 57% +/- 5% and 51% +/- 3% of baseline, respectively (P < 0.05 versus protamine alone and control); coronary flow was 70% +/- 6% and 97% +/- 12% of baseline, respectively (P < 0.05 versus protamine alone; P < 0.05 for isoflurane versus control); and O2 consumption was 69% +/- 6% and 88% +/- 15% of baseline, respectively (P < 0.05 versus protamine; P < 0.05 for isoflurane versus control). In this model, protamine-induced myocardial depression and coronary vasoconstriction were less pronounced in the presence of either isoflurane or SNP. IMPLICATIONS We examined the interactions of isoflurane, sodium nitroprusside, and protamine in a rat heart model and found that both isoflurane and sodium nitroprusside partially protect the heart from the depressant effects of protamine. This finding is significant, as these drugs are often used in heart surgery.

A word of caution: Cerebral air emboli caused by tubing elastic recoil while performing low-flow antegrade cerebral perfusion in a low-birth-weight neonate

coronary artery and its relatively rapid growth as a fibroma. The growth period might have been even less than 34 months because no imaging was undertaken during the postoperative period after aortic valve replacement. The preoperative CT scan and angiogram were of great help in planning complete resection of the tumor, avoiding injury to the coronary arteries and the left ITA under reoperation conditions and without extracorporeal circulation. Because local recurrence is possible in benign, as well as malignant, forms of SFT resected incompletely, radical resection should be strived for in all patients.