Tyrone J. Krause

Psychosocial Factors in Outcomes of Heart Surgery: The Impact of Religious Involvement and Depressive Symptoms

This article reports a prospective study of religiousness and recovery from heart surgery. Religiousness and other psychosocial factors were assessed in 142 patients about a week prior to surgery. Those with stronger religious beliefs subsequently had fewer complications and shorter hospital stays, the former effect mediating the latter. Attendance at religious services was unrelated to complications but predicted longer hospitalizations. Prayer was not related to recovery. Depressive symptoms were associated with longer hospital stays. Dispositional optimism, trait hostility, and social support were unrelated to outcomes. Effects of religious beliefs and attendance were stronger among women than men and were independent of biomedical and other psychosocial predictors. These findings encourage further examination of differential health effects of the various elements of religiousness.

Quality of Life Following Cardiac Surgery: Impact of the Severity and Course of Depressive Symptoms

Objectives: The purpose of this study was to examine the impact of the severity and course of depressive symptoms on change in quality of life (QOL) 6 months after cardiac surgery. Methods: Ninety patients were interviewed before heart surgery and 2 and 6 months after surgery. Depressive symptoms were assessed using the Beck Depression Inventory, and QOL was assessed using physical and psychosocial functioning indices derived from the Medical Outcomes Study instrument. Multiple regression examined the effects of the severity and course of depressive symptoms on QOL adjusting for demographic and biomedical predictors. Results: Higher levels of presurgical depressive symptoms predicted poorer physical functioning after cardiac surgery. A similar effect on psychosocial functioning fell short of significance. An increase in depressive symptoms 2 months after surgery was significantly predictive of poorer physical and psychosocial functioning at 6 months. The effect of increased depressive symptoms on psychosocial functioning was significantly stronger in patients with high presurgical Beck Depression Inventory scores. Conclusions: Both preoperative depressive symptoms and postoperative increases in depressive symptoms seem associated with poorer QOL 6 months after cardiac surgery. Further examination of these associations and the mechanisms they reflect may provide a basis for guiding treatment decisions before and after coronary artery bypass graft surgery. BDI = Beck Depression Inventory; CABG = coronary artery bypass graft surgery; MI = myocardial infarction; MOS = Medical Outcomes Study; QOL = quality of life; SF-36 = MOS 36-item short form health survey.

A comparison of inhaled nitric oxide and milrinone for the treatment of pulmonary hypertension in adult cardiac surgery patients.

OBJECTIVE To investigate the relative effects of milrinone and nitric oxide on pulmonary and systemic hemodynamic responses in cardiac surgery patients with a history of pulmonary hypertension. DESIGN Prospective and randomized. SETTING University hospital. PARTICIPANTS Forty-five adult cardiac surgery patients. INTERVENTIONS Cardiac surgery patients with pulmonary hypertension were randomly assigned to one of three study groups: Group 1 patients (n = 15) were treated with intravenous milrinone on separation from cardiopulmonary bypass, group 2 patients (n = 15) with 20 ppm of inhaled nitric oxide, and group 3 patients (n = 15) with 40 ppm of inhaled nitric oxide. Heart rate, right ventricular ejection fraction, and pulmonary vascular resistance were measured throughout the perioperative period at specific data points. MEASUREMENTS AND MAIN RESULTS There were no significant differences in demographics, anesthesia, surgery, or baseline hemodynamics among the groups. The group receiving 40 ppm nitric oxide had a significantly higher (p<0.05) right ventricular ejection fraction on arrival in the intensive care unit (40% v. 30% for the milrinone group and 33% for the nitric oxide 20 ppm group). The milrinone group required significantly more phenylephrine in the intensive care unit (p<0.05). CONCLUSIONS Treatment of pulmonary hypertension in adult cardiac surgery patients with inhaled nitric oxide compared with milrinone is associated with lower heart rates, higher right ventricular ejection fraction, and a lower requirement for treatment with vasopressor agents.

Psychosocial Factors in Heart Surgery: Presurgical Vulnerability and Postsurgical Recovery

OBJECTIVE Distress and low perceived social support were examined as indicators of psychosocial vulnerability in patients about to undergo heart surgery. DESIGN A total of 550 study patients underwent heart surgeries, including bypass grafting and valve procedures. Psychosocial interviews were conducted about five days before surgery, and biomedical data were obtained from hospital records. MAIN OUTCOME MEASURES Sociodemographic, personality, religious, and biomedical factors were evaluated as predictors of psychosocial vulnerability, and all five sets of variables were evaluated as contributors to hospital length of stay (LOS). RESULTS Patients scoring higher on one or more indicator of presurgical psychosocial vulnerability were younger, more likely to be female, less likely to be married, less well educated, lower in dispositional optimism, higher in trait anger, and lower in religiousness. Older age, depression, low support, and low trait anger each showed an independent, prospective association with greater LOS, and several other predictors had prospective relationships with LOS that were statistically mediated by depression or perceived support. CONCLUSION Evidence that multiple psychosocial factors may influence adaptation to heart surgery has implications for understanding and ameliorating presurgical distress and for improving postsurgical recovery.

Looking Inside the Black Box of “Attendance at Services”: New Measures for Exploring an Old Dimension in Religion and Health Research

Research in religion and health has spurred new interest in measuring religiousness. Measurement efforts have focused on subjective facets of religiousness such as spirituality and beliefs, and less attention has been paid to congregate aspects, beyond the single item measuring attendance at services. We evaluate some new measures for religious experiences occurring during congregational worship services. Respondents (N = 576) were religiously diverse community-dwelling adults interviewed prior to cardiac surgery. Exploratory factor analysis of the new items with a pool of standard items yielded a readily interpretable solution, involving seven correlated but distinct factors and one index variable, with high levels of internal consistency. We describe religious affiliation and demographic differences in these measures. Attendance at religious services provides multifaceted physical, emotional, social, and spiritual experiences that may promote physical health through multiple pathways.

Dose response to nitric oxide in adult cardiac surgery patients

STUDY OBJECTIVE To determine the dose responsiveness to nitric oxide in adult cardiac surgery patients, especially in those patients with pulmonary hypertension. DESIGN Prospective, randomized, nonblinded study. SETTING University teaching hospital. PATIENTS 62 consecutive cardiac surgery patients demonstrating pulmonary hypertension immediately before induction of anesthesia. INTERVENTIONS Subjects were assigned by random number allocation to receive one of five doses of inhaled nitric oxide on termination of cardiopulmonary bypass (CBP; i.e., restitution of pulmonary artery flow). Subjects in Group 1 (n = 11) received 10 ppm of inhaled nitric oxide, Group 2 subjects (n = 12) received 20 ppm, Group 3 subjects (n = 12) received 30 ppm, and Group 4 subjects (n = 12) received 40 ppm. The fifth group (n = 15) received no nitric oxide. This fifth group served as a control and was treated with milrinone only. Those patients who were randomized to the milrinone group, had milrinone initiated by bolus administration (50 microg/kg) 15 min before separation from CPB. Milrinone was maintained at 0.5 microg/kg/min in the operating room thereafter. The conduct of anesthesia, surgery, and CBP were controlled. A therapeutic algorithm dictated the use of vasoactive substances for all patients. MEASUREMENTS Heart rate, mean arterial pressure, pulmonary vascular resistance (PVR), peripheral vascular resistance, cardiac index, and right ventricular ejection fraction were monitored throughout the operative experience. MAIN RESULTS There were no significant differences found in demographic data, baseline hemodynamic data, surgical treatment, conduct of CBP, or the use of inotropic or vasoactive drugs among the five treatment groups. The percentage decrease in PVR on treatment with nitric oxide as compared to baseline values was not significantly different among the groups (10 ppm = 38%, 20 ppm = 50%, 30 ppm = 44%, 40 ppm = 36%, milrinone = 58%, p = 0.86). CONCLUSIONS Treatment with nitric oxide was associated with significant reductions in PVR in all groups. Dosages higher than 10 ppm were not associated with greater reductions in pulmonary vascular tone. In view of the fact that nitric oxide-related toxicity is dose-related, doses greater than 10 ppm do not appear to be justified in this patient population.

Life-threatening fluid extravasation of central venous catheters

The majority of life-threatening injuries secondary to the placement of central venous catheters, such as bleeding and pneumothorax, occur at the time of initial insertion. When a catheter extravasates in the neck, edema of the neck wall or chest is usually seen, and the pump indicates occlusion. We present four cases in which an uneventful, successful placement of four central lines (three superior vena cava, one inferior vena cava) were followed at greater than 48 hours by either hydrothorax or hydroperitoneum, which resulted in either cardiorespiratory collapse or intraabdominal sepsis. In reviewing these cases, all showed both a change in catheter location on a subsequent x-ray and poor or no blood return on aspiration; paradoxically, the infusion pump in each case did not sense a catheter malposition or occlusion. We conclude that, although the success of central line placement may be documented on insertion, a continual reappraisal of both the function and location of the line is necessary.

Mitral valve myxoma.

Cardiac myxomas arising from the mitral valve are extremely rare. We describe the case of an asymptomatic 49-year-old woman who was found to have a 3.6 x 4.0-cm myxoma originating from the atrial side of the anterior mitral leaflet. The lesion was successfully treated by surgical excision and mitral valve replacement. A review of the literature regarding this rare lesion is presented.

An inhibitor of cell proliferation associated with adhesion formation is suppressed by N,O-carboxymethyl chitosan.

Surgical adhesions are a major cause of morbidity and mortality. The ideal barrier agent will both minimize adhesions and provide a milieu for the regeneration of the mesothelium lining of the abdominal and thoracic cavities. N,O-Carboxymethylchitosan (NOCC), a derivation of chitin that markedly reduces adhesions, may function to modulate intracellular signals such as growth factors and cytokines in the inflammatory exudate. Since transforming growth factor-beta is implicated in the fibrotic process, we investigated the possibility that NOCCs effects on adhesion formation reflects a modulation of TGF-beta activity. Using a biological assay for inhibition of cell proliferation to detect TGF-beta activity, we demonstrate that NOCC suppresses the levels of an inhibitor of cell proliferation released into serum and peritoneal exudates after cecal abrasion in the rat. However, this activity was distinct from known forms of TGF-beta as determined using both TGF-beta-neutralizing antisera and a TGF-beta-resistant cell proliferation assay. Thus at least one potential effect of NOCC involves a mechanism distinct from TGF-beta inhibition.

Prevention of Pericardial Adhesions with N-O Carboxymethylchitosan in the Rabbit Model

The presence of mediastinal adhesions significantly increases the morbidity and mortality of reoperative cardiac surgical procedures. Previous investigations have reported on the therapeutic utility of topical hydrogels in reducing the formation of postsurgical adhesions. The goal of the present study is to evaluate the ability of N-O carboxymethylchitosan (a glycosaminoglycan hydrogel derivative) to reduce the formation of postsurgical pericardial adhesions in a large-animal model. Sixteen adult New Zealand white rabbits were randomly assigned to one of two treatment groups. Group 1 subjects (n = 8) had N-O carboxymethylchitosan directly applied to the heart and retrosternal surfaces after sternotomy was performed, while subjects in group 2 (n = 8) had saline applied to these areas. After a period of 14 days the animals were sacrificed under anesthesia, and independent observers, blinded to treatment, graded the formation of pericardial adhesions. The severity of adhesion formation was significantly less in the group treated with N-O carboxymethylchitosan (p < .01). This study demonstrates that N-O carboxymethylchitosan markedly decreases the formation of poststernotomy adhesions in a large-animal model without untoward cardiac side effects. This hydrogel derivative may prove to be of great therapeutic value when used prophylactically in the setting of cardiac surgery.