Off-pump coronary artery bypass grafting does not reduce lymphocyte activation.

OBJECTIVE: In this study, we test the hypothesis that off-pump coronary bypass surgery might result in less lymphocyte activation than on-pump coronary surgery. We also study the behavior of lymphocyte activation markers during and after surgery. BACKGROUND: Coronary artery bypass surgery is known to be associated with changes of inflammatory mediators, immune function, and early phase lymphocyte activation, which could cause postoperative lymphopenia and lymphocyte unresponsiveness. METHODS: We studied lymphocyte activation response in 28 patients randomized to off-pump (n = 13) or on-pump (n = 15) coronary artery bypass surgery. Expression of CD25, CD26, CD69, and DR on T (CD3+) and B (CD19+) lymphocytes on peripheral blood was assessed through flow cytometry. RESULTS: The response of T lymphocytes and their activation markers, as well as B lymphocytes and their activation markers, was similar after on- and off-pump surgery. Overall, T lymphocytes decreased to the lowest level 9 h after surgery and tended to increase later. For B lymphocytes, there was early reduction with increase on the 1st postoperative day. There was early activation of CD69+ and late activation of CD25+ on T lymphocytes. For B lymphocytes, there was early activation of CD69+ and late activation of DR+. CONCLUSIONS: (1) Compared to on-pump cardiopulmonary bypass, off-pump surgery does not reduce lymphocyte activation. (2) Coronary bypass surgery causes the early activation of lymphocytes, as evidenced by the increased expression of lymphocyte activation markers.

Postoperative necrotizing fasciitis of the thorax in cardiac surgery.

Necrotizing fasciitis is a rare soft tissue infection and a life-threatening emergency, often fatal. Its incidence and management are described plentifully in the medical literature regarding the most common anatomical sites involved like the abdomen, lower and upper limbs, and perineum. However, available data and case reports of chest wall necrotizing fasciitis after thoracic procedures are scarce, mainly after major cardiac operations. We report and discuss a case of necrotizing fasciitis of the chest wall occurring in the immediate postoperative period of a cardiac procedure, and include a brief review of the concepts, pathophysiology, and treatment reported in the medical literature. We emphasize the need for early diagnosis and urgent and effective surgical debridement. Of importance is the fact that we have not found any references in the literature to cases similar or equal to the one we describe here, which occurred in the postoperative period of a cardiac procedure.

Partial left ventriculectomy: overall and late results in 44 class IV patients with 4-year follow-up.

BACKGROUND: This study reports long-term results of partial left ventriculectomy (PLV). METHODS: Forty-four patients with dilated cardiomyopathy were operated on in a 4-year study. Echocardiograms, catheterization, and stress tests with oxygen consumption (VO2) were performed. RESULTS: The survivors' preoperative ejection fractions of 22.1% +/- 4.9% improved to 30.9% +/- 9.4%, left ventricular (LV) end-diastolic diameter decreased from 79.4 +/- 9.3 mm to 61.9 +/- 8.2 mm, and maximum VO2 consumption improved from 8.8 +/- 3.9 mL/kg per minute to 15.8 +/- 6.1 mL/kg per minute at 22.6 months. These data also showed improvements in nonsurviving patients, according to the last evaluation before death. Seven of 12 survivors (58.3%) were in New York Heart Association (NYHA) I and II in December 1998. Twelve patients had elevated pulmonary vascular resistance (PVR) contraindicating heart transplant. In five patients the PVR returned to normal and one high-PVR patient was transplanted at the 16th postoperative month. Survival was 56.8%, 47.7%, 38.4%, and 35.9%, respectively, at 3, 6, 12, and 18 months, with a tendency to stabilize at 32.7% thereafter. Arrhythmias and heart failure were the main causes of death. CONCLUSIONS: In spite of improvement of ventricular function and quality of life of the survivors, high mortality is a limiting factor. PLV can be indicated as a bridge to heart transplantation in high-PVR patients or if ventricular assist devices or donor hearts are not available.

Holt-Oram syndrome revisited. Two patients in the same family.

Holt-Oram syndrome was first described in 1960 as an association of familial heart disease and musculoskeletal abnormalities. The most important findings include atrial septal defects, atrioventricular conduction abnormalities, vascular hypoplasia, and upper limb musculoskeletal deformities. We report two patients with this syndrome in the same family and discuss the variability of the musculoskeletal abnormalities and their association with the cardiac morphologic defects. Both patients in this study had associated eosinophilia, which has not been reported in the literature.

End-stage heart failure: is there a role for the Batista procedure?

BACKGROUND: Medically refractory heart failure is traditionally managed with cardiac transplantation although some limited success has also been obtained in selected patients using dynamic cardiomyoplasty or mechanical assist devices. Recently, a new surgical alternative called partial left ventriculectomy (PLV) was introduced by Batista in 1995. The procedure attempts to relieve symptoms of congestive failure by reducing myocardial mass and restoring the normal mass-to-volume ratio of the left ventricle. Despite initial enthusiasm, the results of PLV are not yet known. The aim of this study was to determine survival and clinical outcomes in a group of patients submitted to PLV as a means of surgical treatment for end stage heart disease (ESHD) METHODS: From November 1994 to December 1995, 15 patients with ESHD and dilated cardiomyopathy (DCM) were operated on by the technique described by Randas Batista. We compared preoperative and postoperative assessments of NYHA Functional Class (FC), Quality of Life index (QOL), echocardiographic, ergometric, radioisotopic ventriculography and hemodynamic data at intervals of zero, one, three, six and nine, and twelve months postoperatively. Kaplan-Meier, student t-test and chi-square analysis were applied to the numerical and categoric variables. RESULTS: Survival was 80% at one month, 66% at three months, 53% at six months, 47% at nine months and 40% at one year. We also found that 6 of 7 patients (85%) with tricuspid regurgitation (TR) died compared to 4 of 8 patients (50%) without TR. This was the only risk factor indentified which influenced mortality. Post-operative echocardiographic evaluations demonstrated reduced left ventricular end-diastolic and end-systolic diameters at six months (LVESD 65.5 +/- 8.3 mm preoperatively versus 56.83 +/- 5.74 mm at six months, p=0.007 and LVEDD 73.84 +/- 8.25 mm preoperatively versus 65.33 +/- 5.72 mm at six months, p=0.009). Survivors enjoyed an improved clinical status according to both the NYHA functional class (preoperative Class IV=100% versus postoperative at six months : Class IV = 50%, Class III = 17% and Class II = 33%) and the Quality of Life index (100% were in grade 6 and 7 preoperatively versus 0% at six months). However, statistical significance was not reached in most of these data due to the small number of patients. CONCLUSIONS: Actuarial survival in this series of patients was 53% at six months and 40% at twelve months with survivors showing fewer symptoms and clinical events than preoperatively (100% hospitalized preoperatively versus no patient hospitalized at six months). Therefore, the Batista Operation improves the quality of life patients with dilated cardiomyopathy and can possibly be a new means for bridging to cardiac transplantation in severely ill patients who are not likely to survive long enough to recieve a donor heart. Additional improvements in late results will likely be seen after further experience, evolution of the surgical techniques and better patient selection.

[Involvement of pulmonary function in patients treated with rotated chest muscle flap surgery for the treatment of sternal wound complications after heart surgery]. / Comprometimento da função pulmonar em pacientes submetidos à cirurgia de rotação de retalho do músculo peitoral para correção de complicações do esterno pós-cirurgia cardíaca.

PURPOSE: To evaluate pulmonary function of patients submitted to muscle flap for treatment of mediastinitis. METHODS: Fifteen patients operated with the muscle flap technique were compared with 26 consecutive patients submitted to heart surgery with extracorporeal circulation, that did not present wound complications. Both groups were evaluated for age, sex, body weight, height, surgery, forced vital capacity (FVC), forced expiratory volume in first second (FEV1) and the relation (FEV1/FVC) in absolute and percentual values, espirometry conclusions and clinical evidences of lung disease. RESULTS: There was no statistical difference between preoperative and postoperative period for FVC (p = 0.98), FEV1 (p = 0.68) and FEV1/FVC (p = 0.30) in the group with no sternal complications. In the control group, the median of FVC was 3907 +/- 1053.25 and in the study group was 2818 +/- 766.86 in absolute values (p = 0.0015). The median of FEV1, in the control group, was 2995 +/- 855.68 and in the study group was 2232 +/- 617.68 in absolute values (p = 0.0046). There was statistical difference, between groups, in FVC (104.78 +/- 21.73 and 82.04 +/- 21.16) and FEV1 (99 +/- 22.67 and 79.04 +/- 19.17) in percentual (p = 0.0026 and 0.0067) values. There was no statistical difference for the ratio FEV1/FVC. The study group had five patients diagnosed as having restrictive ventilatory insufficiency by espirometry against none in the control group (p = 0.0031). CONCLUSION: Patients with infectious complications of sternum and mediastinum, treated surgically with muscle flap rotation may present restrictive pulmonary insufficiency in moderate degree, that must be considered in this situation.

[Reinfusion of shed blood after heart surgery]. / Reinfusão de sangue drenado em pós-operatório de cirurgia cardíaca.

PURPOSE: To asses effectivity of postoperative reinfusion of shed mediastinal blood in reduction of homologous transfusions at cardiac surgery and to study the possibility of side effects. METHODS: Fifteen patients submitted to cardiac surgery that had their shed mediastinal blood reinfused after surgery were compared to another group of 15 patients. The two groups were compared in relation to: volume of shed blood, number of units of blood used in postoperative period, culture of shed blood, postoperative complications, number of days of hospitalization, hematocrit at the end of hospitalization and mortality. RESULTS: The use of whole blood and packed blood cells decreased from 25 to 10 units with reinfusion of shed mediastinal blood (p < 0.01). Volume of shed blood, postoperative complications, period of hospitalization, hematocrit at the end of hospitalization and mortality were not different in both groups. Culture of shed blood, in 8 patients of control group and all patients of study group were negative. CONCLUSION: Reinfusion of shed mediastinal blood in postoperative of cardiac surgery proved to be very efficient in decreasing homologous blood transfusions. This procedure is also safe, with no additional risk to patients.