Case Report of Cryo Nerve Block in a Patient Undergoing Full Sternotomy: A Novel Approach to Pain Control in Cardiac Surgery.

We present the case of a 65-year-old man undergoing open-heart surgery through a full sternotomy with the use of bilateral intercostal cryo nerve block (cryoNB) as adjunctive therapy for postoperative analgesia. CryoNB has been previously demonstrated as safe and effective for pain control in thoracotomy procedures as well as bilaterally in adolescent patients with pectus excavatum undergoing Nuss procedure. Herein, we describe for the first time, the cryoNB procedure for postoperative pain management in a patient undergoing full sternotomy.

Inferior mesenteric artery stenting: a solution for chronic mesenteric ischemia.

Chronic mesenteric ischemia (CMI) is a rare entity with potentially tragic consequences. Meanwhile, there is still no consensus regarding the most adequate treatment approach. The authors herein report a case of a 65-year-old woman with severe CMI as a result of an occlusion of both the celiac artery (CA) and superior mesenteric artery (SMA) and a significant stenosis of the inferior mesenteric artery (IMA) ostium. The patient was successfully treated by angioplasty and stenting of the IMA. Even though the usual approach for CMI is revascularization of the CA and the SMA, the present case demonstrates that IMA can have a central role in visceral circulation, and its endovascular revascularization can be the first treatment option in selected cases.

A unified approach to axillosubclavian venous thrombosis in a single hospital admission.

Spontaneous or effort-related thrombosis of the axillosubclavian vein, termed Paget-Schroetter syndrome, is thought to be related to repetitive upper extremity physical activity, most commonly afflicting young, otherwise healthy, individuals. For the past 25 years, the mainstay of treatment for acute axillosubclavian venous thrombosis has consisted of early local catheter-directed thrombolytic therapy, an interval period of anticoagulation (3 months), and late surgical decompression of the thoracic outlet, with either a transaxillary or supraclavicular first rib resection. Immediate thrombolytic therapy followed by early surgical decompression has also been suggested previously, but has only recently been shown to be safe and efficacious, while significantly decreasing the duration of disability suffered by patients with this form of thoracic outlet syndrome. Therefore, a unified approach to acute axillosubclavian venous thrombosis in a single hospital admission should be considered an alternative standard of care for treatment of Paget-Schroetter syndrome.

Effect of NADPH oxidase inhibition on cardiopulmonary bypass-induced lung injury.

Cardiopulmonary bypass (CPB) causes acute lung injury. Reactive oxygen species (ROS) from NADPH oxidase may contribute to this injury. To determine the role of NADPH oxidase, we pretreated pigs with structurally dissimilar NADPH oxidase inhibitors. Low-dose apocynin (4-hydroxy-3-methoxy-acetophenone; 200 mg/kg, n = 6), high-dose apocynin (400 mg/kg, n = 6), or diphenyleneiodonium (DPI; 8 mg/kg) was compared with diluent (n = 8). An additional group was treated with indomethacin (10 mg/kg, n = 3). CPB was performed for 2 h with deflated lungs, complete pulmonary artery occlusion, and bronchial artery ligation to maximize lung injury. Parameters of pulmonary function were evaluated for 25 min following CPB. Blood chemiluminescence indicated neutrophil ROS production. Electron paramagnetic resonance determined the effect of apocynin and DPI on in vitro pulmonary endothelial ROS production following hypoxia-reoxygenation. Both apocynin and DPI attenuated blood chemiluminescence and post-CPB hypoxemia. At 25 min post-CPB with Fi(O(2)) = 1, arterial Po(2) (Pa(o(2))) averaged 52 +/- 5, 162 +/- 54, 335 +/- 88, and 329 +/- 119 mmHg in control, low-dose apocynin, high-dose apocynin, and DPI-treated groups, respectively (P < 0.01). Indomethacin had no effect. Pa(O(2)) correlated with blood chemiluminescence measured after drug administration before CPB (R = -0.60, P < 0.005). Neither apocynin nor DPI prevented the increased tracheal pressure, plasma cytokine concentrations (tumor necrosis factor-alpha and IL-6), extravascular lung water, and pulmonary vascular protein permeability observed in control pigs. NADPH oxidase inhibition, but not xanthine oxidase inhibition, significantly blocked endothelial ROS generation following hypoxia-reoxygenation (P < 0.05). NADPH oxidase-derived ROS contribute to the severe hypoxemia but not to the increased cytokine generation and pulmonary vascular protein permeability, which occur following CPB.

Effect of bronchial artery blood flow on cardiopulmonary bypass-induced lung injury.

Cardiovascular surgery requiring cardiopulmonary bypass (CPB) is frequently complicated by postoperative lung injury. Bronchial artery (BA) blood flow has been hypothesized to attenuate this injury. The purpose of the present study was to determine the effect of BA blood flow on CPB-induced lung injury in anesthetized pigs. In eight pigs (BA ligated) the BA was ligated, whereas in six pigs (BA patent) the BA was identified but left intact. Warm (37 degrees C) CPB was then performed in all pigs with complete occlusion of the pulmonary artery and deflated lungs to maximize lung injury. BA ligation significantly exacerbated nearly all aspects of pulmonary function beginning at 5 min post-CPB. At 25 min, BA-ligated pigs had a lower arterial Po(2) at a fraction of inspired oxygen of 1.0 (52 +/- 5 vs. 312 +/- 58 mmHg) and greater peak tracheal pressure (39 +/- 6 vs. 15 +/- 4 mmHg), pulmonary vascular resistance (11 +/- 1 vs. 6 +/- 1 mmHg x l(-1) x min), plasma TNF-alpha (1.2 +/- 0.60 vs. 0.59 +/- 0.092 ng/ml), extravascular lung water (11.7 +/- 1.2 vs. 7.7 +/- 0.5 ml/g blood-free dry weight), and pulmonary vascular protein permeability, as assessed by a decreased reflection coefficient for albumin (sigma(alb); 0.53 +/- 0.1 vs. 0.82 +/- 0.05). There was a negative correlation (R = 0.95, P < 0.001) between sigma(alb) and the 25-min plasma TNF-alpha concentration. These results suggest that a severe decrease in BA blood flow during and after warm CPB causes increased pulmonary vascular permeability, edema formation, cytokine production, and severe arterial hypoxemia secondary to intrapulmonary shunt.

Pharmacological preconditioning ameliorates neurological injury in a model of spinal cord ischemia.

BACKGROUND: Pharmacological openers of mitochondrial ATP-sensitive potassium (mitoKATP) channels have been shown to mimic ischemic preconditioning (IPC) in both the brain and myocardium. We hypothesized that similar endogenous mechanisms exist in the spinal cord and that diazoxide, a potent mitoKATP opener, could reduce neurologic injury after aortic cross-clamping in a model of spinal cord ischemia. METHODS: The infra-renal aorta was cross-clamped in 45 male New Zealand white rabbits for 20 minutes. Control animals received no pretreatment. Diazoxide-treated animals were dosed (5 mg/kg) 15 minutes before cross-clamp. A third group underwent 5 minutes of IPC 30 minutes before cross-clamp. Two groups received KATP antagonists, 5-hydroxydecanoic acid (5-HD, 20 mg/kg) or glibenclamide (1.0 mg/kg), before diazoxide administration. Systemic hypotension was induced in a final group with excess isoflurane. Tarlov Scoring was used to assess neurologic function at 24 and 48 hours, after which, the spinal cords were procured for histopathological analysis. RESULTS: Tarlov scoring demonstrated marked improvement in the Diazoxide group compared with control at 24 hours (p < 0.02) and 48 hours (p < 0.009). Moreover, no further neurologic injury occurred in this group at 7 days. IPC-treated animals showed neurologic improvement but were not significantly different from controls. Further, administration of glibenclamide was effective in antagonizing diazoxide's protective effect. CONCLUSIONS: Administration of diazoxide resulted in significant improvement in neurologic outcome in this model. This protective effect improved outcome at both early and late time points. Further, the antagonistic effect of glibenclamide implicates diazoxide's ATP-dependent potassium channel agonism as the mechanism of protection. Overall, this study suggests that diazoxide may be useful in the prevention of neurologic injury after thoracic aneurysm surgery.

Heterotopic abdominal heart transplantation: a pilot study.

The increasingly severe shortage of donor hearts has prompted a liberalization of what is considered an acceptable donor heart. The use of marginally acceptable organs has increased in recent years. Although these marginal donors have proved effective, there still remains a tremendous shortage of donors to treat the large number of patients who are candidates for cardiac transplantation. Further use of marginal donors is limited by the requirement to assume immediate and full support of the circulation. New strategies are required to increase donor organ use even further. The authors developed a model of heterotopic abdominal heart transplant (HAHT) to investigate the possibility of using marginal donor hearts to expand the donor pool for cardiac transplantation. The authors' goal was to show that HAHT was technically feasible and could potentially function as auxiliary circulatory support in the setting of low cardiac output. The hemodynamic and metabolic consequences of a HAHT were investigated in a pilot study that provides proof of concept and lays the groundwork for future investigations.

Aortic root replacement in 271 Marfan patients: a 24-year experience.

BACKGROUND: The introduction of composite graft repair of aortic root aneurysm by Hugh Bentall in 1968 promised Marfan patients the choice for a normal life expectancy. We performed our first Bentall composite graft procedure in 1976 and herein report our 24-year experience with 271 Marfan patients. METHODS: Between September 1976 and August 2000, 232 Marfan patients had a composite graft replacement of the aortic root, 15 patients received a homograft, and 24 had a valve-sparing procedure. RESULTS: Two hundred thirty-five Marfan patients underwent elective aortic root replacement with no 30-day mortality. Two early deaths occurred among 36 patients who underwent urgent or emergent operation. Eighty-three percent of patients in this series are currently alive. The actuarial freedom from thromboembolism, endocarditis, and reoperation on the residual aorta 20 years postoperatively was 93%, 90%, and 74%. Twenty-four patients have undergone valve-sparing procedures with encouraging results. CONCLUSIONS: Elective aortic root replacement for Marfan patients can be performed with low operative risk. Elective repair before the aortic root reaches 6 cm in diameter is recommended to minimize risk of dissection and rupture.