Systemic inflammatory response syndrome after extracorporeal circulation: a predictive algorithm for the patient at risk.

INTRODUCTION: Perioperative systemic inflammatory response syndrome (SIRS) remains a catastrophe in cardiac surgery and adequate patient screening is still lacking. We present a prospective trial starting with preoperative data collection. For the first time, the postoperative outcomes of patients after open-heart surgery are evaluated to predict a hazard-constellation for the patient at risk of developing SIRS. METHODS: Of 2315 patients undergoing cardiac surgery over a 2-year period, 107 were considered likely to develop perioperative SIRS based on a high-risk stratification; 12 of them actually developed SIRS and were recruited for this study. Another 20 uneventful consecutive patients served as controls. Blood samples were collected from before the induction of anaesthesia until the morning of the second postoperative day and were analysed for complement, cytokines, adhesion-molecules, endothelin-1 (ET-1), plasminogen-activatorinhibitor (PAI), the coagulation and fibrinolysis cascade and routine laboratory analysis. RESULTS: Significant preoperative differences were observed in leukocytes, lymphocytes, alkaline phosphatase,ICAM-3 and VCAM-1 (p<0.05). Significant positive correlations were found for ET-1 and lactate in the SIRS group. The increase in these parameters was correlated with a prolonged duration of extracorporeal circulation. The best predictive combination for SIRS consisted of alkaline phosphatase, ET-1, ICAM-1, -2, -3, VCAM-1 and ELAM-1. CONCLUSIONS: The results suggest a new theory regarding the development of perioperative SIRS. It is not the extracorporeal circulation itself that represents the main trigger, but rather an a priori activation of the endothelial cells, lymphocytes and leukocytes. This activation impairs the microcirculation and finally leads to multi-organ failure. The current data allow the identification of the patient at risk and can thus influence the individual operative schedule.

HeartMate II ventricular assist device thrombosis-an echocardiographic approach to diagnosis: can Doppler evaluation of flow be useful?

A 68-year-old man was admitted to the hospital 4 months after HeartMate II ventricular assist device implantation, because his clinical status had deteriorated and his levels of lactate dehydrogenase and free hemoglobin had increased. Transthoracic echocardiography performed at admission revealed decreased basic diastolic continuous flow velocity with a pulsatile increase in flow velocity during ventricular contraction in both inflow and outflow cannulas. Twelve hours after beginning lytic therapy, basal diastolic continuous flow velocity had increased, and the amplitude between diastolic and systolic flow velocity had decreased. The clinical status of the patient improved, and his lactate dehydrogenase decreased. A decrease in basal diastolic flow may be a valuable marker of flow disturbance in continuous flow ventricular assist devices.