Effect of cardiopulmonary bypass on a patient with endocarditis and malaria.

Knowledge about the effects of cardiopulmonary bypass on malarial patients is scant. Malaria-induced hemolysis can exercerbate by performing extracorporeal circulation on a patient infected with Plasmodium and may, therefore, lead to a critical hemolysis jeopardizing the clinical outcome. A 52-year-old patient suffering from malaria and endocarditis was scheduled for urgent aortic valve replacement. During extracorporeal circulation, free hemoglobin showed an increase to maximum of 392.5 mg/L (normal range < 50 mg/L), while haptoglobin decreased to the lowest value of 0.56 g/L (normal range 0.3-2.0 gL). Although hemolysis increased, pump run, weaning, and the postoperative course were uneventful.

Influence of modified ultrafiltration on coagulation, fibrinolysis and blood loss in adult cardiac surgery.

OBJECTIVES: Modified ultrafiltration (MUF) significantly reduce blood loss and transfusion requirements in pediatric cardiac surgery presumably by a reduction in inflammatory mediators which decrease the inflammatory axes and decrease the cross-activation of fibrinolysis and thrombosis. The influence of MUF on blood loss and homologous blood transfusion in adult cardiac surgery has not yet been determined. Furthermore, data about the influence on routine coagulation tests, platelet activation as well as the coagulation and fibrinolytic systems are limited. METHODS: In a prospective randomized study 48 patients scheduled for elective myocardial revascularization were randomized into a control group (n=16), a conventional ultrafiltration (CUF) group (n=16) and a MUF group (n=16). Perioperatively, serial blood samples were drawn at specific intervals to evaluate coagulation, fibrinolysis, and platelet function. RESULTS: Neither the coagulation nor the fibrinolytic system was positively influenced by MUF or CUF. The routine clotting tests were comparable except for a significantly higher antithrombin III activity after MUF compared to the CUF control group persisting 24 h postoperatively. Platelet factor 4 activity and platelet counts showed no differences among the groups. MUF considerably reduced the postoperative blood loss (MUF, 6.4+/-1.7 ml/kg bw per 24 h vs. CUF, 9.2+/-2.5 ml/kg bw per 24 h (P=0.003) vs. control, 8.9+/-2.2 ml/kg bw per 24 h (P=0.008)) and allogeneic blood transfusion (MUF, 2.0+/-3.4 ml/kg bw per 24 h vs. CUF, 6.9+/-5.1 ml/kg bw per 24 h (P=0.034) vs. control, 7.0+/-6.3 ml/kg bw per 24 h (P=0.029)). CONCLUSIONS: MUF in adult cardiac surgery significantly reduces postoperative blood loss and transfusion requirements. The mechanism for reduced blood loss could not be elucidated in this study.

Triangular resection of the anterior leaflet for repair of the mitral valve.

Isolated anterior mitral leaflet prolapse, unlike posterior prolapse, is a difficult lesion to repair and may become a demanding surgical procedure. We report our experience with a technique of a triangular resection of the anterior leaflet to repair isolated segmental anterior leaflet prolapse in 18 patients. This technique simplifies the repair procedure and is a safe and rapid procedure which allows excellent results.

Papillary muscle repair surgery in ischemic mitral valve patients.

BACKGROUND: Ischemic mitral regurgitation (MR), when ischemia/infarction has resulted in fibrotic degeneration and elongation of papillary muscles, carries a high risk for the patient and a technical challenge for the surgeon. We have developed a papillary-shortening plasty for this specific pathology. METHODS: Papillary muscle repair was performed in 88 patients (7.2%) where degenerated and fibrotic elongated papillary muscles were found, which resulted in a prolapse of one or more parts of the mitral valve leaflets (MR III-IV). All patients had a papillary muscle-shortening plasty using a pericardium pledged-reinforced polytetrafluoroethylene suture and a ring annuloplasty. Because the cause of regurgitation in this specific group of patients was ischemic, concomitant coronary bypass grafting was required in all patients, with 2.2 grafts/patient. RESULTS: There were five hospital deaths (5.7%). Postoperative mitral valve function was satisfactory in all patients: no residual mitral regurgitation (MR 0) was found in 80 patients (90.9%), mild regurgitation (MR I) in 5 patients (5.7%), and moderate regurgitation (MR I-II) was observed in 3 patients (3.4%). Within a short mean follow-up period of 18.6 months (3 to 40 months), there was one late death (1.2%). The actuarial freedom from reoperation and thromboembolic complications was 100%, but there were two anticoagulation-induced gastric bleeding complications (2.3%). All patients were in New York Heart Association functional class I or II at the time of follow-up. CONCLUSIONS: Our data show that careful assessment of papillary muscle pathology is mandatory, and that a papillary muscle-shortening plasty is a simple but valuable surgical tool to repair the mitral valve in this specific group of high-risk patients with ischemic mitral regurgitation.

Hydrodynamics of aortic arch vessels during perfusion through the right subclavian artery.

BACKGROUND: Performing subclavian artery cannulation in patients with an atherosclerotic ascending aorta or acute aortic dissection is of growing interest. To increase knowledge about pressure and flow distribution in the arch vessels, we investigated the in vitro perfusion characteristics in right subclavian artery cannulation. METHODS: Pressures and flow rates in the arch vessels of an aortic arch model were measured during perfusion through the right subclavian artery with different geometries and varying flow rates. Flow visualization was performed by laser light. RESULTS: In normal subclavian artery geometries, pressure and flow showed a significant increase in only the right common carotid artery (8 mm Hg and 25.5 mL/min, respectively, at 5.5 L/min pump flow). In cases of 50% stenosis at the right subclavian artery origin, a reduction of pressure and flow (6 mm Hg and 22.5 mL/min, respectively, at 5.5 L/min pump flow) in the right carotid artery caused by a suction effect was observed. CONCLUSIONS: Right subclavian artery cannulation provides a valuable alternative for ascending aortic cannulation, enabling nearly balanced arch vessel perfusion. Stenosis at the right subclavian artery origin carries the potential risk of slightly reduced perfusion of the right common carotid artery with questionable clinical relevance.

An in-vitro evaluation of aortic arch vessel perfusion characteristics comparing single versus multiple stream aortic cannulae.

OBJECTIVE: During extracorporeal circulation design and orientation of aortic cannulae tips mainly determine flow pattern in the aortic arch and arch vessels which is the objective of this in vitro study, comparing single versus multiple stream cannulae. METHODS: In an aortic arch glass model, jet streams of 21-24 French aortic cannulae which were inserted in the ascending aorta were directed alternatively at the different arch vessels. Flows and pressures in the arch vessels were measured at pump flows of 3-6 l/min. RESULTS: With optimal orientation of the jet stream in the aortic arch, no preferential flow in the arch vessels was seen. In the single jet stream aortic cannulae group a significant parallel increase in flow and pressure in the jet streamed arch vessels compared to the non-jet streamed arch vessels occurred (P < 0.05). With the jet stream directed on vessel 2 (left carotid vessel) there was a significant pressure and flow difference comparing the two non-jet streamed vessels with each other (P < 0.03). In the single stream 24 French cannulae the highest vessel pressure of 168 mmHg and an increase in flow of 186 ml/min was measured in the jet streamed left carotid artery at 6 l/min pump flow. The multiple stream cannulae provoked the highest vessel pressure of 106 mmHg in the corresponding jet streamed vessel and an increase in flow of 20 ml/min. CONCLUSION: Tip design of aortic cannulae and the orientation of its jet stream are potential sources of remarkable imbalance of arch vessel perfusion especially with single jet stream cannulae. These effects are more pronounced with single jet stream cannulae. These results may have important clinical implications regarding perfusion of arch vessels during extracorporeal circulation.

[Gastric mucosal tonometry as a monitoring method in cardiac anesthesia. Empirical findings on the postoperative outcome under various volume controls]. / Magenmukosa-Tonometrie als Monitoringverfahren in der Kardioanästhesie. Empirische Befunde zum postoperativen Outcome unter besonderer Berücksichtigung des Volumenhaushaltes.

OBJECTIVES: Several studies documented higher complication rates after cardiac surgery in patients with splanchnic hypoperfusion. Although it is prone to errors, gastric tonometry probably is the method of choice for detecting splanchnic hypoperfusion. While there are many reasons for splanchnic hypoperfusion, low cardiac output because of hypovolemia is one of the important ones in cardiac surgery. Thereby endogenous vasoactive substances, such as angiotensin II and the kinins, might be of special interest. METHODS: Following approval from the local ethics committee, 40 patients undergoing elective cardiac surgery were studied. Every patient received a TRIP NGS Catheter (Tonometrics Division Instrumentarium Corp., Helsinki, Finland). Using radioimmunoassays and chromatography angiotensin II and bradykinin was measured before, during and immediately after cardiopulmonary bypass. Using saline tonometry gastric mucosal CO2 was measured ten times perioperatively. Patients were shifted into two groups by dichotomization at the median of gastric mucosal pH (pHi) and the pCO2 gap (gastric mucosal pCO2-arterial pCO2) before surgery. Volume substitution, use of vasoactive drugs, haemodynamic instability and time of extubation were documented. RESULTS: During cardiopulmonary bypass group I (pHi < 7.32 and CO2 gap > 3.85 mmHg) showed higher expression of angiotensin II and lower expression of bradykinin then group II (pHi > 7.32 and CO2 gap < 3.85 mmHg). The most significant difference was found on bypass. Immediately post bypass there was still a difference in the bradykinin expression. Before bypass no differences was found. In group I significantly more volume had to be substituted for haemodynamic stabilisation. These patients needed more often vasoactive drugs and in tendency were extubated later. At the time of extubation no group-difference was found as in the pHi as in the CO2 gap as in the amount of substituted volume. Patients with previous high pHi and low CO2 gap had lowest respectively highest values at the time, when fluid-balance was most negative. CONCLUSIONS: Splanchnic hypoperfusion in cardiac surgery probably correlates with hypovolemia and therefore leads to vasoconstriction, wich is shown in higher expression of angiotensin II and lower of bradykinin. Gastric mucosal tonometry in cardiac surgery probably detects hypovolemia and therefore predicts haemodynamic instability. Therefore gastric mucosal tonometry could probably be used as a therapeutical sign for a sufficient cardiac output and therefore for tissue oxygenation in general.

Discrepancies between sizer and valve dimensions: implications for small aortic root.

BACKGROUND: Precise labeling of sizer and valve diameters is crucial for optimal valve selection especially in the small aortic root. This study examines the accuracy of manufacturers' markings on small aortic prostheses and sizers. METHODS: Sizer and valve dimensions of 22 different mechanical aortic prostheses (19 to 23 mm) were evaluated by caliper micrometer measurements. RESULTS: Nearly all sizers exceeded their marked dimensions by up to 1.0 mm. Measured tissue annulus diameters for 19-mm-labeled valves varied between 18.3 and 19.6 mm, for 21-mm valves from 20.5 to 21.6 mm, and for 23-mm valves from 22.4 to 23.5 mm, respectively. The orifice areas ranged from 1.5 to 2.06 cm2 for 19-mm valves, from 2.0 to 2.55 cm2 for 21-mm valves, and from 2.4 to 3.09 cm2 for 23-mm valves, respectively. CONCLUSIONS: Actual sizer dimensions and tissue annulus diameters of various small mechanical aortic prostheses varied considerably from their marked diameters. These differences should be considered to ensure the optimal prosthesis selection for each patient.

[A new probe holding device for continuous bilateral measurements of blood flow velocity in basal brain vessels]. / Eine neue Sondenhalterung für kontinuierliche bilaterale Messungen von Flussgeschwindigkeiten in basalen Hirngefässen.

The clinical relevance of transcranial Doppler sonography for the evaluation of cerebral perfusion and cerebrovascular regulatory mechanisms, as well as for the registration of embolic events, has increased considerably as a technique of non-invasive monitoring. The continuous measurement of blood flow velocities in two different vessel segments, either ipsilateral or contralateral, is limited by intricate probe fixation and positioning for optimal insonation of the vessel on the one hand. On the other hand probes are displaced frequently during anaesthesiological measures, so that continuous registration during induction of anaesthesia is not always guaranteed. In view of these limitations, a new probe-positioning and holding device has been developed and tested in a clinical study of patients undergoing cardiac surgery (n = 22). The newly designed probe-positioning and holding device allowed the unilateral adjustment and continuous measurement of the blood flow velocity in the middle cerebral artery (Vmca) from anaesthesia induction to endotracheal intubation in all patients (n = 9). This was possible in only 61.5% (n = 8) of the patients who were monitored via conventional mode of probe fixation (n = 13). The new method rendered possible the positioning, insonation and measurement in two vessel segments in 77.8% of the patients, in contrast to 53.8% of the patients where the conventional technique was used. The newly designed probe holding device meets all standard requirements from the anaesthesiological viewpoint, and facilitates the perioperative application of transcranial Doppler sonography for non-invasive monitoring.

New method for monitoring the functional state of a dynamic cardiomyoplasty.

OBJECTIVE: To assess the impact of a dynamic cardiomyoplasty on failing hearts, it is essential to estimate the contraction force of the skeletal muscle and how its contraction is synchronized with the heart cycle. METHODS: In a 6-month study a small fluid-filled, balloon-mounted catheter was placed between the myocardium and the muscular wrap in five adult female Boor goats and two female domestic pigs. The catheter was connected to a subcutaneous measuring chamber whereby pressure monitoring could be accomplished. Distinct pressure signals as a result of function of the dynamic cardiomyoplasty and the heart were detected initially in all animals. RESULTS: Maximal relative pressure from the dynamic cardiomyoplasty was calculated as 336.2% +/- 69.4% on day 24 +/- 6.1 (n = 7) and end-stage pressure as 59.8% +/- 9.7% on day 174.6 +/- 13.1 (n = 4). A functional loss of pressure signals from the dynamic cardiomyoplasty was correlated to severe histologic muscle damage (n = 3). Pressure signals transferred from the contracting myocardium to the catheter showed defined segments of contraction, ejection, and filling periods, allowing a mechanical synchronization of the dynamic cardiomyoplasty to the heart cycle. CONCLUSIONS: This monitoring catheter enabled the assessment of the functional state of the dynamic cardiomyoplasty and allowed a synchronization to the heart cycle. It will promote understanding and might help to avoid muscle damage in dynamic cardiomyoplasty for an improved outcome of the surgical treatment of end-stage heart failure.