Endothelin receptor blockade reduces ventricular dysfunction and injury after reoxygenation.

BACKGROUND: Reoxygenation of hypoxic myocardium during repair of congenital heart defects results in poor ventricular function and cellular injury. Endothelin-1 (ET-1), a potent vasoconstrictor that increases during hypoxia, may suppress myocardial function and activate leukocytes. The objective was to determine whether administration of an endothelin receptor antagonist could improve ventricular function and decrease cardiac injury after hypoxia and reoxygenation. METHODS: Fourteen piglets underwent 90 minutes of ventilator hypoxia, 1 hour of reoxygenation on cardiopulmonary bypass, and 2 hours of recovery (controls). Nine additional animals received an infusion of Bosentan, an ET(A/B) receptor antagonist, (5 mg/kg per hour) during hypoxia and reoxygenation. RESULTS: Right and left ventricular dP/dt in controls decreased to 78% and 52% of baseline, respectively, after recovery (p < 0.05). In contrast, Bosentan-treated animals had complete preservation of RV dP/dt and less depression of LV dP/dt. Bosentan reduced the hypoxia and reoxygenation-induced elevation of ET-1 and iNOS mRNA at the end of recovery (p < 0.05). Bosentan-treated animals had diminished myocardial myeloperoxidase activity and lipid peroxidation compared with controls (p < 0.05). Myocardial apoptotic index, elevated by hypoxia and reoxygenation, was lower in the Bosentan-treated animals (p < 0.05). CONCLUSIONS: Endothelin-1 receptor antagonism improved functional recovery and decreased leukocyte-mediated injury after reoxygenation. The reduction in cardiac cell death might also improve long-term outcome after reoxygenation injury.

Alternative methods for anticoagulation monitoring in pediatric patients with applicability to a patient with severe hemophilia A and circulating inhibitor.

Anticoagulation monitoring in pediatric patients can be problematic because of the immaturity of the coagulation system in this population. In addition, the hemodilution required to place a small patient on bypass can interfere with standard monitoring methods. In this institution, the Hemochron Jr. ACT (activated clotting time)+ assay has been the standard of care for anticoagulation monitoring since 1997. This assay, with a target ACT of 400 s for initiating bypass, was compared to both the Medtronic HMS system (N = 7) and the Hemochron HiTT assay (N = 6) in pediatric patients. All three assays were then employed to monitor a pediatric Hemophilia A patient (Factor VIII <1%) with high inhibitor titer. Both the HiTT clotting time and the HMS heparin level showed statistically significant correlation to the ACT+ (HiTT, N = 24, r = 0.761; HMS, N = 31, r = 0.818). An HMS target heparin level of 1.5 mg/kg and a HiTT target clotting time of 180 s were found to be clinically equivalent to the 400-s ACT+ as indicators of the need for additional heparin. When a 7-year-old male with severe hemophilia A and high inhibitor titer required tricuspid valve replacement, all three assays were used to ensure appropriate anticoagulation management. During bypass, this patient's ACT+ remained out of range (>1005 s). The HiTT was maintained at >180 s and the HMS heparin level at >1.5 mg/kg. Heparin was administered when any single parameter was below the cutoff value. The use of the combination of three distinct monitoring assays for this patient allowed the surgical team an added level of confidence that appropriate anticoagulation had been maintained.

Bosentan prevents hypoxia-reoxygenation-induced pulmonary hypertension and improves pulmonary function.

BACKGROUND: Acute hypoxia results in increased pulmonary vascular resistance. Despite reoxygenation, pulmonary vascular resistance remains elevated and pulmonary function is altered. Endothelin-1 might contribute to hypoxia-reoxygenation-induced pulmonary hypertension and to reoxygenation injury by stimulating leukocytes. This study was carried out using an established model of hypoxia and reoxygenation to determine whether endothelin-1 blockade with Bosentan could prevent hypoxia-reoxygenation-induced pulmonary hypertension and reoxygenation injury. METHODS: Twenty neonatal piglets underwent 90 minutes of hypoxia, 60 minutes of reoxygenation on cardiopulmonary bypass, and 2 hours of recovery. Control animals (n = 12) received no drug treatment, whereas the treatment group (n = 8) received the endothelin-1 receptor antagonist, Bosentan, throughout hypoxia. RESULTS: In controls, pulmonary vascular resistance increased during hypoxia to 491% of baseline and remained elevated after reoxygenation; however in the Bosentan group, it increased to only 160% of baseline by end-hypoxia, then decreased to 76% at end-recovery. Arterial endothelin-1 levels in controls increased to 591% of baseline after reoxygenation. Arterial nitrite levels decreased during hypoxia in controls but were maintained in the Bosentan group. Consequently, animals in the Bosentan group had better postreoxygenation pulmonary vascular resistance, A-a gradient, and airway resistance along with lower myeloperoxidase levels than controls. CONCLUSIONS: Acute hypoxia and postreoxygenation pulmonary hypertension was attenuated by Bosentan, which maintained nitric oxide levels during hypoxia, decreased leukocyte-mediated injury, and improved pulmonary function.

Squamous cell papilloma of the esophagus: a case report and review of the literature.

Squamous cell papilloma of the esophagus is exceedingly rare. This is the seventh case to be presented since histological verification began in 1959. Clinical, radiographic and microphotographic evidence are presented, together with a survey of the literature.