TLR2 and TLR4 expression on blood monocytes and granulocytes of cardiac surgical patients is not affected by the use of cardiopulmonary bypass.

Cardiac surgery is inseparably linked to the activation of innate immunity cells recognizing danger signals of both endogenous and exogenous origin via pattern recognition receptors such as TLR receptors. Therefore, we followed by flow cytometry TLR2 and TLR4 expression on blood monocytes and granulocytes of patients who underwent coronary artery bypass grafting using beating heart surgery (off-pump, n = 34), with use of standard cardiopulmonary bypass (CPB), (on-pump, n = 30), and miniinvasive CPB (mini on-pump, n = 25), respectively, before, during surgery, and up to 7th postoperative day. TLR2 and TLR4 expression both on monocytes and granulocytes was significantly diminished already at the end of CPB being highly significantly decreased at the end of surgery in all patients' groups. TLR2 and TLR4 expression reached preoperative value at the 1st postoperative day being significantly higher at the 3rd postoperative day. Using intracellular staining we found the peak of TLR2 and TLR4 expression inside of monocytes and granulocytes at the first postoperative day in a subgroup of on-pump patients. In conclusion, TLR2 and TLR4 expression is significantly modulated in patients undergoing coronary artery bypass grafting as a part of adaptive homeostatic mechanisms induced by major surgery. The very surgical trauma is responsible for TLR2 and TLR4 modulation. Surprisingly, cardiopulmonary bypass itself was little contributing to the modulation of TLR2 and TLR4 expression.

Chylothorax--a rare complication after cardiac surgery (a case report).

Chylothorax is a rare but severe complication of cardiac surgery. The authors present the case of a 76-year-old woman suffering from ischemic heart disease, after coronary artery bypass grafting that included a left internal mammary artery pedicle graft. On the ninth postoperative day the left-sided fluidothorax developed. The results of biochemical analysis were consistent with the chyle. Combined treatment with pleural drainage and total parenteral nutrition was effective.

Controlled hemostasis in thoracic surgery using drugs with oxidized cellulose.

The authors demonstrate the possibility of improving surgical results by the reduction of perioperative bleeding in thoracic surgery associated with extended resection procedures. We focused on patients in whom the expected perioperative blood loss was greater than 500 ml. The first group consisted of patients with lung cancer stage III A after neoadjuvant chemotherapy had been indicated to extend the resection procedure. The second group consisted of patients with chest wall and mediastinum tumors of various etiologies. The third group consisted of patients with post-inflammatory thoracic complications in whom combined decortication and pleurectomy was necessary. By the using the local hemostyptic Traumastem TAF on the basis of oxidized cellulose, it is possible to minimize the perioperative blood loss, thus sparing the blood derivative requirement and enabling surgeons to provide the desired treatment even to high-risk patients.

The effect of cardiac surgery on peripheral blood lymphocyte populations.

BACKGROUND: Cardiac surgery using cardiopulmonary bypass (CPB) is associated with some adverse postoperative complications caused by an altered immune response. An alternative approach to cardiac surgery, operating without the use of CPB (i.e. off-pump surgery), seems to display less adverse impacts on the immune response. PATIENTS AND METHODS: Peripheral blood lymphocytes in 40 patients undergoing cardiac surgery either with CPB ("on-pump") or without CPB ("off-pump") were followed using flow cytometry. The samples of peripheral blood were taken at five intervals: preoperatively, after termination of the surgery, on the first, on the third and on the seventh postoperative day, respectively. RESULTS: The most substantial changes appeared on the first postoperative day in both subgroups of patients. While the percentage of both total T cells and CD4+ T cells were decreased, the percentage of HLA-DR+ activated lymphocytes was increased. These changes were more profound in the "on-pump" subgroup compared to the "off-pump" subgroup. CONCLUSION: Our results may suggest that the "off-pump" surgical approach reveals less adverse impact on adaptive immune responses.

The expression of CD38 ADP-ribosyl cyclase ectoenzyme in immune cells of cardiac surgical patients.

BACKGROUND: This study was aimed at following the changes in the expression of CD38 ADP-ribosyl cyclase ectoenzyme on peripheral blood immune cells of patients undergoing cardiac surgical operations. PATIENTS AND METHODS: The expression of CD38 on lymphoid and myeloid cells was determined by immunofluorescence and flow cytometry in forty cardiac surgical patients assigned to surgery either using ("on-pump", n=20) or without the use ("off-pump", n=20) of cardiopulmonary bypass. RESULTS: There was a very rapid upregulation of CD38 expression in "on-pump" patients, becoming significant at declamping of aorta (p<0.01) for myeloid cells and at the weaning from CPB (p<0.001) for lymphocytes. The increased expression of CD38 on lymphocytes in "off-pump" patients was prolonged for the entire observation period. However, significant differences in the expression of CD38 between "on-pump" and "off-pump" patients were not found either in lymphoid or myeloid cells. CONCLUSION: CD38 expression in immune cells of cardiac surgical patients is upregulated early during surgery, providing additional activation stimuli to the cell substrate of the inflammatory response induced by cardiac surgery.

Peripheral tissue metabolism during off-pump versus on-pump coronary artery bypass graft surgery: the microdialysis study.

OBJECTIVE: The aim of this study was to monitor and compare metabolic changes in the skeletal muscle during coronary artery bypass grafting surgery with and without cardiopulmonary bypass (CPB) by means of interstitial microdialysis. Glucose, lactate, pyruvate and glycerol were assessed as markers of basic metabolism and tissue perfusion. METHODS: Twenty patients undergoing surgical myocardial revascularization were enrolled in this pilot study. Ten patients were operated on without CPB (group A, off-pump) and 10 patients using normothermic CPB (group B, on-pump). Interstitial microdialysis was performed by a CMA 60 (CMA/Microdialysis AB, Sweden) probe, inserted into the patient's left deltoid muscle. Microdialysis measurements were performed at 30 min intervals. Glucose, lactate, pyruvate and glycerol were measured in samples using a CMA 600 Analyser (CMA/Microdialysis AB, Sweden). Results in both groups were statistically processed and the groups were compared. RESULTS: Both groups were similar with regards to preoperative characteristics. Dynamic changes of interstitial concentrations of the measured analytes were found in off-pump (group A) and on-pump (group B) patients during the operation. There were no significant differences in dialysate concentrations of glucose and lactate between the groups. Significant differences were detected in pyruvate concentrations, lactate-pyruvate ratio and glycerol concentrations between off-pump versus on-pump patients. Pyruvate concentrations were higher in the off-pump group (p<0.05), the lactate-pyruvate ratios indicating the aerobic/anaerobic metabolism status were lower in the off-pump group (p<0.01) and the values of the concentrations of glycerol were lower in the off-pump group (p<0.01). CONCLUSION: Dynamic changes in the interstitial concentrations of the glucose, glycerol, pyruvate and lactate were found in both groups of patients (off-pump and on-pump). The presented preliminary results suggest that extracorporeal circulation during cardiac operations could compromise skeletal muscle energy metabolism.

The inflammatory response in cardiac surgery. An up-to-date overview with the emphasis on the role of heat shock proteins (HSPs) 60 and 70.

Cardiac surgical operations are associated with the development of a systemic inflammatory response syndrome (SIRS). In most cases, the inflammatory response is apparent only in its subclinical form. In some cases, however, it can become clinically manifest or even life-threatening. This review article presents some new data regarding its biological importance, along with an insight into the recently discovered role played by heat shock proteins 60 and 70.

Essential PTX3 biology (not only) for cardiologists and cardiac surgeons.

Inflammation has been recognized to form an integral part of the atherosclerotic process. Much consideration has been given lately to the role played in atherogenesis by C-reactive protein (CRP). Although not accepted unequivocally, CRP appears to be not only a marker, but also an active mediator of the atherosclerotic process. Pentraxin 3 (PTX3) is a newly identified acute phase reactant which shares some structural and some functional properties with CRP. On the other hand, pentraxin 3 displays unique biological properties of its own, including a possible role in the pathogenesis of cardiovascular diseases and in processes accompanying the natural evolution of surgical wounds. This review article discusses recent information concerning basic pentraxin 3 biology in inflammation and in innate immunity reactions as viewed by a cardiologist in the context of acute coronary events and by a surgeon in patients struck with multiple wounds who are at the same time menaced by bacterial infections.

Expression of an activated form of integrin beta2 chain CD18 in cardiac surgical operations.

BACKGROUND: Myeloid cells are extensively activated in patients undergoing cardiosurgical operations. It is supposed that this activation is more profound in patients operated with cardiopulmonary bypass (CPB) ("on-pump") in comparison with patients operated without CPB ("off-pump"). AIMS: To evaluate changes in the expression of a novel activation marker expressed on myeloid cells recognized by MEM-148 antibody. PATIENTS AND METHODS: The expression of MEM-148 positive myeloid cells was evaluated by flow cytometry in 40 patients who underwent coronary artery bypass surgery (CABG) randomly assigned to "on-pump" or "off-pump" technique. RESULTS: The relative and absolute number of MEM-148 positive myeloid cells is significantly diminished during "on-pump" surgery. A significant increase in their number in postoperative period in both "on-pump" and "off-pump" patients was found. There were no significant differencies between "on-pump" and "off-pump" patients. CONCLUSIONS: The very trauma of surgery seems to be more relevant in starting on activation of myeloid cells them CPB itself.

Posttraumatic pneumopericardium: a sign of severe injury or radiodiagnostic rarity?

We present three cases of pneumopericardium following blunt chest trauma injury. All three patients were victims of road traffic accidents. All had multiple associated injuries and pneumopericardium was found as the additional finding. Pneumopericardium was treated conservatively with thoracic drains placement and patients observation. Transesophageal echocardiography was used as a method of choice for exclusion of cardiac air tamponade. All three patients survived.

Use of two parallel oxygenators in a very large patient (2.76 m2) for an acute "A" dissecting aortic aneurysm repair.

The very large patient (weight 142 kg, height 197 cm, body surface 2.76 m2) was referred to acute operation with dissecting type A ascending aortic aneurysm. The calculated blood flow was 6.63 l/min. To anticipate potential difficulties with perfusion and oxygenation two oxygenators connected in parallel were incorporated into the circuit. Bentall procedure with ACB to the RCA was performed. The perfusion was uneventful. Bypass time was 259 minutes, cross clamp time 141 minutes, circulatory arrest 7 minutes. The highest oxygenators gas flow was 2.6 l/min with maximum FiO2 0.42. The use of two in parallel connected oxygenators is a very effective, easy and safe method in such extreme perfusions, offering to the perfusionist a great reserve of oxygenator output.

Vascular complications of the intra-aortic balloon counterpulsation.

From September 1994 to December 2002, 6,274 cardiosurgery operations were performed at the Department of Cardiac Surgery, University Hospital, Hradec Kralove, Czech Republic. Intra-aortic balloon counterpulsation (IABP) was applied in 192 cases (3.1%). From this group of 192 counterpulsated patients 103 were successfully treated (53.6%); 89 counterpulsated patients (46.4%) died from the surgical procedure (30-day mortality rate). In 5 cases (2.6%) from the group of 192, the IABP was introduced before the operation. Ischemic changes of the limb were observed in 11 cases (5.7%). Significant bleeding occurred at the site of puncture in 6 cases (3.1%). Dissection of the femoral and iliac arteries was found in 2 patients (1.0%), perforation of the iliac artery in 1 case (0.5%). In 2 cases (1.0%) the balloon was led into the venous system. In case report No. 1 an introduction of the balloon under a sclerotic plaque of the descending aorta and iliac artery is described. In case report No. 2 a placement of the balloon in the venous bloodstream is reported.