Expression of High Mobility Group Protein B1 in Cardiac Tissue of Elderly Patients with Coronary Artery Disease with or without Inflammatory Rheumatic Disease.

BACKGROUND: It is known from clinical practice and observational studies that elderly patients with a diagnosis of inflammatory rheumatic diseases (IRD) bear a significantly increased risk for cardiovascular diseases such as coronary artery disease (CAD) and heart failure. The molecular mechanism, however, is still not known. Recently, high mobility group protein B1 (HMGB1), a ubiquitous, highly conserved single polypeptide expressed in all mammal eukaryotic cells, has been identified to mediate myocardial dysfunction in vitro once released from the nuclei of cardiomyocytes. OBJECTIVE: To investigate whether HMGB1 and its receptors are expressed in cardiac muscles of elderly patients with CAD with or without IRD. METHODS: HMGB1 and its 3 well-known receptors, receptor for advanced glycation end products, Toll-like receptor 2 (TLR2), and TLR4, were examined by immunohistochemistry on myocardial biopsy specimens from 18 elderly patients with CAD (10 with IRD, 8 without IRD). Furthermore, total HMGB1 protein levels were measured by Western blot from the cardiac biopsies in 5 patients with and 5 without IRD. RESULTS: Pathologic cytosolic HMGB1 in cardiomyocytes was massively recorded in all patients with IRD, but only slightly expressed in 1 patient without IRD. Total HMGB1 levels were also consistently lower in myocardial muscle biopsies of patients with IRD compared to those without IRD. Furthermore, all 3 HMGB1 receptors were expressed in cardiomyocytes of all patients. CONCLUSION: The increased cytosolic expression of HMGB1 in cardiomyocytes and the lower total amount of HMGB1 in the cardiac specimens of IRD patients is consistent with a greater release of HMGB1 from the myocardial nuclei in IRD than non-IRD individuals. Thus, the HMGB1 signaling pathways may be more easily activated in elderly CAD patients with concomitant IRD and trigger a detrimental inflammatory process causing severe cardiovascular problems. Therefore, targeting HMGB1 in IRD patients might reduce the risk for cardiovascular events.

Immediate rescue operations after failed diagnostic or therapeutic cardiac catheterization procedures.

OBJECTIVES: Although rare, life-threatening complications requiring emergency cardiac surgery do occur after diagnostic and therapeutic cardiac catheterization procedures. The operative mortality has been persistently reported to remain high. The purpose of this observational study was to evaluate and report the outcomes, with particular emphasis on early mortality, of these risky operations that were performed in a single highly specialized cardiac centre. METHODS: Between June 1997 and August 2007, 100 consecutive patients, 13 after diagnostic complicated cardiac catheterization (0.038% of 34,193 angiographies) and 87 after crashed percutaneous coronary intervention (PCI; 0.56% of 15,544 PCIs), received emergency operations at the Feiring Heart Center. In the same period, 10,192 other patients underwent open cardiac surgery. Early outcome data were analysed and compared between the cohorts. Follow-up was 100% complete. RESULTS: The preoperative status of the 100 patients was that 4 had ongoing external cardiac massage, 24 were in cardiogenic shock, 32 had frank enduring ST-segment infarction but without shock and 40 had threatened acute myocardial infarction. There was 1% (1 patient) 30-day mortality in the study group, which is equal (0.9%, P=0.60) to that of all other operations. Postoperative myocardial infarction and prolonged ventilator use were significantly higher in the crash group, whereas the rate of stroke, renal failure, reopening for bleeding and mediastinitis were similar between the groups. CONCLUSIONS: With rapid transfer to an operation room, minimizing the time of warm myocardial ischaemia, and by performing complete coronary revascularization, it is possible to obtain equally low operative mortality in patients with life-threatening cardiac catheterization-associated complications, as is the case with open cardiac operations in general.

Avoidance of noninfectious sternal dehiscence: figure-of-8 wiring is superior to straight wire closure.

OBJECTIVES: Comparison of figure-of-8 wiring or simple straight-wiring technique assessed by the frequency of early noninfectious sternal dehiscence. DESIGN: Observational register study with 7835 patients having sternal closure with figure-of-8 steel wires was compared with 2122 patients, where the sternotomy was closed by simple interrupted straight wires. The endpoint was the rate of early (within 30 days) sterile sternal dehiscence. RESULTS: Fourteen patients (0.66%) with single wires and five patients (0.06%) with figure-of-8 wires underwent re-operation for nonmicrobial sternal disruption (p < 0.0001). The median time-point for re-intervention was 6 days for both groups. In more than 6000 patients, the sternotomy was closed with five figure-of-8 wires without dehiscence in any of them. CONCLUSION: In a large cohort of consecutive cardiac operations, it was found that sternal closure with figure-of-8 wires is better than closure with simple interrupted wires.

Fluid overload during cardiopulmonary bypass is effectively reduced by a continuous infusion of hypertonic saline/dextran (HSD).

OBJECTIVE: Cardiopulmonary bypass (CPB) is associated with fluid overload. We examined how a continuous infusion of hypertonic saline/dextran (HSD) influenced fluid shifts during CPB. MATERIALS AND METHODS: Fourteen animals were randomized to a control-group (CT-group) or a hypertonic saline/dextran-group (HSD-group). Ringer's solution was used as CPB-prime and as maintenance fluid at a rate of 5 ml/kg/h. In the HSD group, 1 ml/kg/h of the maintenance fluid was substituted with HSD. After 60 min of normothermic CPB, hypothermic CPB was initiated and continued for 90 min. Fluid was added to the CPB-circuit as needed to maintain a constant level in the venous reservoir. Fluid balance, plasma volume, total tissue water (TTW), intracranial pressure (ICP) and fluid extravasation rates (FER) were measured/calculated. RESULTS: In the HSD-group the fluid need was reduced with 60% during CPB compared with the CT-group. FER was 0.38(0.06) ml/kg/min in the HSD-group and 0.74 (0.16) ml/kg/min in the CT-group. TTW was significantly lower in the heart and some of the visceral organs in the HSD-group. In this group ICP remained stable during CPB, whereas an increase was observed in the CT-group (p<0.01). CONCLUSIONS: A continuous infusion of HSD reduced the fluid extravasation rate and total fluid gain during CPB. TTW was reduced in the heart and some visceral organs. During CPB ICP remained normal in the HSD-group, whereas an increase was present in the CT-group. No adverse effects were observed.