[Rupture of the internal thoracic artery 6 weeks after MIDCAB operation]. / Ruptur der A. thoracica interna 6 Wochen nach MIDCAB-Operation.

The minimally invasive coronary bypass operation is a procedure that has been firmly established in cardiac surgery for several years now. Only a few reports exist regarding the complications of this procedure. This case study reports on a 51-year-old man who collapsed 27 days after a left-sided internal mammary artery bypass on the anterior interventricular artery, when the bypass vessel ruptured. After pericardial puncture and cardiopulmonary resuscitation the patient was transported via air ambulance to a cardio-surgical center where he was successfully operated upon.

Perioperative elastase activity in cardiac surgery and its role in endothelial leakage.

OBJECTIVE AND DESIGN: The functional activity and pathophysiological effects of polymorphonuclear elastase (PMNE) in cardiac surgery patients are unknown. This in vitro study was done to evaluate whether PMNE activity in patient blood samples may be correlated with decreased endothelial wall integrity. METHODS AND SUBJECTS: PMNE was serially analyzed by PMNE activity in plasma samples from 40 high risk cardiac surgery patients. Endothelial cell cultures were used to study the influence of patient serum on the intercellular integrity. RESULTS: Ex vivo, samples with high PMNE activity (>1.0 mg/ ml), found in 14 patients (35%), neither induced hyperpermeability in cultured endothelial cells nor resulted in intracellular redistribution of the junction molecules cadherin-5 or beta-catenin. However, pretreatment of endothelial cells with these samples but not with low activity (<0.5 mg/ml) samples augmented neutrophil transendothelial migration (>20-fold) in conjunction with formation of intercellular gaps and irregular membrane-associated beta-catenin staining. Neutrophil transmigration was inhibited by blocking neutrophil beta1 integrin but not by the proteinase inhibitor methoxysuccinyl-Ala-Ala-Pro-Ala. CONCLUSIONS: Augmented PMNE activity in cardiac surgery patients does not directly induce endothelial leakage but may indirectly promote neutrophil extravasation and thus perioperative endothelial hyperpermeability.

Do surface modifying additives (SMA) influence blood loss and thrombogenicity in conventional cardiopulmonary bypass for coronary artery bypass grafting?

Cardiopulmonary bypass (CPB) leads to activation of the coagulation and fibrinolytic cascades, partially associated with foreign surface contact. Hemorrhage and the need for blood products is associated with rising cost and increased risk of infection. Treatment with surface modifying additives (SMA) has been shown to reduce thrombogenicity and improve biocompatibility. 76 elective CABG-patients were randomly assigned to surface modifying additives (group I, n=39) or untreated circuits that were otherwise identical (group II, n=37). Measurements of coagulation activity and fibrinolysis, platelet count and function were made. The postoperative blood loss and blood product replacement was also assessed. Thrombin formation measured by prothrombin fragments 1+2 (5.7+/-0.4 nmol/l vs. 5.6+/-0.4 nmol/l), fibrinolytic activity measured by plasmin-antiplasmin complex (1752.6+/-216.8 microg/l vs.1180.0+/-74.8 microg/l) and the postoperative platelet count and function did not differ significantly between the two groups. Blood loss and transfusion requirements were slightly lower in the SMA group. The treatment of extracorporeal surfaces with surface modifying additives does not appear to reduce coagulation disorders and bleeding after conventional CPB.

Leukocyte filtration fails to limit functional neutrophil activity during cardiac surgery.

OBJECTIVE AND DESIGN: The beneficial effects of leukocyte filtration on the outcome of cardiac surgery with cardiopulmonary bypass (CPB) is probably due to the limitation of pathogenesis mediated by over-stimulated neutrophils. However, the influence of leukocyte filtration on the functional neutrophil activity has not been studied in detail. Therefore, by using different filtration timing strategies we determined neutrophil effector functions before and after the filter passage as well as blood surrogate markers for neutrophil activation. METHODS: We randomly assigned 80 cardiac surgery patients to four groups (n = 20 each) without (1) and with three different filtration timing strategies (II-IV). As functional end points neutrophil phagocytic activity and oxidative burst upon ex vivo stimulation with E.coli were analyzed from blood of 31 patients whereas polymorphonuclear elastase (PMNE), myeloperoxidase, and malondialdehyde (MDA), a marker for lipid peroxidation was determined in plasma samples from 80 patients. Blood was harvested immediately before and behind the filter (Pall LG6) at different times during CPB. RESULTS: We found that none of the filtration strategies either reduced the number of neutrophils capable of eliciting phagocytic activity and oxidative burst or the activity per cell. In contrast, PMNE and MPO levels in peripheral venous blood were found to be significantly increased in groups II-IV compared with group I throughout the entire filtration period in all patients. MDA was not enhanced in the filter groups. CONCLUSIONS: Our results show that the leukocyte depletion filter in the arterial line of the heart-lung machine failed to limit neutrophil stimulation but rather augmented PMNE plasma levels. We speculate that augmented PMNE and MPO levels mainly stem from neutrophils that are captured within the mesh of the leukocyte filter.

Totally endoscopic coronary artery bypass grafting on cardiopulmonary bypass with robotically enhanced telemanipulation: report of forty-five cases.

BACKGROUND: Robotically enhanced telemanipulation is a new powerful tool for minimally invasive procedures that allows totally endoscopic cardiac surgery. Between June 1999 and February 2001, 45 robotically enhanced totally endoscopic coronary artery bypass grafting procedures on the arrested heart were performed at our institution with the use of the da Vinci telemanipulation system (Intuitive Surgical, Inc, Mountain View, Calif). METHODS: In 37 patients a single-vessel totally endoscopic coronary bypass operation was performed. Eight patients had different types of multivessel revascularization with both internal thoracic arteries. The initial conversion rate was 22% and dropped to 5% in the last 20 patients. Two patients required reexploration via median sternotomy. The first 22 patients had excellent graft patency on discharge. The procedural time for single-vessel totally endoscopic bypass was 4.2 +/- 0.4 hours, bypass time was 136 +/- 11 minutes, and aortic crossclamp time amounted to 61 +/- 5 minutes. CONCLUSION: The present data show the feasibility of closed chest single- and double-vessel revascularization, with good clinical results. However, procedural time is prolonged and the complex endoscopic and endoaortic occlusion techniques, as well as the extensive anesthesiologic monitoring, are demanding. The need for conversion to an open procedure diminished after a relatively short learning curve. All postulated benefits of totally endoscopic surgery other than excellent cosmesis must be evaluated in larger cohorts.

Echocardiographic findings in minimally invasive coronary artery bypass grafting: The role of intrathoracic CO2 - insufflation and single lung ventilation.

BACKGROUND: Current options for surgical treatment of coronary single vessel disease range from beating heart procedure without cardiopulmonary bypass via a mini thoracotomy (MIDCAB) to totally endoscopic robot-assisted techniques (TECAB) with cardiopulmonary bypass. Both procedures are associated with considerable stress even before revascularization such as single lung ventilation, temporary coronary occlusion, Luxatio cordis, intrathoracic CO2 insufflation and extended bypass and operating time. The aim of the this study was to document the extent of intraoperative segmental wall motion abnormalities (SWMA) by echocardiography, and to identify variables affecting SWMA. MATERIALS AND METHODS: Forty patients with coronary single vessel disease were included in the study. 16 patients were operated with the MIDCAB technique, and 24 patients underwent TECAB. In both groups of patients sequential transesophageal echocardiograms (2D-loops) were recorded and analyzed. Hemodynamic and electrocardiographic data as well as oxygenation parameters were acquired during echo exams. In both groups of patients mild, but significant perioperative SWMA were identified, which increased in the course of the operation. These SWMA were more pronounced in the TECAB as compared to the MIDCAB group. Independent of operating time these changes disappeared completely until the ends of surgery. Significant hemodynamic or elektrocardiographic modifications were not observed. CONCLUSION: The application of minimally invasive techniques for the surgical treatment of coronary single vessel disease is associated with significant perioperative SWMA. The more pronounced SWMA in the TECAB group may be a consequence of intrathoracic CO2-insufflation. Both techniques can be applied without significant myocardial ischemia, provided that appropriate intraoperative monitoring is performed, and intrathoracic CO2 pressure in TECAB patients is limited.

Correction of simple congenital heart defects in infants and children through a minithoracotomy.

BACKGROUND: Minimally invasive surgical techniques in pediatric cardiac surgery have evolved throughout the last 10 years. Advantages of minimally invasive procedures include excellent cosmetic results and superior postoperative outcome. However, safety of minimally invasive techniques has to be proven. METHODS: In 21 female infants and children, a right anterolateral thoracotomy was performed. Mean age was 7.1 years (0.5 to 16.6 years) and mean body weight was 20.8 kg (8.3 to 56 kg). The following defects were repaired: atrial septum defect type II (n = 14); partial atrioventricular septum defect (n = 3); partial anomalous pulmonary venous connection (n = 2); ventricular septum defect (n = 2); mitral valve insufficiency (n = 1); and resection of an embolized atrial septum defect occluder (n = 1). In two cases, aortic cross-clamping was performed by using a transthoracic clamp. In 5 patients, femoral cannulation was performed. Skin incisions were limited to 4 to 7 cm. RESULTS: There was no operative or late mortality. Mean operation time, bypass time, and aortic cross-clamp time were 138 (95 to 275), 72 (32 to 179), and 35 (12 to 120) minutes, respectively. Mean postoperative mechanical ventilation time, mean intensive care unit stay, and mean hospital stay were 3.9 hours (1 to 12 hours), 1.4 days (1 to 3 days), and 12 days (8 to 18 days), respectively. Postoperative complications included hemorrhage in 1 patient requiring surgical intervention. Mean follow-up period was 13.3 months (1 to 36 months). All patients were in New York Heart Association class I postoperatively. Trivial mitral insufficiency was evident in 1 patient operated for partial atrioventricular septum defect. CONCLUSIONS: A small right anterolateral thoracotomy as a minimally invasive technique in pediatric cardiac surgery is a safe and suitable alternative in the operative management of simple congenital heart defects. Cosmetic results are superior, however, improved postoperative outcome has to be proven.

Leukocyte filtration in cardiac surgery: a review.

Leukocyte filtration has evolved as an important technique in cardiac surgery with cardiopulmonary bypass to prevent pathogenic effector functions mediated by activated leukocytes. The underlying mechanisms that result in an improvement of laboratory variables as well as clinical outcome are not resolved yet. Moreover, the optimum strategy for the use of current filtration technology has not been systematically evaluated. This paper, therefore, reviews how activated leukocytes may lead to tissue damage, summarizes the known effects of leukocyte filtration on clinical outcome and laboratory parameters, and deals with current experimental and clinical efforts to further limit the pathogenic effects of leukocytes in cardiac surgery.

Heparin coating of the extracorporeal circuit combined with leukocyte filtration reduces coagulation activity, blood loss and blood product substitution.

BACKGROUND: Cardiopulmonary bypass is associated with activation of the coagulation cascade. Occasionally, this results in postoperative hemorrhage and consequently the need for blood products associated with increasing costs and risk of infection. Contact activation of the intrinsic coagulation pathway, and damage to cellular blood components with the release of proteolytic substances from neutrophil granulocytes have been linked to these coagulation disorders. METHODS: Eighteen routine CABG-patients were randomly assigned to totally heparin coated circuits (Bioline coating) combined with leukocyte filtration in a double blind protocol (group I), 34 patients served as controls (group II). Leukocyte filters were activated before release of the aortic crossclamp. Coagulation activity, postoperative blood loss, and substitution with blood products were assessed. RESULTS: Blood loss in the first 24h after surgery was significantly lower with combined application of heparin coating and leukocyte filters (group I) vs. controls (group II) (526+/-78 ml vs. 786+/-88 ml; p<0.05). Thrombin formation represented by prothrombin fragments 1+2 was significantly lower in group I vs. group II after declamping of the aorta (2.1+/-0. 3 nmol/L vs. 4.0+/-0.3 nmol/L; p<0. 05). Group I showed higher AT II plasma than group II (48.8+/-3.2% vs. 41.5+/-1.77%; p<0.05). CONCLUSIONS: Leukocyte filtration during reperfusion in heparin coated cardiopulmonary bypass circuits is associated with lower coagulation activation, decreased blood loss and reduced transfusion of packed red cells in elective CABG patients.

Hemodynamics and gas exchange during carbon dioxide insufflation for totally endoscopic coronary artery bypass grafting.

BACKGROUND: In addition to single-lung ventilation (SLV), positive-pressure CO2 insufflation is mandatory for totally endoscopic coronary artery bypass grafting. Studies on the effects of unilateral CO2 insufflation on hemodynamics produced controversial results, and bilateral insufflation has not been studied to our knowledge. The present study sought to investigate hemodynamics and gas exchange during unilateral and bilateral CO2 insufflation in patients who underwent totally endoscopic coronary artery bypass grafting. METHODS: Eleven hemodynamic and gas exchange variables were monitored during 22 totally endoscopic coronary artery bypass grafting procedures with unilateral (n = 17) or bilateral (n = 5) CO2 insufflation at a pressure of 10 to 12 mm Hg. Data were obtained at baseline with double-lung ventilation, after institution of SLV, during insufflation, after cardiopulmonary bypass during SLV, and after return to double-lung ventilation. RESULTS: Arterial oxygen tension decreased significantly during SLV, whereas the peak inspiratory pressure increased. In addition, central venous pressure and heart rate increased significantly during insufflation, but mean arterial pressure remained unchanged. Although the end-tidal CO2 pressure did not change, arterial carbon dioxide tension increased progressively to a maximum of 44.6 +/- 5.9 mm Hg during unilateral insufflation, and 55.7 +/- 14.6 mm Hg during bilateral insufflation (p < 0.05 versus baseline and between groups). Mixed venous oxygen saturation declined during SLV regardless of CO2 insufflation and recovered to baseline once double-lung ventilation was restarted. Left and right ventricular ejection fractions remained unaltered. No patient required inotropic or vasopressor support. CONCLUSIONS: Carbon dioxide insufflation for totally endoscopic coronary artery bypass grafting with SLV had no adverse effects on hemodynamics. In contrast to a moderate increase of arterial carbon dioxide tension during unilateral insufflation, markedly elevated arterial carbon dioxide tension levels remain a cause of concern during bilateral insufflation.

Timing of leukocyte filtration during cardiopulmonary bypass.

The effects of leukocyte filtration on the outcome of cardiac surgery with cardiopulmonary bypass (CPB) have been shown by numerous investigators. In the majority of cases a leukocyte filter is placed in the arterial line instead of a standard arterial line filter and used throughout CPB. However, protocols to optimize onset and duration of leukocyte filtration have not been sufficiently evaluated to date. In this paper, current efforts to improve such protocols are demonstrated and discussed. These efforts are based on studies of leukocyte pathogenicity during cardiac surgery. A first study (double-blind randomized) was performed in routine coronary artery bypass graft (CABG) patients to evaluate whether short-term leukocyte filtration during reperfusion by release of the aortic crossclamp would reduce reperfusion-associated myocardial damage. Further data compare the efficacy of three different filtration concepts to reduce CPB- and/or reperfusion-associated leukocyte pathogenicity. Clinical endpoints, standard laboratory variables and functional in vitro assays are provided and discussed.

Leukocyte filtration in the early reperfusion phase on cardiopulmonary bypass reduces myocardial injury.

Improved myocardial protection and cardiopulmonary bypass (CPB) have limited, but not abolished, intraoperative myocardial damage due to surgical reperfusion injury after release of the aortic crossclamp. In this double-blind, randomized study, we evaluated whether short-term leukocyte filtration during reperfusion may further reduce myocardial damage. Thirty-eight patients with coronary artery disease were randomly assigned to CPB with (group I; n = 19) or without leukocyte filtration (group II; n = 19). There was no difference in bypass time or crossclamp time between the groups. No patient in group I required catecholamines, whereas three patients in group II were supported with adrenaline or dobutamine on the first and second postoperative day. In addition, troponin T plasma levels were lower in group I (p < 0.05), whereas other markers for tissue injury (CK, CK-MB, LDH, S-GOT and S100B) did not differ. In conclusion, leukocyte filtration during reperfusion may further improve CPB by reducing myocardial damage.

Uncontrolled reoxygenation by initiating cardiopulmonary bypass is associated with higher protein S100 in cyanotic versus acyanotic patients.

BACKGROUND: The systemic reoxygenation injury produced by initiating cardiopulmonary bypass (CPB) in infants with cyanotic heart disease may be associated with cerebral dysfunction and injury. Increased protein S100 (S100) serum levels may indicate cerebral and blood brain barrier damage as well as inflammatory changes, therefore serving to quantify these changes. The present clinical study assessed S100 in cyanotic patients undergoing CPB with normoxic versus hyperoxic paO2 in acyanotic cases and in controls without CPB. METHODS: 43 patients with congenital heart disease aged 5 days to 15 years (mean 4.4 years) were enrolled consecutively and divided in four groups: (1) Cyanotic infants undergoing controlled normoxic reoxygenation on CPB (n = 12), (2) cyanotic infants undergoing uncontrolled hyperoxic reoxygenation on CPB (n = 9), (3) acyanotic infants operated with CPB (n = 16) and (4) patients operated without CPB (n = 6). Blood samples were collected after induction of anesthesia (A), up to 4 hours after surgery (B) and at postoperative day one (C). RESULTS: Preoperative S100 serum levels [microg/l] in all groups were below clinical relevance. S100 increased markedly after surgery in groups 1 and 2. Differences in postoperative S100 levels were significant between groups 1 (0.45 +/- 0.13) and 3 (0.35 +/- 0.09; p = 0.018), between groups 2 (1.41 +/- 0.47) and 3 (p = 0.01), and between groups 2 and 4 (0.29 +/- 0.09; p = 0.045). There were no significant differences in postoperative S100 levels (B) between groups 1 and 2 (p = 0.05), groups 1 and 4 (p = 0.05), or groups 3 and 4 (p = 0.93). CONCLUSION: Uncontrolled hyperoxic reoxygenation on CPB for surgical correction of congenital heart defects is associated with higher S100 levels in cyanotic infants as compared to acyanotic patients undergoing comparable operations.

Patient selection for Port-Access multi vessel revascularization.

Minimally invasive multivessel revascularization is rarely performed due to the difficult exposure of the aorta as well as the complete coronary anatomy through a small thoracotomy. The Port-Access technique bears additional contraindications for this procedure, which limits its potential as compared with other approaches to 'less invasive surgery'. Our aim was to show the applicability of this surgical technique to a wide range of patients with coronary artery disease. In our initial experience with this method (31 patients), the quality of anastomoses, graft patency, and clinical outcome are good, and do not differ from standard multivessel coronary artery bypass grafting. Port-Access multivessel revascularization can be performed safely and is appropriate for a large patient population.

Synthetic protein treated versus heparin coated cardiopulmonary bypass surfaces: similar clinical results and minor biochemical differences.

OBJECTIVE: Complications associated with cardiopulmonary bypass (CPB) have gained more attention due to increased interest in coronary artery bypass grafting without CPB. The impact of heparin coating of CPB circuits has been discussed controversially. The present study examines if the treatment of the oxygenator surface with a synthetic protein may serve as an alternative to a completely heparin coated circuit. METHODS: Fifty-eight patients undergoing coronary artery bypass grafting with CPB were randomly assigned to completely heparin coated circuits or synthetic protein treated oxygenators in a double blind protocol, focussing on the inflammatory reaction resulting in membrane damage, coagulation changes and markers of cerebral injury or dysfunction. Treatment groups did not differ as to preoperative demographics, and intraoperative clinical data. Patients with any neurologic disease or risk factors for cerebral dysfunction were not included in the study. RESULTS: Postoperative clinical data did not differ between groups. Both surface treatments resulted in similar coagulation activation, hyperfibrinolysis and disseminated intravascular coagulation. Platelet count displayed a difference in favour of the heparin coated group (P = 0.029). Increased leukocyte activation reflected by rising myeloperoxidase concentrations on CPB was present in both synthetic protein and heparin coating groups. Interleukins 6 and 8 reacted similarly, but interleukin 8 increased significantly more (P = 0.0061) at the end of surgery in patients treated with protein treated oxygenators. The same pattern was observed for complement activation as determined by total complement complex (P = 0.006). Both surface changes resulted in moderately increased S-100B protein and neuron specific enolase, without difference between groups. Both markers did not reach concentrations associated with clinical manifestation of cerebral injury. CONCLUSIONS: These results in routine patients with short bypass time, imply that protein treated oxygenators are associated with a limited increase of biochemical markers similar to heparin coating. However, significantly lower interleukin 8 release and complement activation can be achieved by heparin coating. The protein treatment is a standard feature of the oxygenator examined in both groups. It is not associated with additional cost and therefore appropriate for use in routine patients.

Influence of different routes of flush perfusion on the distribution of lung preservation solutions in parenchyma and airways.

OBJECTIVE: The present study was performed to investigate the influence of different routes of perfusion on the distribution of the preservation solutions in the lung parenchyma and upper airways. METHODS: Pigs were divided into four groups: control (n = 6), pulmonary artery (PA) (n = 6), simultaneous PA + bronchial artery (BA) (n = 8), and retrograde delivery (n = 6). After preparation and cannulation, cardioplegia solution and Euro-Collins solution (ECS) for lung preservation were given simultaneously. After removal of the heart, the double lung bloc was harvested. Following parameters were assessed: total and regional perfusion (dye-labeled microspheres), tissue water content, PA, aorta, left atrial and left ventricular pressures, cardiac output and lung temperature. RESULTS: Our data show that flow of the ECS in lung parenchyma did not reach control values (9.4+/-1.0 ml/min per g lung wet weight) regardless of the route of delivery (PA 6.3+/-1.5, PA + BA 4.8+/-0.9, retrograde 2.7+/-0.9 ml/min per g lung wet weight). However, flow in the proximal and distal trachea were significantly increased by PA + BA delivery (0.970+/-0.4, respectively, 0.380+/-0.2 ml/min per g) in comparison with PA (0.023+/-0.007, respectively, 0.024+/-0.070 ml/min per g), retrograde (0.009+/-0.003, respectively, 0.021+/-0.006 ml/min per g) and control experiments (0.125+/-0.0018, respectively, 0.105+/-0.012 ml/g per min). Similarly the highest flow rates in the right main bronchus were achieved by PA + BA delivery (1.04+/-0.4 ml/min per g) in comparison with 0.11+/-0.03 in control, 0.033+/-0.008 in PA, and 0.019+/-0.005 ml/min per g in retrograde group. Flows in the left main bronchus were 0.09+/-0.02 ml/min per g in control, 0.045+/-0.012 ml/min per g in PA, and 0.027+/-0.006 ml/min per g in retrograde group. The flow rates were significantly (P = 0.001) increased by PA + BA delivery of the storage solution (0.97+/-0.3 ml/min per g). CONCLUSIONS: Our data show that the distribution of ECS for lung preservation is significantly improved in airway tissues (trachea and bronchi) if a simultaneous PA + BA delivery is used.

Effect of internal thoracic artery preparation on blood loss, lung function, and pain.

BACKGROUND: Postoperative blood loss, respiratory distress, and pain after coronary artery operation were assessed in a prospective, randomized, clinical study comparing two techniques of internal thoracic artery preparation. METHODS: In group A (n = 57) the internal thoracic artery was dissected with the entire surrounding connective tissue after opening the pleura, using routine lateral pleural drainage. In group B (n = 55) a venoarterial pedicle was prepared without surrounding muscle leaving the pleura intact. We assessed blood loss, clinical outcome, lung function, location, intensity, and quality of pain 6 days and 3 months after the operation. RESULTS: Significantly higher blood loss was observed in group A (A, 608+/-58 mL; B, 470+/-48 mL; p = 0.027). Forced expiratory volume in 1 second was significantly decreased in group A 6 days after surgery (A, 76.0%+/-1.6%; B, 83.2%+/-1.6%; p = 0.020). The forced expiratory volume in 1 second correlated to inspiratory vital capacity, which confirmed the advantage of the venoarterial technique (A, 0.771+/-0.021; B, 0.832+/-0.020; p = 0.003). Vital capacity was significantly higher in the venoarterial group at 3 months (A, 85.2%+/-2.1%; B, 98.5%+/-1.2%; p = 0.009), but not on postoperative day 6. The incidence of pleural effusion and atelectasis was significantly higher in group A (effusion: A, 52.6%; B, 23.6%; p = 0.002; atelectasis: A, 42.1%; B, 20.0%, p = 0.015). Sternal pain (A, 36.8%; B, 9.1%; p = 0.001) and suspenders pain (A, 33.3%; B, 7.3%; p = 0.001) occurred more often in group A. When using a multidimensional pain score, patients in group A experienced significantly sharper (6 days: A, 6.7+/-0.3; B, 3.3+/-0.2; p = 0.018; 3 months: A, 3.5+/-0.3; B, 1.4+/-0.3; p = 0.046) and more annoying pain (6 days: A, 7.6+/-0.2; B, 2.7+/-0.1; p = 0.036; 3 months: A, 6.6+/-0.3; B, 2.3+/-0.2; p = 0.040). CONCLUSIONS: These results demonstrate that the venoarterial preparation technique is superior to conventional internal thoracic artery preparation regarding postoperative blood loss, lung function, and pain.

Angiotensinogen M235T polymorphism is associated with plasma angiotensinogen and cardiovascular disease.

BACKGROUND: Genes encoding components of the renin-angiotensin system have been associated with elevated blood pressure (BP) and an increased risk of coronary artery disease. To explore the role of the angiotensinogen (AGT) gene in coronary atherosclerosis and thrombosis, we studied the effect of the AGT M235T gene variant on plasma AGT levels and BP in patients with coronary artery disease and in the subgroup of survivors of myocardial infarction as compared with angiographically defined control subjects. METHODS AND RESULTS: This was a case-control study of 301 white male subjects examined at Frankfurt University medical center. Plasma AGT levels increased stepwise according to the number of T235 alleles present (no T235 allele, 14.8 +/- 3.9 nmol/L; 1 allele, 15.7 +/- 5.1 nmol/L; 2 alleles, 17.3 +/- 4.7 nmol/L; P =.006). In a multivariate model, circulating AGT emerged as the most important predictor of diastolic pressure (P =.001). In addition, AGT M235T gene polymorphism remained a significant predictor of diastolic BP in a multivariate model adjusted for age, body mass index, fasting glucose, apolipoprotein B, presence of coronary artery disease, and treatment with antihypertensive agents ( P <.05). Finally, homozygosity for T235 was associated with increased univariate risk of coronary artery disease and myocardial infarction (odds ratio estimates 1.5; 95% confidence intervals 1.1 to 2.1, P =.03, and 1.0 to 2.1, P =.05, respectively). CONCLUSIONS: The significant relations observed between the AGT M235T variant, its protein product, and the cardiovascular disease phenotypes provide evidence for a possible role of elevated circulating AGT in the pathogenesis of coronary artery disease.

Complications of port-access cardiac surgery.

Port-Access cardiac surgery is a recent technology that is undergoing rapid development. The learning curve associated with this technique is a challenge even for the skilled and experienced cardiac surgeon. Mainly because of femoral cannulation, the use of guidewires, and working through small incisions, Port-Access cardiac surgery contains certain pitfalls that are clearly associated with the technology involved. These pitfalls currently require troubleshooting, but as the technology progresses, this may become less of an issue. Communicating these pitfalls to others is important to help others to avoid or better manage complications and to contribute to improving the technology of Port-Access techniques.

Neuropsychological changes after cardiopulmonary bypass for coronary artery bypass grafting.

BACKGROUND: An alarming incidence (1% to 83%) of neuropsychological dysfunction has been reported after operations using cardiopulmonary bypass (CPB). The present clinical study re-evaluates these complications with current CPB technology in a strictly selected low-risk group of coronary artery bypass (CABG) patients. METHODS: 76 CABG patients, without history of stroke or internal carotid artery stenosis, were examined before, 5 days after, and 2 months after surgery. A neuropsychological test battery was employed according to the "Statement of Consensus on Assessment of Neurobehavioral Outcomes after Cardiac Surgery". Tests include the Block Design Test (problem-solving strategies, recognition and analysis of forms), the Trail Making Test (cognitive achievement at speed), and the Digit Span Test (short-term memory and memory of figures). RESULTS: Both postoperative test scores were not significantly decreased as compared to preoperative values. In contrast, neuron specific enolase (NSE) and S100 b protein, biochemical markers of cerebral injury, increased markedly during and immediately after surgery (NSE preop.: 7.07 +/- 2.40 ng/ml, 1 h postop.: 13.64 +/- 4.50 ng/ml, p < 0.001; S100 b preop.: 0.04 +/- 0.07 ng/ml, after crossclamp: 0.90 +/- 0.69 ng/ml, p < 0.001). One patient displayed postoperative transitional syndrome, another patient suffered from transitory paresis and hypesthesia of the left arm, which disappeared during hospital stay. CONCLUSIONS: Biochemical markers demonstrate significant postoperative cerebral injury during and immediately after CPB. However, CPB for CABG does not lead to marked impairment of neuropsychological scores, and clinically relevant neurological findings were observed in one patient only.