The Clinical Outcomes in Patients with Critical Limb Ischemia One Year after Spinal Cord Stimulation.

BACKGROUND: The aim of this study was to evaluate the long-term outcomes of spinal cord stimulation in patients with critical limb ischemia and to test the hypothesis that the dynamics of clinical changes one year after therapy depend both on the clinical determinants associated with the underlying disease and on factors related to systemic atherosclerosis. METHODS: This prospective cohort study included 56 patients with critical limb ischemia. All patients before and after spinal cord stimulation were examined in terms of the dynamics of their clinical changes using the Rutherford scale and transcutaneous oxygen tension (TcPO2, mm Hg) in the affected foot. The active orthostatic test was used to assess the functional state of peripheral perfusion. RESULTS: One year after spinal cord stimulation, 74% of patients showed positive clinical outcomes. No changes were observed in 9.3% of patients, whereas adverse clinical outcomes were revealed in 16.7% of cases. The TcPO2 values were significantly reduced before spinal cord stimulation: 10.5 (6.4-16.0) mm Hg. The functional status of the peripheral microvasculature was also disturbed. One year after therapy, TcPO2 significantly increased and the adaptive mechanisms of the microvasculature were improved in more than 70% of patients. Logistic regression analysis showed that the initially low TcPO2 values (<10 mm Hg) with a lack of gain in TcPO2 during the orthostatic test are associated with the negative clinical outcomes after spinal cord stimulation. The gain in TcPO2 during the orthostatic test to >10 mm Hg is associated with the positive clinical outcomes after spinal cord stimulation. The age-adjusted Charlson Comorbidity Index >5 and duration of critical ischemic symptoms also had a negative effect on the clinical outcomes after spinal cord stimulation. CONCLUSIONS: The positive clinical outcomes were revealed in most patients with critical limb ischemia one year after spinal cord stimulation. The low values of peripheral tissue metabolism with the disturbed functional status of the microvasculature are associated with the negative clinical outcome. The patients with baseline TcPO2 <10 mm Hg can recover if they still have a sufficient microcirculatory reserve capacity. Duration of critical ischemic symptoms and high comorbidity burden with allowance for age are negative factors affecting the clinical outcome.

Outcomes of Double-patch and Warden Techniques in Patients With Supracardiac Partial Anomalous Pulmonary Venous Connection.

AIM: This study compared outcomes following the double-patch and Warden procedures for correcting partial anomalous connection of the right pulmonary veins to the superior vena cava. METHODS: Eighty (80) patients, aged <18years old, and with partial anomalous connection of the right pulmonary veins to the superior vena cava were randomly assigned into double-patch method (n=40) and Warden procedure (n=40) groups. The median follow-up was 22.5 (range, 12-39) months. The primary endpoint was sinus node dysfunction at the mid-term follow-up period. RESULTS: No early or late mortality occurred. In the early postoperative period, sinus node dysfunction was observed in 27.5% and 5% of cases after double-patch correction and the Warden procedure, respectively (risk ratio, 5.50; 95% confidence interval, 1.30-23.25; p=0.01). At follow-up, sinus node dysfunction persisted in two (5%) patients after double-patch correction. All patients had normal sinus rhythm after the Warden procedure. No early or late pacemaker implantation occurred in either group. No patients had significant pulmonary veins or superior vena cava stenosis. CONCLUSIONS: The double-patch technique and Warden procedure both showed excellent early and mid-term results with no mortality and minimal morbidity. The Warden procedure was associated with less sinus node dysfunction in the early postoperative period than the double-patch technique. There was no significant between-group difference in sinus node dysfunction at the mid-term follow-up.

Single-Centre Experience of Surgical Myectomy for Hypertrophic Obstructive Cardiomyopathy.

BACKGROUND: Septal myectomy is the gold standard treatment for hypertrophic obstructive cardiomyopathy. This study aimed to evaluate the results from patients with hypertrophic cardiomyopathy who had undergone septal myectomy. METHODS: Data were analysed that has been prospectively collected over 7 years from 345 patients with hypertrophic cardiomyopathy who underwent septal myectomy at Meshalkin National Medical Research Center. RESULTS: Six (6) patients (1.7%) died within 30 days of surgery. The mean (standard deviation, SD) resting left ventricular outflow tract gradients reduced from 83.4 (24.2) mmHg preoperatively to 16.2 (8.5) mmHg at discharge (p < 0.001). Of the 345 patients, 329 (95.4%) attended the most recent follow-up assessments, and of these, 254 (77.2%) were categorised as New York Heart Association (NYHA) class I, 64 (19.5%) class II, and 11 (3.3%) class III. The mean overall long-term survival rate after septal myectomy was 95.7% (SD 1.7%) (95% CI, 90.0-97.9). This did not differ from the age-matched and gender-matched general population (log-rank, p = 0.109). At the last follow-up assessments, six of 67 patients who had undergone concomitant Cox-Maze IV procedures had late atrial tachyarrhythmia recurrences. A preoperative short-axis view of left atrial diameter of 57.5 mm (hazard ratio, 1.30 (95% CI, 1.03-1.65), p < 0.001) predicted late atrial tachyarrhythmias (p < 0.002). CONCLUSIONS: At this hypertrophic cardiomyopathy centre, septal myectomy is associated with low operative and early mortality rates (<2%), a low risk of early adverse events, and acceptable intermediate-term clinical and haemodynamic results.

History and Current Status of Cardiac Anesthesiology in Russia.

Anesthesiology, the branch of medicine concerning anesthesia and management of the vital functions of patients undergoing surgery, has played an important role in the development of cardiac surgery. In the middle of the last century, medical professionals had little experience in the treatment of congenital and acquired heart diseases. Progress of cardiac anesthesiology in Russia, as well as in countries across the globe, was due to requests to increase the safety of surgical procedures and to improve survival rates for the increasing number of patients with complex heart diseases. The development of cardiac surgery and anesthesiology in Russia evolved in 2 directions simultaneously in the mid-1950s. Some surgeons widely accepted the use of perfusionless hypothermia (hypothermia caused by surface cooling without perfusion); others were in favor of cardiopulmonary bypass technology. This review focuses on major historic milestones of cardiac anesthesiology in Russia, including its current status and the major problems it faces today.

Incidence of atrial fibrillation detected by continuous rhythm monitoring after acute myocardial infarction in patients with preserved left ventricular ejection fraction: results of the ARREST study.

Aims: Cardiac arrhythmias following acute myocardial infarction (AMI) can be associated with major adverse cardiovascular events. Data on the "real incidence" of post-MI arrhythmias are limited. We aimed to determine the rate and burden of cardiac arrhythmias by the use of insertable cardiac monitors (ICM) in patients with preserved left ventricular ejection fraction (LVEF) after AMI. Methods and results: In this prospective observational study, patients with LVEF ≥40% who underwent PCI within 7 days following AMI were enrolled to receive an ICM. Primary outcome was the incidence of new-onset atrial fibrillation (AF) measured by the ICM during a follow-up of 2 years; results: Of 165 consecutive patients with AMI, 50 (30.3%) eligible patients were recruited (mean age 57.8 ± 8.3, 88% male). During follow-up, AF was the most frequently detected arrhythmia. Twenty-nine (58%, 95% CI: 42-70%) patients developed new-onset AF, with a cumulative rate of all detected arrhythmias of 65%. Median time to the first detected AF episode was 4.8 months and the peak cumulative AF burden was detected between 3 and 6 months. Twenty-seven (93%) out of 29 patients with AF were asymptomatic. Cox regression analysis found that baseline troponin level (hazard ratio [HR] for 1 ng/mL increment: 1.03, 95% CI: 1.01-1.06, P = 0.01) and CHA2DS2-VASc score of 4 (HR: 11.42, 95% CI: 1.01-129.06, P = 0.04) were independent risk factors of new-onset AF post-AMI. Conclusion: AF is a frequent but largely underestimated cardiac arrhythmia after AMI. More rigorous monitoring strategies resulting in crucial medical interventions (e.g. implementation of oral anti-coagulation) are needed. Clinical Trial Registration: http://www.clinicaltrials.gov. Unique identifier: NCT02492243.

Factors affecting the quality of life before and after surgery in patients with chronic thromboembolic pulmonary hypertension.

PURPOSE: To test the hypothesis that quality of life (QoL) parameters before surgery in patients with chronic thromboembolic pulmonary hypertension (CTEPH) are influenced by clinical determinants related to the underlying disease and to examine QoL parameters affected in the long-term after the operation by complications presenting in the early postoperative period. METHODS: This prospective cohort study included 128 patients who presented with CTEPH before and after pulmonary thromboendarterectomy (PTE; 1-year follow-up). All patients were examined regarding QoL using the Short-Form 36 Health Survey Questionnaire (SF-36). RESULTS: In patients with CTEPH, PTE provided immediate improvement in terms of pulmonary hemodynamic parameters and favorable effects on long-term outcome, including QoL 1 year after surgery. Multivariate analysis showed that systolic pulmonary arterial pressure, right ventricular ejection fraction, and the presence of coronary artery disease and chronic obstructive pulmonary disease (COPD) were independent factors affecting QoL on several SF-36 subscales in patients with CTEPH prior to surgery. The factors that affect patient QoL 1 year after surgery on some SF-36 subscales included the presence of coronary artery disease, COPD, heart failure, residual pulmonary hypertension, and prolonged ventilation, neurological complications in the early postoperative period of PTE. CONCLUSIONS: Surgical treatment for CTEPH leads to an increase in QoL in all SF-36 subscales, excluding general health perceptions. Factors affecting QoL in patients with CTEPH included severity of pulmonary arterial hypertension, comorbidity, and complications in the early postoperative period after PTE, such as heart failure, neurologic problems, residual pulmonary hypertension, and prolonged ventilation.

Determinants of Health-Related Quality of Life 1 Year after Pulmonary Thromboendarterectomy.

BACKGROUND: Pulmonary thromboendarterectomy (PTE) is a recognized treatment for patients with chronic thromboembolic pulmonary hypertension (CTEPH), with good long-term hemodynamic results. The aim of this study was to test the hypothesis that the dynamics of health-related quality of life (QoL), 1 year after PTE, depend both on the clinical determinants associated with the underlying disease and the adverse events occurring in the early postoperative period. METHODS: This prospective cohort study included 136 patients with CTEPH. All patients before and after PTE (1-year follow-up) were examined in terms of QoL, by using the Short Form 36 Health Survey Questionnaire. RESULTS: One year after PTE, a significant improvement in the QoL of patients was observed in all subscales of the Short Form 36 Health Survey Questionnaire, except in the general health scale. Multivariate analysis showed that the predictors adversely affecting the dynamics of QoL after PTE were the presence of comorbidities (such as chronic obstructive pulmonary disease [COPD] and coronary artery disease) and early postoperative complications (specific ones for this category of patients are residual pulmonary hypertension and neurological complications, and nonspecific ones are atrial fibrillation and heart failure). CONCLUSIONS: The determinants that affect the dynamics of QoL 1 year after PTE in patients with CTEPH were the presence of comorbidities (COPD and coronary artery disease) and adverse events in the early postoperative period (residual pulmonary hypertension, neurological complications, atrial fibrillation, and heart failure).

Postcardiotomy refractory ventricular fibrillation: rescue using veno-arterial extracorporeal membrane oxygenation.

We present a case of 7-hour ventricular fibrillation with successful use of veno-arterial extracorporeal membrane oxygenation as a bridge to recovery in a 30-year-old patient with grown-up congenital heart disease who underwent pulmonary valve replacement.

Deep Hypothermic Circulatory Arrest vs. Antegrade Cerebral Perfusion in Cerebral Protection during the Surgical Treatment of Chronic Dissection of the Ascending and Arch Aorta.

Circulatory arrest during aortic surgery presents a risk of neurological complications. The present study aimed to investigate the effectiveness of deep hypothermic circulatory arrest (DHCA) vs. antegrade cerebral perfusion (ACP) in cerebral protection during the surgical treatment of chronic dissection of the ascending and arch aorta and to assess the quality-of-life (QoL) in the long-term postoperative period with respect to the used cerebral protection method. In a prospective, randomized study, 58 patients with chronic type I aortic dissection who underwent ascending aorta and aortic arch replacement surgery were included. Patients were allocated in two groups: 29 patients who underwent surgery under moderate hypothermia (24°C) combined with ACP and 29 patients who underwent surgery under DHCA (18°C) with craniocerebral hypothermia. The regional hemoglobin oxygen saturation (rSO2, %) were compared during surgery, neurological complications were analyzed during the early postoperative period, QoL was compared in the long-term postoperative period (1-year follow-up). During the early postoperative period, 37.9% of patients in the DHCA group exhibited neurological complications, compared with 13.8% of those in the ACP group (p < .05). The risk of neurological complications in the early postoperative period was dependent on the extent of rSO2 decrease during circulatory arrest. In the ACP group, rSO2 decreased by ≤17% from baseline during circulatory arrest. In the DHCA group, a more profound decrease in rSO2 (>30%) was recorded (p < .05). QoL in the long-term period after surgery improved, but it was not dependent on the cerebral protection method used during surgery. ACP during aortic replacement demonstrated the most advanced properties of cerebral protection that can be evidenced by a lesser degree of neurological complications, compared with patients who underwent surgery under conditions of DHCA. QoL after surgery was not dependent on the cerebral protection method used during surgery.

Efficiency of Various Cerebral Protection Techniques Used during the Surgical Treatment of Chronic Pulmonary Thromboembolism.

Circulatory arrest during pulmonary thromboendarterectomy (PTE) for chronic pulmonary embolism leads to an increased risk of cerebral ischemia and neurological complications. This study aimed to assess the efficacy of various cerebral protection techniques used during the surgical treatment of chronic pulmonary thromboembolism. We prospectively studied 61 patients with chronic pulmonary thromboembolism who underwent PTE. We compared the dynamics of cerebral oxygen saturation (rSO2, %) during the surgical treatment and analyzed neurological complications during the early postoperative period in two groups of patients: 30 patients who underwent surgery under conditions of moderate hypothermia (23°C-24°C) combined with antegrade unilateral cerebral perfusion (ACP group) and 31 patients who underwent thromboendarterectomy under deep hypothermic circulatory arrest (18°C, DHCA group) combined with craniocerebral hypothermia. In the ACP group, regional rSO2 decreased by less than 20% from baseline during the course of PTE. In the DHCA group, a more profound reduction of cerebral oxygen supply (by >30% from baseline) was recorded compared with the ACP group (p < .05). During the early postoperative period, 29% of patients in the DHCA group exhibited neurological complications, compared with only 7% of patients from the ACP group. The results of logistic regression analysis indicated that the risk of progressive neurological deficit depended on the duration of the intraoperative period when the absolute values of regional rSO2 were <40%. The method with the best adjustment to human physiology in patients with chronic pulmonary thromboembolism was antegrade cerebral perfusion. This method provides a smaller decrease in cerebral oxygen supply during thromboendarterectomy and significantly reduces the risk of ischemia and neurological complications in the early postoperative period.

Hypothermic versus normothermic cardiopulmonary bypass in patients with valvular heart disease.

OBJECTIVE: The aim of this study was to test the hypothesis that normothermic cardiopulmonary bypass (CPB) is as effective as hypothermic CPB in terms of cardiac protection (cTnI level) and outcome in patients with valvular heart disease. DESIGN: Prospective randomized study. SETTING: A tertiary cardiothoracic referral center. PARTICIPANTS: 140 patients who had valvular heart disease, with/without coronary artery disease, surgically treated under CPB. INTERVENTIONS: The patients were allocated randomly to undergo either hypothermic (temperature [T], 31 °C-32 °C) or normothermic CPB (T>36 °C). MEASUREMENTS AND MAIN RESULTS: The primary endpoint was the dynamics of troponin I. The secondary endpoints were ventilation time, the need for inotropic support, intensive care unit (ICU) and hospital stay durations, complications, and mortality. There were no significant intergroup differences in dynamics of troponin I. Ventilation time was significantly lower in the hypothermic group (6 (5-9) and 8 (5-12); p = 0.01). CONCLUSIONS: Normothermic CPB in patients with valvular heart disease was as effective as hypothermic perfusion in terms of myocardial protection after the surgery assessed by cTnI release. The short ventilation duration in patients who underwent hypothermic CPB needs to be confirmed in a future investigation.

Randomized trial of fish oil infusion to prevent atrial fibrillation after cardiac surgery: data from an implantable continuous cardiac monitor.

OBJECTIVE: To test the hypothesis that perioperative OMEGA-3 polyunsaturated fatty acid infusion would reduce the incidence of postoperative atrial fibrillation in patients after coronary artery bypass grafting as assessed by an implantable continuous cardiac monitor. DESIGN: Prospective, randomized, double-blind, placebo-controlled study. SETTING: Tertiary cardiothoracic referral center. PARTICIPANTS: Thirty-nine patients with coronary artery disease who underwent surgery with cardiopulmonary bypass. INTERVENTIONS: Patients were assigned randomly to receive either OMEGA-3 polyunsaturated fatty acids (200 mg/kg/day starting before anesthesia induction for 24 hours followed by 100 mg/kg/day for 7 days) or placebo. The primary outcome was freedom from atrial fibrillation at 2-year follow-up. Reveal(®) cardiac monitor was implanted subcutaneously in all patients. Data from the cardiac monitor were collected on the 10th day and 3, 6, 12, and 24 months postoperatively. MEASUREMENT AND MAIN RESULTS: Postoperative atrial fibrillation developed in 4 (19%) patients in the control group and in 5 (27.8%) patients in the study group at 10-day follow-up (p = 0.88). At 2-year follow-up, 5 (27.8%) patients in the control group and 6 (35.3%) patients in the study group had atrial fibrillation (p = 0.9). Atrial fibrillation duration predicted risk of cardiovascular hospitalization at the 2-year follow-up (regression coefficient estimate = 0.24, standard error 0.02, p<0.0001; R(2) = 0.74). CONCLUSIONS: Infusion of OMEGA-3 polyunsaturated fatty acids failed to prevent the occurrence of atrial fibrillation in 2 years after coronary artery bypass grafting surgery. The cumulative atrial fibrillation duration registered by the continuous cardiac monitor at the 2-year follow-up was a significant predictor of an adverse outcome.

Mortality prediction in patients with dialysis-dependent acute kidney injury after cardiac surgery with cardiopulmonary bypass.

BACKGROUND: To build a predictive model for patients with dialysis-dependent acute kidney injury (AKI-D) after cardiac surgery with the cardiopulmonary bypass (CPB), according to disease severity. METHODS: A single-centre, retrospective cohort study was performed to determine the demographic and clinical parameters (including the specific factor, CPB duration) for risk of poor outcome in patients requiring RRT after cardiac surgery with CPB. A new model was built for mortality prediction in these patients on the basis of the identified risk factors and Sequential Organ Failure Assessment score. RESULTS: The newly developed model showed good discriminatory ability for predicting death in patients with AKI-D after cardiac surgery with CPB. The area under the receiver-operating characteristic (ROC) curve for the score was 0.892 (95% confidence interval, 0.852-0.925). We also determined the criterion for the choice of RRT modality by applying this model. On applying the new model in intermittent haemodialysis patients, a score of ≤3.2 was found safe for selecting the RRT modality. CONCLUSIONS: The new scoring system was valid and accurate in predicting death for AKI-D patients after open-heart surgery. This system and value for choice of RRT were determined for guidance only, to facilitate decision-making in difficult situations.

Cryoballoon versus radiofrequency for pulmonary vein re-isolation after a failed initial ablation procedure in patients with paroxysmal atrial fibrillation.

AIM: Catheter ablation of paroxysmal atrial fibrillation (PAF) is associated with an important risk of early and late recurrence, necessitating repeat ablation procedures. The aim of this prospective randomized patient-blind study was to compare the efficacy and safety of cryoballoon (Cryo) versus radiofrequency (RF) ablation of PAF after failed initial RF ablation procedure. METHODS: Patients with a history of symptomatic PAF after a previous failed first RF ablation procedure were eligible for this study. Patients were randomized to Cryo or RF redo ablation. The primary endpoint of the study was recurrence of atrial tachyarrhythmia, including AF and left atrial flutter/tachycardia, after a second ablation procedure at 1 year of follow-up. All patients were implanted with a cardiac monitor (Reveal XT, Medtronic) to continuously track the cardiac rhythm. Patients with an AF burden (AF%) ≤ 0.5% were considered AF-free (Responders), while those with an AF% > 0.5% were classified as patients with AF recurrences (non-Responders). RESULTS: Eighty patients with AF recurrences after a first RF pulmonary vein isolation (PVI) were randomized to Cryo (N = 40) or to RF (N = 40). Electrical potentials were recorded in 77 mapped PVs (1.9 ± 0.8 per patient) in Cryo Group and 72 PVs (1.7 ± 0.8 per patient) in RF Group (P = 0.62), all of which were targeted. In Cryo group, 68 (88%) of the 77 PVs were re-isolated using only Cryo technique; the remaining 9 PVs were re-isolated using RF. In RF group, all 72 PVs were successfully re-isolated (P = 0.003 vs Cryo). By intention-to-treat, 23 (58%) RF patients were AF-free vs 17 (43%) Cryo patients on no antiarrhythmic drugs at 1 year (P = 0.06). Three patients had temporary phrenic nerve paralysis in the Cryo group; the RF group had no complications. Of the 29 patients who had only Cryo PVI without any RF ablation, 11 (38%) were AF-free vs 20 (59%) of the 34 patients who had RF only (P = 0.021). CONCLUSION: When patients require a redo pulmonary vein isolation ablation procedure for recurrent PAF, RF appears to be the preferred energy source relative to Cryo.

Catheter versus surgical ablation of atrial fibrillation after a failed initial pulmonary vein isolation procedure: a randomized controlled trial.

INTRODUCTION: The aim of this prospective randomized study was to compare the efficacy and safety of catheter ablation (CA) versus surgical ablation (SA) in the treatment of paroxysmal and persistent AF after failed initial pulmonary vein isolation procedure. METHODS AND RESULTS: Patients with a history of symptomatic AF after a previous failed first ablation procedure were eligible for this study. Patients were randomized to CA (n = 32) or SA (n = 32) redo ablation. The primary endpoint was recurrence of atrial tachyarrhythmia at 1 year of follow-up. At the 12-month follow-up, 26 (81%) of the 32 SA group patients and 15 (47%) of the 32 CA group were AF/AT-free on no antiarrhythmic drugs (P = 0.004, log-rank test). In patients with PAF, 17 (85%) patients of the 20 in SA group and 10 (56%) patients of the 18 in CA group were AF-free (P = 0.04, log-rank test). In patients with PersAF, 9 (75%) patients of the 12 in SA group and 5 (36%) patients of the 14 in CA group were AF-free (P = 0.04, log-rank test). The number of the serious adverse event in the SA group was significantly higher (1 CA group vs 7 SA group; P = 0.02). CONCLUSION: In patients with PAF and PersAF after failed initial CA, SA is superior to CA for maintenance of sinus rhythm, although serious adverse event rate is significantly higher for SA.

Evaluation of nutritional screening tools among patients scheduled for heart valve surgery.

BACKGROUND AND AIM OF THE STUDY: The study aim was to detect the most sensitive nutritional screening tool and to assess its prognostic value with regards to an adverse clinical course in patients with heart valve disease undergoing cardiopulmonary bypass (CPB). METHODS: This prospective cohort study included 441 adult patients who were screened using four nutritional screening tools: Nutritional Risk Screening 2002 (NRS-2002); Malnutrition Universal Screening Tool (MUST); Mini Nutritional Assessment (MNA); and Short Nutritional Assessment Questionnaire (SNAQ). Nutritional assessment was performed using a Subjective Global Assessment (SGA). In-hospital mortality, postoperative complications, and duration of hospital stay were each analyzed. RESULTS: With regards to the detection of malnutrition, the sensitivities of MUST, SNAQ, MNA and NRS-2002 were 100%, 92%, 84.6% and 43.6%, respectively. Malnutrition identified by MUST and MNA were associated with postoperative complications (OR 1.63, p = 0.033 and OR 1.6, p = 0.035) and prolonged hospitalization (OR 1.57, p = 0.048 and OR 1.7, p = 0.02). According to multivariate logistic regression analysis, along with well-known age and duration of CPB, malnutrition identified by MUST and MNA was associated with a risk of development of complications (OR 1.6, p = 0.049 and OR 1.6, p = 0.04, respectively). The sensitivities of SNAQ, MUST, NRS-2002 and MNA with regards to postoperative complications were 26.8%, 28.8%, 10%, and 31.6%, respectively. CONCLUSION: The MUST tool is preferable with regards to the detection of malnutrition. Both, MUST and MNA independently predicted postoperative complications. SNAQ and NRS-2002 proved insensitive with regards to the postoperative course among patients with heart valve disease who were scheduled for cardiothoracic surgery.

Hypertonic solution decreases extravascular lung water in cardiac patients undergoing cardiopulmonary bypass surgery.

OBJECTIVE: To test the hypothesis that the infusion of hypertonic solution would decrease extravascular lung water postoperatively and thus improve pulmonary function. DESIGN: Prospective, randomized, blinded trial. SETTING: Tertiary cardiothoracic referral center. PARTICIPANTS: Twenty-six patients with coronary artery disease who underwent surgery with cardiopulmonary bypass (CPB). INTERVENTIONS: Patients were allocated randomly to receive 4 mL/kg of 7.2% NaCl/hydroxyethyl starch, 200/0.5 (HSH group) or an equal volume of 0.9% NaCl (control group) for 30 minutes starting after anesthesia induction. The extravascular lung water index, hemodynamic and biochemical data, and the rate of complications were analyzed. MEASUREMENTS AND MAIN RESULTS: The extravascular lung water index was significantly lower (7 v 9.5 mL/kg) in the HSH group at the first postoperative day (p < 0.01). The index of arterial oxygenation efficiency was significantly higher at 5 minutes and 2 and 4 hours after cardiopulmonary bypass (CPB) in the HSH group (p < 0.05). The alveolar-arterial oxygen tension difference was significantly lower at 5 minutes and 2 and 4 hours after CPB in the HSH group (p < 0.01). The cardiac index was significantly higher at 5 minutes after infusion in the HSH group (p < 0.05). CONCLUSIONS: The infusion of HSH leads to significant decreases in the extravascular lung water index during and after cardiac surgery and is associated with better preservation of pulmonary function and transient increases in the cardiac index. Further trials are needed to clarify the clinical advantages of hypertonic solution administration in patients undergoing surgery with CPB.

Methylprednisolone use is associated with endothelial cell activation following cardiac surgery.

BACKGROUND: The objective of this study was to investigate the effect of the perioperative use of methylprednisolone in medium doses on markers of endothelial cell activation in patients with coronary artery disease undergoing cardiopulmonary bypass. METHODS: In this prospective, double-blinded, placebo-controlled, randomised study, 44 patients, undergoing a coronary artery bypass graft surgery received either methylprednisolone 20 mg/kg or a placebo intraoperatively after anaesthesia induction. The primary endpoint was endothelin-1, and secondary endpoints were E-selectin, interleukin (IL)-6 and IL-10, PaO(2)/FiO(2) coefficient, and microalbuminuria. RESULTS: Endothelin-1 was higher in the study group postoperatively at 10 min (p=0.0008), 2 h (p=0.02), 4 h (p=0.005), and 24 h (p=0.004). IL-6 was lower in the study group postoperatively at 2 h (p=0.03), 4 h (p=0.04), and 24 h (p<0.0001). IL-10 was higher in the study group postoperatively at 10 min (p<0.0001), 2 h (p=0.009), and 4 h (p=0.001). PaO(2)/FiO(2) was lower in the study group at 24 h after surgery (p=0.03). Microalbuminuria was similar in both groups. CONCLUSION: Despite an obvious anti-inflammatory effect, methylprednisolone causes endothelial cell activation in patients undergoing cardiopulmonary bypass.