Cytokine responses and myocardial injury in coronary artery bypass grafting.

OBJECTIVE: Cardiopulmonary bypass is acknowledged to be one of the major causes of a complex systemic inflammatory response after cardiac surgery, and it may contribute to postoperative complications and even multiple organ dysfunction. We here compared the cytokine responses and the degree of myocardial injury after coronary artery bypass grafting with or without cardiopulmonary bypass. METHODS: Nine patients underwent off-pump revascularization and 13 with cardiopulmonary bypass. Plasma levels of tumor necrosis factor-alpha (TNF-alpha), interleukin (IL)-6, IL-8 and IL-10 were measured before anesthesia induction, and 5 min, 1, 4, and 20 h after reperfusion to the myocardium. Levels of the MB isoenzyme of creatine kinase (CK-MB) were also measured after the operation. RESULTS: Levels of TNF-alpha were low in both groups. A delayed elevation of IL-6 was noted in the off-pump group. IL-8 and IL-10 levels were significantly higher in the CPB than in the off-pump patients after reperfusion (p=0.006 and 0.001 respectively). Postoperative CK-MB levels were significantly higher in the CPB than in the off-pump group (p=0.001). Cytokine levels correlated with CK-MB values. CONCLUSION: The results indicated that off-pump revascularization was associated with reduced cytokine responses and less severe myocardial injury. The degree of myocardial injury, as defined by CK-MB release, correlated with cytokine release. Intervention designed to reduce cytokine responses in cardiac surgery may be advantageous for patients with severe comorbidity.

Combined mitral valve and coronary artery surgery.

During the past 10 years, 50 patients underwent combined coronary artery bypass grafting (CABG) and mitral valve replacement (MVR) at our clinic, with additional aortic valve replacement (AVR) in six cases. The early mortality was 8%. During the first half of the study period this mortality was 4/11 patients, but in the second half it was 0/39. All six patients with CABG + MVR + AVR survived the operation. Adverse factors were found to be advanced functional impairment, female sex, concomitant untreated aortic valvulopathy and elevated pulmonary vascular resistance. All 46 patients who survived the operation were followed up for a mean period of 31 months, and during that time there were nine deaths. The survival rate was 54% after 3 years and 40% after 5 years. Most of the patients had improved by at least one functional class. The good results in this series probably were attributable to improvements in surgical procedure (introduction of cold potassium cardioplegia) and in postoperative management (intra-aortic balloon pumping).

Hernia through the foramen of Winslow.

An incarcerated internal hernia through the foramen of Winslow is an extremely rare cause of intestinal obstruction and about 105 such cases have been reported. An additional patient, in whom a part of jejunum was incarcerated through the foramen into the lesser sac and who was successfully treated surgically, is reported. The etiology, diagnosis, treatment and prognosis of this rare condition are discussed.