Time course of cytokine release and complement activation after implantation of the HeartMate left ventricular assist device.

Pro-inflammatory mediators, including interleukin-6 (IL-6), IL-8, and complement C3a, are released after cardiac surgery as part of the inflammatory response related to blood-biomaterial interaction in the cardiopulmonary bypass circuit. Post operative time course data for these mediators are not fully defined in patients receiving left ventricular assist device (LVAD) support. The authors performed enzyme linked immunosorbent assays for concentrations of IL-6, IL-8, and C3a in plasma in six HeartMate LVAD recipients at the following times: pre operatively; 4, 8, 16, 24, 36, and 48 hr post operatively; daily through the first week; and weekly thereafter for 6 weeks. All patients survived without major complications during the study. Pre operative concentrations of IL-6 and C3a in plasma were significantly increased compared with age matched controls. Post operatively, the concentrations of IL-6 and IL-8 in plasma took longer to return to baseline values after insertion of the LVAD than the trends reported in the literature after routine cardiopulmonary bypass alone. Concentrations of IL-6 and complement C3a continued to decrease to lower than baseline post operatively, reaching statistical significance after 6 weeks of LVAD support. The authors conclude that the presence of the HeartMate LVAD delays the return of pro-inflammatory mediator concentrations back to baseline values compared with routine cardiopulmonary bypass alone, but the device does not appear to be an ongoing source of cytokine release or complement activation.

Rabbit rectus femoris muscle for ischemia-reperfusion studies: an improved model.

The rabbit rectus femoris muscle was evaluated as a potential model for skeletal muscle reperfusion injury studies. Six white New Zealand rabbits were used. On one randomly selected hind limb, ischemia was induced by direct clamping of the rectus femoris muscle's vascular pedicle. On the other side, blood flow was interrupted by clamping the femoral artery above and below the origin of the vascular pedicle that supplies the rectus femoris muscle. The duration of normothermic ischemia was 4 hr and was followed by 24 hr of normothermic reperfusion. The interruption and restoration of blood flow was monitored using a laser flow meter. The rectus femoris muscles were weighed on a suspension spring balance prior to ischemia and at the end of reperfusion to estimate edema. The extent of muscle necrosis was determined using planimetry following staining with nitroblue tetrazolium. The muscle necrosis obtained by direct clamping of the vascular pedicle (66.9 +/- 14.3%) was significantly greater than that obtained by indirect clamping (18.6 +/- 11.4%) (P < 0.03 by t test). Unlike the indirect clamping technique, direct clamping achieved a good magnitude of muscle necrosis, thus allowing that specific model to be used in skeletal muscle reperfusion injury studies. The muscle weight gain observed in the direct clamping muscle group was 19.8 +/- 9.0% and was significantly greater than that observed in the opposite group being 6.3 +/- 6.5% (P < 0.05 by t test). The rabbit rectus femoris muscle is a suitable model for evaluating skeletal muscle reperfusion injury provided that direct clamping of the vascular pedicle is utilized.

Selection of patients for cardiac evaluation before peripheral vascular operations.

PURPOSE: This study evaluated the value of preoperative cardiac screening with dipyridamole thallium scintigraphy and radionuclide ventriculography in vascular surgery patients. METHODS: From July 1, 1989, to Dec. 31, 1991, we routinely (irrespective of the patient's cardiac history or symptomatology) performed dipyridamole thallium scintigraphy (DTS) and radionuclide ventriculography (RVG) in 394 patients being considered for an elective vascular operation. Patients with reversible defects on DTS underwent coronary arteriography. RESULTS: DTS results were normal in 146 patients (37%), showed a fixed defect in 75 (19%), and showed a reversible defect in 173 (44%). Patients with and without a history of angina or myocardial infarction had identical rates of reversible defects. Normal left ventricular function (> 50%) was noted in 76% of the patients; 17% had moderate dysfunction (35% to 50%) and 7% had a low ejection fraction (< 35%). The finding of severe coronary artery disease led to cardiac revascularization in 17 patients who had no prior history of cardiac disease and in 13 patients with a history of angina or myocardial infarction. Two deaths and nine major complications were associated with coronary arteriography and cardiac revascularization. Vascular procedures (144 aortic, 53 carotid, 146 infrainguinal) were ultimately performed in 343 patients, with a mortality rate of 1.7% (3.5% aortic, 0% carotid, and 0.7% infrainguinal bypass). The nonfatal perioperative myocardial infarction rate was 2.0%. We monitored all 394 patients for cardiovascular events, with a mean follow-up of 40 months. Patients who underwent cardiac revascularization had a 4-year survival rate of 75%, which was similar to those with a normal DTS. Late cardiac events were significantly more frequent in patients who had either a reversible DTS or RVG < 35%. CONCLUSIONS: Routine cardiac screening of vascular surgery patients had similar impact on patients irrespective of their prior history or current symptoms suggesting coronary artery disease. Routine screening did not result in substantial benefit. Screening studies such as DTS or RVG may be most useful as part of an overall risk versus benefit assessment in patients without active symptoms of coronary artery disease who have less compelling indications for vascular intervention (claudication, moderate-sized aortic aneurysms, or asymptomatic carotid disease).