[Fever, atrial fibrillation, and angina pectoris in a 58-year-old man]. / Fieber, Vorhofflimmern und Angina pectoris bei einem 58-jährigen Patienten.

Primary cardiac lymphoma (PCL) respresents a very rare type of cardiac tumour. This report illustrates a case of PCL in an immunocompetent 58-year-old man presenting with atrial fibrillation and febrile syndrome. Comprehensive imaging [computer tomography (CT), cardiac magnetic resonance imaging (cMRI), 3-dimensional transesophageal echocardiography (3D-TEE)] identified a large right atrial tumour, leading to pericardial effusion. Isolated cardiac involvement was confirmed by positron emission tomography (PET)-CT. A diffuse large B-cell lymphoma (DLBCL) was diagnosed based on the results of a TEE-guided biopsy. A normalized PET scan (PETAL study) indicated complete remission following R-CHOP 14 immunochemotherapy. Thus, an interdisciplinary and multimodal approach avoided unnecessary cardiac surgery.

Comparison of sequential left internal thoracic artery grafting and separate left internal thoracic artery and venous grafting : A 5-year follow-up.

OBJECTIVES: The superiority of left internal thoracic artery (LITA) grafting to the left anterior descending artery (LAD) is well established. Patency rates of 80%-90% have been reported at 10-year follow-up. However, the superiority of sequential LITA grafting has not been proven. Our aim was to compare patency rates after sequential LITA grafting to a diagonal branch and the LAD with patency rates of LITA grafting to the LAD and separate vein grafting to a diagonal branch. METHODS: A total of 58 coronary artery bypass graft (CABG) patients, operated on between 01/2000 and 12/2002, underwent multi-slice computed tomography (MSCT) between 2006 and 2008. Of these patients, 29 had undergone sequential LITA grafting to a diagonal branch and to the LAD ("Sequential" Group), while in 29 the LAD and a diagonal branch were separately grafted with LITA and vein ("Separate" Group). Patencies of all anastomoses were investigated. RESULTS: Mean follow-up was 1958±208 days. The patency rate of the LAD anastomosis was 100% in the Sequential Group and 93% in the Separate Group (p=0.04). The patency rate of the diagonal branch anastomosis was 100% in the Sequential Group and 89% in the Separate Group (p=0.04). Mean intraoperative flow on LITA graft was not different between groups (69±8ml/min in the Sequential Group and 68±9ml/min in the Separate Group, p=n.s.). CONCLUSION: Patency rates of both the LAD and the diagonal branch anastomoses were higher after sequential arterial grafting compared with separate arterial and venous grafting at 5-year follow-up. This indicates that, with regard to the antero-lateral wall of the left ventricle, there is an advantage to sequential arterial grafting compared with separate arterial and venous grafting.

Chronic AT1-receptor blockade does not alter cerebral oxygen supply/demand ratio during cardiopulmonary bypass in hypertensive patients.

BACKGROUND: The angiotensin II receptor type 1 antagonist candesartan has been hypothesized to alter vasopressor requirements and brain-blood flow by changing cerebrovascular autoregulation. Therefore, we assessed the effects of a pre-anaesthetic treatment course with candesartan on cerebral arterial-jugular bulb oxygen content difference, middle cerebral artery blood velocity, and vasopressor requirements in hypertensive patients undergoing elective on-pump coronary artery bypass graft surgery. METHODS: In a randomized, double-blind, placebo-controlled study, we evaluated the effects of candesartan (8 mg po/d, given for 6-8 days before surgery) in 35 hypertensive patients. The mean arterial pressure was maintained above 60 mmHg by bolus administration of phenylephrine, if required, and dosages were recorded. RESULTS: Candesartan did not significantly alter oxygen content difference across the cerebral circulation, mean middle cerebral artery blood velocity during cardiopulmonary bypass, or phenylephrine requirements either before (0.0067 microg/kg/min+/-0.0042 vs. 0.0056 microg/kg/min+/-0.0049, P=0.48) or during cardiopulmonary bypass (0.0240 microg/kg/min+/-0.0240 vs. 0.0250 microg/kg/min+/-0.0190, P=0.97) compared with placebo. CONCLUSION: Thus, a 6-8-day treatment course with candesartan does not alter global cerebral perfusion and oxygen supply/demand ratio during cardiopulmonary bypass, or vasopressor requirements in hypertensive patients undergoing on-pump coronary artery bypass graft surgery, and no deleterious consequences of AT1-receptor blockade were detected.

Intraoperative coronary graft flow determination--does it have a prognostic value for midterm graft patency?

OBJECTIVE: To characterise the prognostic value of intraoperative ultrasonic graft flow determination during CABG for mid-term patency. METHODS: From 01/2000 to 08/2003 3146 CABG procedures were performed at our institution. Graft flow was determined in all patients. Lumen diameter was given in mm and a sclerosis score was applied for the target vessel. 100 of these patients (3.2%) underwent postoperative coronary angiography at a mean time interval of 8.0 +/- 0.5 months. RESULTS: In 100 patients, 114 LITA and 204 venous anastomoses were performed. At re-angiography 112 LITA (98%) and 174 venous (85%) anastomoses were patent. The amount of occluded LITA grafts was to low to perform statistical analyses. Mean graft flow of patent vein grafts was 48 +/- 2 ml/min vs. 32 +/- 4 ml/min in occluded vein grafts (p = 0.001). After multiple logistic regression analysis, only intraoperative vein graft flow was found to be a predictor for patency at mid-term (p = 0.005, odds ratio 0.97, 95% confidence interval (CI) from 0.95-0.99). No differences were found concerning sclerosis scores or vessel lumen between patent and occluded grafts. CONCLUSIONS: Significant differences concerning intraoperative graft flow were found between vein grafts patent or occluded at re-angiography. The predictive power of intraoperative vein graft flow for mid-term patency was confirmed by multiple logistic regression analysis.

Off pump coronary artery bypass grafting - midterm results.

OBJECTIVE: Off pump coronary artery bypass (OPCAB) grafting is still discussed controversially in the cardiac surgical community. Early perioperative results are encouraging. Only few reports have focused on mid-term recurrence of angina and freedoms from death or re-intervention. - METHODS: 107 OPCAB patients (mean age 63 +/- 1 years, 77 male, log EuroScore 5.6 +/- 0.7, number of distal anastomoses 2.0 +/- 0.1), operated on between January 1999 and December 2003, were systematically followed up comparing pre- and post-op NYHA- and CCS-classifications and assessing freedom from death and re-intervention. 52 of 107 patients underwent postoperative angiography or multi-slice computed tomography (MSCT); 6 of the latter 52 patients were symptomatic, 3 with unstable angina, the others underwent follow-up studies having given their informed consent. - RESULTS: The 30 day mortality was 2%. Freedom from death or re-intervention at 5.5 years was 91% and 80%, respectively. Only three patients required re-intervention in an OPCAB-related vessel. CCS classification was 2.8 +/- 0.1 before surgery and 1.8 +/- 0.2 (p<0.01) at follow-up (3.3 +/- 0.3 years). NYHA classification was 2.7 +/- 0.1 and 2.2 +/- 0.1 (p<0.01), respectively. Out of 107 patients, 52 underwent coronary angiography or MSCT (6 for cardiac symptoms) at a mean follow-up of 2.2 +/- 0.3 years. Left internal thoracic artery was patent in 91%, venous graft patency rate was 83%. - CONCLUSIONS: In this small but consecutive OPCAB population with a considerable perioperative risk according to the EuroScore, freedom from death and re-intervention at 5.5 years is acceptable and graft patency rate at 2.2 +/- 0.3 years is in the expected range. Significant reduction in both CCS and NYHA classification indicate sustained clinical improvement at mid-term.

Impact of intraoperative myocardial cellular damage on early hemodynamics after off-pump versus on-pump coronary artery bypass surgery.

BACKGROUND: Due to the surgical trauma a small amount of myocardial cellular damage is inherent during coronary artery bypass grafting (CABG). The purpose of the present study was to assess the degree of myocardial cellular damage after off-pump (OPCAB) and on-pump CABG (ONCAB) as measured by cardiac troponin I (cTnI), creatine kinase (CK), its MB isoenzyme (CK-MB) and myoglobin (Myo) and to examine its impact on early hemodynamics after surgery. METHODS: Ninety-nine consecutive OPCAB patients, operated between 01/1999 and 01/2004, were enrolled in the present study and compared to 99 ONCAB patients operated during the same period of time, who were matched for baseline data and mean number of grafts per patient. Early hemodynamics, cTnI, CK/CK-MB and Myo were measured preoperatively and at 1, 6, 12, 24 and 48 hours (h) postoperatively. Perioperative inotropic support, clinical data and potoperative outcome were recorded prospectively. RESULTS: The two groups were similar concerning preoperative characteristics. The mean number of distal grafts/patient was 2.1 +/- 1.0 in OPCAB and 2.1 +/- 0.8 in ONCAB patients (mean +/- SD). There was no significant difference among the groups regarding early hemodynamics in terms of cardiac index (CI), systemic vascular resistance index (SVRI), and left ventricular stroke work index (LVSWI), and inotropic support. However, cTnI, CK/CK-MB but not Myo levels were significantly lower in OPCAB compared to ONCAB patients at 1, 6, 12, 24, 36 and 48 h postoperatively (P<0.05). CONCLUSIONS: Off-pump surgery results in equal early hemodynamics despite a significantly lower release of cTnI and CK, suggesting a reduced myocardial cell damage as compared to ONCAB surgery.

Preischaemic as well as postischaemic application of a calcium antagonist affords cardioprotection in the isolated guinea pig heart.

OBJECTIVE: The aim was to answer the following questions: (1) Does treatment with calcium antagonists have to be begun before ischaemia or is postischaemic application also protective? (2) When applied before ischaemia, do calcium antagonists have to depress preischaemic cardiac function in order to elicit protection? (3) Is cardioprotection a matter of improved reflow or do the agents influence the degree of oxidative injury during reperfusion? METHODS: Isolated working guinea pig hearts underwent ischaemia (15 min) and reperfusion (15 min). The calcium antagonist gallopamil was given either before (0.1 nM and 1 nM) or after ischaemia (0.1 nM) during early reperfusion (first 5 min). Recovery was defined as postischaemic compared to preischaemic external heart work, expressed in percent. Oxidative stress was assessed by the release of glutathione (GSH). Lactate release served as a measure of the ischaemic challenge. The ability of gallopamil to scavenge oxygen radicals directly was investigated in an in vitro chemiluminescence assay. RESULTS: Pump function of control hearts recovered to only 28% after reperfusion. Pretreatment with 0.1 and 1 nM gallopamil improved recovery to the same extent (48.7% and 43.4%, respectively); however, postischaemic application of 0.1 nM gallopamil afforded equal protection (45.4% recovery). Only the higher concentration of 1 nM gallopamil depressed preischaemic external heart work (by 11%). During earliest reperfusion (1-5 min), release of GSH only tended to be lower in treated hearts. During the subsequent minutes of reperfusion (5-15 min), release of GSH was significantly less in hearts postischaemically treated with 0.1 nM gallopamil (40 pmol.min-1 v 940 pmol.min-1 for controls). In contrast, ischaemia-induced lactate release did not differ between the groups. Gallopamil did not scavenge reactive oxygen species in vitro. CONCLUSIONS: Short term postischaemic application of the calcium antagonist gallopamil is almost as effective at restoring pump function as preischaemic application which, in turn, does not have to depress preischaemic cardiac function in order to elicit protection. A reduction of oxidative stress during reperfusion seems to contribute to the beneficial effects of postischaemic application of gallopamil, but a direct oxygen radical scavenging activity of gallopamil is not involved.

Acute cardiac inflammatory responses to postischemic reperfusion during cardiopulmonary bypass.

OBJECTIVES: The investigation centers on whether there is a reperfusion-induced specific cardiac inflammatory reaction after bypass surgery. BACKGROUND: Cardiopulmonary bypass (CPB) leads to systemic inflammation. Additionally, cardiac inflammation due to reperfusion could occur. Knowledge about nature and time course of this reaction might help to develop cardioprotective interventions. METHODS: In 12 patients receiving coronary bypass grafts, arterial and coronary venous blood was obtained before onset of CPB, and 1, 5, 10, 25, 35 and 75 min after cardiac reperfusion. Plasma levels of IL6 and IL8 were measured by immunoassay. CD11b, CD41, and CD62 on blood cells were quantified by flow cytometry. Measurement of CD41, a platelet marker, on neutrophils and monocytes allowed detection of leukocyte-platelet microaggregates. RESULTS: Transcardiac veno-arterial difference of IL6 rose in the 10th and 25th min of reperfusion (from 0 to 7 pg/ml; p < 0.05), and after 75 min (15 pg/ml). IL8 did not change. CD11b on neutrophils (PMN) decreased transcardially to 95, 88 and 82% of the initial level in the 5th, 10th, and 75th min, respectively, suggesting sequestration of activated neutrophils. CD62 on platelets rose about 30% in the 75th min. Initially, leukocyte-platelet microaggregates were formed during coronary passage (+31% of the arterial level for PMN, +23% for monocytes). During reperfusion, coaggregates were retained (PMN: -1% and -7% in the 5th and 10th min, monocytes: -22%, -13% and -12% in the 1st, 5th and 10th min. CONCLUSIONS: During early reperfusion after aortic declamping, the coronary bed is already a source of proinflammatory stimuli and target for activated leukocytes, partly in conjunction with platelets. Mitigation of these phenomena might help to improve cardiac function after CPB especially in patients at risk.

Ultrastructural discrimination between malignant melanomas and benign nevocytic nevi using high-resolution image and multivariate analyses.

Prompted by the well-known difficulties of reliable and objective histologic differentiation between initial malignant melanoma (MM) and benign nevocytic nevi (NN), ultrastructural high-resolution image and multivariate analyses were evaluated for their diagnostic efficiency. Thirty-seven different features describing morphometry (area, circumference, and shape factor), amount of heterochromatin and euchromatin, chromatin homogeneity, and presence of smaller dark chromatin aggregations were determined by a MICROVAX 3500 computer in each of 1840 intraepidermal melanocytic nuclei of 17 MM and 20 NN. A strategy for the classification of cases based on the identification of markedly atypical melanocytic cells (MACS) was developed. MACS, selected in multivariate analysis with a linear combination of the eight most important features for cell classification, were found in 39.4% of the melanoma cells, but only in 0.3% of nevocytic nevus cells. The presence of MACS allowed a clear differentiation between MM and NN. All cases of MM had more than four MACS, whereas 17 cases of nevocytic nevi were MACS negative, and in each of the remaining three cases only one MAC was present. The percentage of MACS detected within intraepidermal parts of MM by using computerized high-resolution image analysis was found to be a highly efficient diagnostic marker. The new classification strategy has the potential of saving considerable time in subsequent studies, because preselected sampling and the calculation of only a few criteria have proven sufficient for correct classification of malignant melanomas.

Taurine protects the heart from neutrophil-induced reperfusion injury.

Deficiency of the amino acid taurine is implicated in various pathologic states of the heart. Besides other effects, taurine has been proposed to be an antioxidant. However, its benefit under conditions associated with the generation of reactive oxygen species in the heart has not been clearly demonstrated. To assess the potential of taurine to influence neutrophil-dependent reperfusion injury, a model was developed based on the isolated working guinea pig heart. After an initial work phase, hearts were subjected to 15 min of global ischemia. Reperfusion, in a nonworking mode, was carried out in the absence or presence of homologous neutrophils (PMN) and/or taurine. After 15 min, work was resumed and percentage recovery of function was determined another 20 min later. During the reperfusion phase, coronary venous effluent was collected to quantify release of lactate and glutathione, markers of ischemic challenge and redox-stress, respectively. Furthermore, direct effects of taurine on radical formation were investigated in a chemiluminescence assay. Control hearts without application of PMN or taurine had a postischemic recovery of external heart work (EHW) of 76%, in the presence of taurine (15 mM) recovery was 72%. The application of PMN for merely the first minute of reperfusion led to a significant decrease in recovery to 30%, PMN having no effect without a foregoing ischemia. When taurine was additionally applied during reperfusion, EHW recovered to 60%. Release of lactate and of oxidized glutathione (GSSG) did not differ between the groups. In contrast, effluent concentrations of reduced glutathione (GSH) were considerably elevated by the presence of PMN in the sample and remained high even after PMN-washout. Taurine tended to attenuate this PMN effect. At the 5th and 10th min of reperfusion, GSH release of individual hearts correlated inversely with postischemic recovery of EHW. Surprisingly, taurine, by itself, did not significantly alter glutathione release. However, taurine (15 mM) markedly reduced luminol-dependent chemiluminescence elicited by activated guinea pig PMN as well as by chemically generated hypochlorous acid and hydroxyl radicals, but not superoxide radicals. Our results demonstrate that taurine protects the heart from PMN-induced reperfusion injury and oxidative stress. Because respiratory burst activity of PMN was also significantly reduced in the presence of taurine, the beneficial effect appears to be mediated by antioxidative properties of taurine.

Evidence for inflammatory responses of the lungs during coronary artery bypass grafting with cardiopulmonary bypass.

OBJECTIVE: The occurrence of a systemic inflammatory reaction during cardiac surgery with cardiopulmonary bypass (CPB) has been well established, and the heart itself has been shown to release inflammatory mediators after ischemia. The hypothesis of the present study was that the lungs are also a site of inflammatory responses during early reperfusion. METHODS: In 20 consecutive patients undergoing coronary artery bypass grafting, blood was simultaneously drawn from the right atrium (RA) and the pulmonary vein (PV) before CPB and at 1 min, 10 min, and 20 min of reperfusion. The levels of interleukin (IL)-6, IL-8, IL-10, and tumor necrosis factor (TNF)-alpha were determined, as well as the adhesion molecules CD41 and CD62 on platelets and CD11b and CD41 on leukocytes. As a measure of the pulmonary release, ratios of PV and RA levels were calculated. RESULTS: Before CPB, the concentrations of cytokines tended to be lower in the PV compared with the RA. At 1 min of reperfusion, no significant concentration increases were found in the PV. At 10 min of reperfusion, the PV/RA ratio (mean +/- SEM) for IL-6 was 2.06 +/- 0.37 and 1.24 +/- 0.15 for IL-8 (p = 0.02 and p = 0.04, respectively, compared with the pre-CPB ratios of 0.89 +/- 0.4 and 0.99 +/- 0.2). At 20 min of reperfusion, PV/RA ratios for IL-6 (1.95 +/- 0.37) and IL-10 (0.99 +/- 0.4) were higher than before CPB (0.89 +/- 0.04, p = 0.05 and 0.85 +/- 0.06, p = 0.03, respectively). Adhesion molecule counts on platelets and polymorphonuclear neutrophils (PMNs) tended to be higher in the PV than in the RA before CPB. At 1 min of reperfusion, the PV/RA ratio of CD41 on monocytes (0.89 +/- 0.04) and of CD41 on PMNs (1.05 +/- 0.05) was less than before CPB (1.24 +/- 0.08, p = 0.0002 and 1.55 +/- 0.14, p = 0.0002). At 10 min and 20 min of reperfusion, similar changes were found. CONCLUSIONS: The observed changes indicate an inflammatory response of the lungs. Proinflammatory cytokines are increased in pulmonary venous blood. At the same time, activated blood cells are retained in the pulmonary circulation. This may contribute to pulmonary dysfunction almost routinely observed after CPB.

Sodium nitroprusside in patients with compromised left ventricular function undergoing coronary bypass: reduction of cardiac proinflammatory substances.

OBJECTIVE: The aim of the present study was to investigate whether the nitric oxide donor sodium nitroprusside can reduce the cardiac inflammatory response during coronary artery bypass grafting in patients with severely compromised left ventricular function. METHODS: Patients (n = 30) were assigned to receive placebo or sodium nitroprusside (0.5 microg. kg(-1). min(-1)) for the first 60 minutes of reperfusion. Interleukin 6, interleukin 8, and tumor necrosis factor alpha levels; platelet adhesion molecule CD41 and CD62 levels; and CD11b on leukocytes were determined in the radial artery and coronary sinus before cardiopulmonary bypass and during reperfusion (1, 5, 10, 35, and 75 minutes). RESULTS: At 1 minute of reperfusion, coronary venous levels of CD41-positive polymorphonuclear leukocytes were 8% lower than arterial levels in the placebo group and 18% higher in the sodium nitroprusside group (P =.021). At 5 minutes of reperfusion, the respective levels were 29% and 1% for interleukin 6 (P =.015), -5% and 20% for CD41-positive monocytes (P =.032), and -2% and 16% for CD11b-positive monocytes (P =.038). At 10 minutes of reperfusion, these levels were -14% and 21% for CD41-positive monocytes (P =.006). At 35 minutes of reperfusion, these levels were -13% and 7% for CD41-positive monocytes (P =.017), -41% and 23% for CD11b-positive monocytes (P =.001), and 7% and 25% for CD62-positive platelets (P =. 041). At 75 minutes of reperfusion, the levels were 15% and -7% for tumor necrosis factor alpha (P =.025) and -10% and 10% for CD62-positive platelets (P =.041). CONCLUSIONS: Transcardiac production of proinflammatory cytokines is reduced in patients undergoing coronary artery bypass grafting treated with the nitric oxide donor sodium nitroprusside. At the same time, less activated leukocytes and platelets are retained in the coronary circulation.

Sodium nitroprusside during coronary artery bypass grafting: evidence for an antiinflammatory action.

BACKGROUND: It was the aim of the present study to investigate whether a nitric oxide donor can reduce systemic inflammation and the cardiac inflammatory response during coronary artery bypass grafting with cardiopulmonary bypass. METHODS: Patients undergoing elective coronary artery bypass grafting (n = 22) were randomly assigned to treatment with either sodium nitroprusside (0.5 microg x kg(-1) x min(-1)) or placebo (controls), both for the first 20 minutes of reperfusion. Interleukin-6 and interleukin-8 levels, the adhesion molecules CD41 and CD62 on platelets and CD41 on monocytes and PMN (as markers for coaggregate formation), CD11b on monocytes and PMN, as well as platelet and leukocyte counts were determined in radial artery and coronary sinus blood before cardiopulmonary bypass and during reperfusion (1, 5, 10, 25, and 35 minutes). RESULTS: A reduction of systemic interleukin-6 levels (15.4+/-3.5 pg/mL, 36.7+/-5.9 pg/mL, and 46.8+/-8.0 pg/mL versus 33.4+/-7.7 pg/mL, 76.7+/-13.2 pg/mL, and 106.0+/-26.5 pg/mL, respectively, at 1, 25, and 35 minutes of reperfusion) and interleukin-8 (29.6+/-4.5 pg/mL versus 54.0+/-9.4, pg/mL, resp., at 35 minutes of reperfusion) resulted from treatment with sodium nitroprusside. No intracardiac production of interleukin-8 in sodium nitroprusside-treated patients (-1.1+/-0.4 pg/mL and -2.8+/-2.2 pg/mL, resp., for the coronary sinus-radial artery difference at 5 and 25 minutes of reperfusion) was observed, whereas cardiac production of interleukin-8 was present in controls (2.5+/-1.5 pg/mL and 5.5+/-2.8 pg/mL, resp.). Retention of platelet/leukocyte coaggregates occurred during coronary passage in controls (coronary sinus-radial artery difference for CD41-positive monocytes at 1 and 10 minutes of reperfusion, -16.3%+/-8.5% and -8.8%+/-2.6%, resp.). This was reduced in sodium nitroprusside-treated patients (with 5.8%+/-5.2% and 0.0%+/-3.2%). Retention of platelets in controls (ratio of coronary sinus to radial artery platelet count at 5 and 10 minutes of reperfusion, 88%+/-6% and 91%+/-5%) was compared to washout in treated patients (108%+/-6% and 113%+/-7%). CONCLUSIONS: In patients undergoing routine coronary artery bypass grafting, administration of sodium nitroprusside during early reperfusion alleviates systemic inflammation and the cardiac inflammatory response.

Intraoperative flow measurement of native coronary artery can help decision making before CABG.

We report the case of a patient with three-vessel coronary artery disease whose right coronary artery had been stented at the time of the diagnostic procedure. He had recurrent angina 12 days later and was transferred for urgent coronary artery bypass grafting. No repeat coronary angiography was performed. In the operating room, the flow on the native right coronary artery was determined with an ultrasonic flow probe.

Reduction of pro-inflammatory cytokine levels and cellular adhesion in CABG procedures with separated pulmonary and systemic extracorporeal circulation without an oxygenator.

OBJECTIVE: We have recently shown that a considerable amount of pro-inflammatory cytokines is released during pulmonary passage after aortic declamping in patients undergoing coronary artery bypass grafting. The present study was performed to investigate whether bilateral extracorporeal circulation with the lungs as oxygenators can reduce the inflammatory responses of the lungs. METHODS: Eighteen consecutive patients undergoing coronary artery bypass grafting were randomly assigned to routine extracorporeal circulation with cannulation of right atrium and aorta (routine circulation, ten patients) or to a bilateral extracorporeal circulation with additional cannulation of left atrium and pulmonary artery (bilateral circulation, eight patients). Blood was simultaneously drawn from right atrium and pulmonary vein at 1, 10 and 20 min reperfusion. The levels of interleukin (IL)-6 and IL-8 and the adhesion molecules CD41 and CD62 on platelets and CD11b and CD41 on leukocytes were determined. Because of considerable interindividual scatter, the pulmonary venous levels are normalized to percent of the respective right atrial value at each time point. RESULTS: At 1 min reperfusion pulmonary venous levels of IL-6 and IL-8 in routine circulation were +44+/-15% and +43+/-28% of the respective right atrial values. The respective values in bilateral circulation were -3+/-4% and -6+/-7% (P=0.02 and P=0.05 vs. respective right atrium). Similar increments were found after 10 and 20 min. Platelet-monocyte coaggregates were retained during pulmonary passage at 1 min reperfusion in routine circulation (-21+/-6%), but washed out in bilateral circulation (+5+/-8%, P=0. 007). At 20 min reperfusion, activated polymorphonuclear neutrophils (PMN) were retained in routine circulation (-16+/-9%) but washed out in bilateral circulation (+19+/-29%, P=0.05; all data given as mean+/-SEM). CONCLUSIONS: Bilateral extracorporeal circulation without an artificial oxygenator significantly reduces the inflammatory responses during pulmonary passage after aortic declamping.

Influence of intact left atrial appendage on hemodynamic parameters of isolated guinea pig heart.

BACKGROUND: In isolated working guinea pig heart preparations using the conventional technique of cannulating the left atrium via the atrial appendage, the resulting cardiac output is often insufficiently low (15-20 ml/min). This is a problem in ischemia reperfusion studies where small absolute differences can be responsible for large relative changes comparing pre- and postischemic values. In an attempt to increase cardiac output, the left atrium was left intact in isolated working guinea pig hearts. The two techniques were compared for hemodynamic parameters and their similarity to the physiological condition. METHODS: The left atrium was cannulated either via the orifices of the pulmonary veins or via an incision in the atrial appendage with its subsequent ligation around the cannula (n = 45-46/group). After 20 min of pressure-volume work cardiac output, heart rate and oxygen partial pressures were measured and myocardial oxygen consumption and cardiac efficiency were calculated. RESULTS: Cardiac output was higher in hearts with intact atrial appendage (64 +/- 2 ml/min) than in hearts with ligated atrial appendage (33 +/- 1 ml/min). Myocardial oxygen consumption (6.1 +/- 0.2 and 8.4 +/- 0.3 micromol/min, resp.) and cardiac efficiency (12.8 +/- 0.6% and 19.9 +/- 0.8%, resp.) were significantly higher in hearts with intact left atrial appendage. CONCLUSIONS: Isolated working guinea pig hearts with an intact left auricle exhibit higher values for important hemodynamic parameters compared to a preparation technique involving ligation of the left auricle.

Significant leukocyte and platelet retention during pulmonary passage after declamping of the aorta in CABG patients.

During reperfusion of the heart and the lungs in patients undergoing coronary artery bypass grafting, these organs have been shown to release inflammatory mediators. The present study was performed to quantitatively determine cellular retention or washout during pulmonary passage in early reperfusion. In 14 consecutive patients undergoing coronary artery bypass grafting blood was simultaneously drawn from right atrium and pulmonary vein at 1, 10 and 20 min reperfusion. The counts for platelets, leukocytes and the leukocyte subsets polymorphonuclear neutrophils (PMN), lymphocytes and monocytes were determined. Pulmonary veno-right atrial (transpulmonary) differences are given in percent with respective right atrial values being considered as 100%. Before CPB leukocyte counts were 4.7 +/- 0.5 in right atrium and 4.2 +/- 0.4 in pulmonary vein, x10(9)/l, resp. (transpulmonary difference of -8 +/- 3%). During reperfusion, pulmonary retention was in the range of 20-23% (p <0.01 vs. right atrial value). The basal values for PMN were 2.4 +/- 0.3 in right atrium and 1.9 +/- 0.3 in pulmonary vein, x10(9)/l, resp. (transpulmonary difference -15 +/- 8%). Thereafter, retention was in the range of 25-30% (p <0.01 vs. right atrium). Basal values for lymphocytes were 1.5 +/- 0.2 in right atrium and 1.6+/-0.3 in pulmonary vein, x10(9)/l, resp. (transpulmonary difference +6 +/- 10%). A tendency towards a washout of lymphocytes at 1 min reperfusion (+1 +/- 12%) was followed by retention of these cells at 10 and 20 min reperfusion (-14 +/- 12% and -10 +/- 5%, p <0.05 vs right atrium). Before ischemia monocyte counts were 0.7 +/- 0.2 in right atrium and 0.6 +/- 0.2 in pulmonary vein, x10(9)/l, resp. (transpulmonary difference -10 +/- 4%) and -9 +/- 9%, -27 +/- 12% (p <0.05 vs right atrium) and -22 +/- 14% at 1, 10 and 20 min reperfusion. During early reperfusion of the lungs after declamping of the aorta, significant amounts of leukocytes, platelets and the leukocyte subsets are retained in the pulmonary vascular bed. These retained cells may be responsible for the previously described pulmonary release of cytokines.