Safe time limits of aortic cross-clamping and cardiopulmonary bypass in adult cardiac surgery.

OBJECTIVES: We evaluated the impact of aortic cross-clamping time (XCT) and cardiopulmonary bypass time (CPBT) on the immediate and late outcome after adult cardiac surgery and attempted to identify their safe time limits. METHODS: This study includes 3280 patients who underwent adult cardiac surgery of various complexities. Myocardial protection was achieved with tepid continuous antegrade/retrograde blood cardioplegia. RESULTS: Receiver operating characteristics (ROC) curve analysis showed that XCT (area under the curve, AUC: 0.66), CPBT (AUC: 0.73) and CPBT with unclamped aorta (AUC: 0.77) were significantly associated with 30-day postoperative mortality. XCT of increasing 30-minute intervals (Odds Ratio (OR) 1.21, 95%C.I. 1.01-1.52) and CPBT of increasing 30-minute intervals (OR 1.47, 95%C.I. 1.27-1.71) were independent predictors of 30-day mortality. The best cutoff value for XCT was 150 min (30-day death: 1.8% vs. 12.2%, adjusted OR 3.07, 95%C.I. 1.48-6.39, accuracy 91.5%) and for CPBT 240 min (30-day death: 1.9% vs. 31.5%, adjusted OR 8.78, 95%C.I. 4.64-16.61, accuracy 96.0%). These parameters were significantly associated also with postoperative morbidity, particularly with postoperative stroke. CONCLUSIONS: XCT and CPBT are predictors of immediate postoperative morbidity and mortality. In our experience, cardiac procedures with CPBT<240 min and XCT<150 min were associated with a rather low risk of immediate postoperative adverse events independently of the complexity of surgery patient's operative risk.

TF-XRD examination of surface-reactive TiO2 coatings produced by heat treatment and CO2 laser treatment.

When surface-reactive (bioactive) coatings are applied to medical implants by means of CO2 laser processing, the bioactivity of the surface of the implant can be locally modified to match the properties of the surrounding tissues to provide a firm fixation of the implant. The aim of this study was to compare the heat treated TiO2 coatings with the laser-treated TiO2 coatings in terms of amorphous-crystalline-phase development. The coatings were characterized with thin-film X-ray diffraction (TF-XRD), atomic force microscopy (AFM) and scanning electron microscopy (SEM). The TiO2 coatings heat treated at 500 degrees C known to be bioactive in SBF (simulated body fluid) consisted mainly of anatase with some rutile-phase, suggesting a predominant effect of anatase on reactivity of coatings. However, the coatings preheat-treated at 500 degrees C with further laser treatment exhibited enhanced bioactivity while consisting mainly of rutile. These findings indicated a key role of both rutile and anatase for the reactivity of the coatings. Without preheat treatment, by laser treatment alone, the amorphous titania coatings developed into mixed anatase/rutile containing coatings. This structural organization and the increase in crystal size are thus considered to be the reasons for their bioactivity. The SBF results indicate the possibility to control bioactivity by altering laser power used through the anatase/rutile crystallinity enhancement.

Osteoblast differentiation with titania and titania-silica-coated titanium fiber meshes.

Two surface-reactive sol-gel coatings, namely titania (TiO2) and a mixture of titania and silica (TiSi), were applied to titanium fiber meshes. Differentiation of rat bone marrow stromal cells toward an osteogenic phenotype with coated and uncoated (cpTi) substrates was compared. The amount of DNA in cpTi and TiSi matrices did not increase after day 3, but with TiO2 matrices the amount increased for 7 days. The prolonged period of proliferation with TiO2 scaffolds resulted in a delay in alkaline phosphatase induction. However, osteocalcin incorporation into extracellular matrix by day 14 was greater with TiO2 scaffolds than with cpTi scaffolds. Calcium deposition was also greater with TiO2-coated substrates than with uncoated substrates. With the TiSi scaffolds osteocalcin production and mineralization were lower than with the cpTi scaffolds. The current study confirms our previous findings that titanium fiber mesh supports attachment, growth, and differentiation of rat bone marrow stromal cells. Furthermore, the osteogenic capacities of cell-scaffold constructs under cell culture conditions were increased with a sol-gel-derived titania coating, but not with a titania-silica coating.

Calcium phosphate formation and ion dissolution rates in silica gel-PDLLA composites.

Sol-gel derived silicas are potential biomaterials both for tissue regeneration and drug delivery applications. In this study, both SiO(2) and calcium and phosphate-containing SiO(2) (CaPSiO(2)) are combined with poly-(DL-lactide) to form a composite. The main properties studied are the ion release rates of biologically important ions (soluble SiO(2) and Ca(2+)) and the formation of bone mineral-like calcium phosphate (CaP) on the composite surface. These properties are studied by varying the quality, content and granule size of silica gel in the composite, and porosity of the polymer. The results indicate that release rates of SiO(2) and Ca(2+) depend mostly on the formed CaP layer, but in some extent also on the granule size of silicas and polymer porosity. The formation of the bone mineral-like CaP is suggested to be induced by a thin SiO(-) layer on the composite surface. However, due to absence of active SiO(2) or CaPSiO(2) granules on the outermost surface, the suitable nanoscale dimensions do not contribute the nucleation and growth and an extra source for calcium is needed instead. The result show also that all composites with varying amount of CaPSiO(2) (10-60 wt%) formed bone mineral-like CaP on their surfaces, which provides possibilities to optimise the mechanical properties of composites.

Use of sol-gel-derived titania coating for direct soft tissue attachment.

A firm bond between an implant and the surrounding soft tissue is important for the performance of many medical devices (e.g., stents, canyls, and dental implants). In this study, the performance of nonresorbable and reactive sol-gel-derived nano-porous titania (TiO(2)) coatings in a soft tissue environment was investigated. A direct attachment between the soft tissue and the sol-gel-derived titania coatings was found in vivo after 2 days of implantation, whereas the titanium control implants showed no evidence of soft tissue attachment. The coated implants were in immediate contact with the connective tissue, whereas the titanium controls formed a gap and a fibrous capsule on the implant-tissue interface. The good soft tissue attachment of titania coatings may result from their ability to initiate calcium phosphate nucleation and growth on their surfaces (although the formation of poorly crystalline bonelike apatite does not occur). Thus, the formation of a bonelike CaP layer is not crucial for their integration in soft tissue. The formation of bonelike apatite was hindered by the adsorption of proteins onto the initially formed amorphous calcium phosphate growth centers, thus preventing the dissolution/reprecipitation processes required for the formation of poorly crystalline bonelike apatite. These findings might open novel application areas for sol-gel-derived titania-based coatings.

Nanoporous TiO(2) thin film on titanium oral implants for enhanced human soft tissue adhesion: a light and electron microscopy study.

BACKGROUND: Previous experimental studies have demonstrated direct soft tissue attachment for nanoporous titanium dioxide (TiO(2) ) thin film on implants, while implants without TiO(2) thin film have not shown this capability. PURPOSE: The aims were to evaluate and compare TiO(2) surface-modified experimental microimplants with unmodified microimplants with respect to tissue interaction of the human oral mucosa evaluated by light microscopy on ground sections and semithin sections and transmission electron microscopy on ultrathin sections, and to characterize the inflammatory response and the level of the marginal bone resorption. MATERIALS AND METHODS: The study was a single-center, randomized, comparative, clinical investigation with intrasubject comparison of implants with and without TiO(2) thin film in 15 patients. RESULTS: Two comparator microimplants showed mild erythema and expulsion of fluids. The surrounding tissues around all test implants were clinically healthy. The oral mucosa in contact with the abutment part of the microimplant was 72% for the test implants and 48% for the comparator implants, a statistically significant difference (p =.0268). No statistically significant difference was found in other histological variables. The marginal bone loss in 14 weeks was 0.5 mm for the stable test (n = 11) and 1.7 mm for the stable comparator implants (n = 9; p = .0248). CONCLUSIONS: The nanoporous TiO(2) surface modification has potential clinical benefits because of increased adherence of soft tissue and possible reduced bone resorption.

Effect of hydroxyapatite and titania nanostructures on early in vivo bone response.

PURPOSE: Hydroxyapatite (HA) or titania nanostructures were applied on smooth titanium implant cylinders. The aim was to investigate whether nano-HA may result in enhanced osseointegration compared to nano-titania structures. MATERIALS AND METHODS: Surface topography evaluation included detailed characterization of nano-size structures present at the implant surface combined with surface roughness parameters at the micro- and nanometer level of resolution. Microstructures were removed from the surface to ensure that bone response observed was dependent only on the nanotopography and/or chemistry of the surface. Early in vivo histological analyses of the bone response (4 weeks) were investigated in a rabbit model. RESULTS: In the present study, nano-titania-coated implants showed an increased coverage area and feature density, forming a homogenous layer compared to nano-HA implants. Bone contact values of the nano-titania implants showed a tendency to have a higher percentage as compared to the nano-HA implants (p = .1). CONCLUSION: Thus, no evidence of enhanced bone formation to nano-HA-modified implants was observed compared to nano-titania-modified implants. The presence of specific nanostructures dependent on the surface modification exhibiting different size and distribution did modulate in vivo bone response.

Antibacterial effect of bioactive glasses on clinically important anaerobic bacteria in vitro.

Bioactive glasses (BAGs) of different compositions have been studied for decades for clinical use and they have found many dental and orthopaedic applications. Particulate BAGs have also been shown to have antibacterial properties. This large-scale study shows that two bioactive glass powders (S53P4 and 13-93) and a sol-gel derived material (CaPSiO II) have an antibacterial effect on 17 clinically important anaerobic bacterial species. All the materials tested demonstrated growth inhibition, although the concentration and time needed for the effect varied depending on the BAG. Glass S53P4 had a strong growth-inhibitory effect on all pathogens tested. Glass 13-93 and sol-gel derived material CaPSiO II showed moderate antibacterial properties.

Bactericidal effects of bioactive glasses on clinically important aerobic bacteria.

Bioactive glasses (BAGs) have been studied for decades for clinical use, and they have found many dental and orthopedic applications. BAGs have also been shown to have an antibacterial effect e.g., on some oral microorganisms. In this extensive work we show that six powdered BAGs and two sol-gel derived materials have a clear antibacterial effect on 29 clinically important bacterial species. We also incorporated a rapid and accurate flow cytometric (FCM) method to calculate and standardize the numbers of viable bacteria inoculated in the suspensions used in the tests for antibacterial activity. In all materials tested growth inhibition could be demonstrated, although the concentration and time needed for the effect varied depending on the BAG. The most effective glass was S53P4, which had a clear growth-inhibitory effect on all pathogens tested. The sol-gel derived materials CaPSiO and CaPSiO II also showed a strong antibacterial effect. In summary, BAGs were found to clearly inhibit the growth of a wide selection of bacterial species causing e.g., infections on the surfaces of prostheses in the body after implantation.

Sol-gel-derived TiO(2)-SiO (2) implant coatings for direct tissue attachment. Part I: design, preparation and characterization.

A series of sol-gel derived TiO(2)-SiO(2) mixed oxide coatings were prepared by carefully controlling the process parameters to obtain silica-releasing coatings consisting of nanoparticles. These features are of paramount importance for enhanced cell adhesion and activation. To achieve both these goals the Ti-alkoxide and Si-alkoxide were first separately hydrolysed and the titania-silica mixed sol was further reacted before the dipping process to obtain the desired particle sizes resulting to the biologically favourable topographical features. Silica release was observed from all the prepared coatings and it was dependent on SiO(2) amount added to the sols, i.e., the higher the added amount the higher the release. In addition, calcium phosphate was able to nucleate on the coatings. From the obtained SiO(2) dissolution data, together with the detailed XPS peak analysis, the mixed oxide coatings are concluded to be chemically heterogeneous, consisting of TiO(2) and SiO(2) species most likely linked together by Ti-O-Si bonds. TiO(2) is chemically stable making long-term implant coating possible and the desired nanoscale dimensions were well preserved although the composition was changed as a consequence of SiO(2) dissolution under in vitro conditions.

Sol-Gel-derived TiO2-SiO2 implant coatings for direct tissue attachment. Part II: Evaluation of cell response.

Silica-releasing sol-gel derived TiO2-SiO2 coatings with tailored nanostructure were evaluated in fibroblast and osteoblast cell cultures. The adhesion of both fibroblasts and osteoblasts proceeded within two hours. The highest fibroblast proliferation activities were observed on the TiO2-SiO2 (70:30) and (30:70) coatings. However, the cell layer on TiO2-SiO2 (30:70) coating was disordered. Prolonged osteoblast activity was observed on the coatings as a function of increased amount of released silica. At day 21 the surfaces were fully covered by the calcified nodules and extracellular matrix except for the coatings TiO2-SiO2 (10:90) i.e. having the highest SiO2 amount. The results suggested that TiO2-SiO2 (70:30) was the best for fibroblasts and TiO2-SiO2 (30:70) for osteoblasts. The applicability of the sol-gel derived TiO2 and TiO2-SiO2 coatings as an alternative for the calcium phosphate based implant coatings are discussed.