Trace elements in patients with aortic valve sclerosis.

BACKGROUND: Aortic valve sclerosis (AVSc) is defined as the thickening and calcification of aortic valve cusps, in the absence of obstruction of ventricular outflow. AVSc is linked with a clear imbalance in some trace elements. AIMS: The objective of this study was to investigate the relationship between AVSc and serum levels of iron (Fe), zinc (Zn), selenium (Se), and copper (Cu). Additionally, this research aimed to explore the clinical significance of human serum zinc, selenium, copper, and iron concentrations as a potential new biomarker for AVSc patients and to clarify the pathophysiological role in individuals at risk of developing AVSc. PATIENTS AND METHODS: The study included 40 subjects with AVSc (25% male and 75% female) who were compared with a healthy control group with the same gender ratio. AVSc was based on comprehensive echocardiographic assessments. Blood samples were taken and Zn and Cu concentrations were determined through the use of atomic absorption spectroscopy. Se was measured using an inductively coupled plasma mass spectrometry device and Fe was measured using a Beckman Coulter instrument. RESULTS: There was a significant difference in the prevalence of diabetes, blood pressure levels, and body mass index between the patients and the healthy subjects (p < 0.05). The differences between the serum Fe, Se, and Cu levels of the AVSc patients and the healthy subjects (p > 0.05) were recorded. The serum Zn of AVSc patients when compared was significantly lower compared with that of the control group (p < 0.01). CONCLUSION: Patients with AVSc had an imbalance in some of the trace elements in their blood. The patient group's valves had higher serum Cu levels and lower serum Se, Zn, and Fe concentrations compared with the healthy group's valves. In the valve patients as compared, AVSc had a high prevalence of obesity, hypertension, and diabetes.

Comparison of the effects of lanthanum carbonate and calcium carbonate on the progression of cardiac valvular calcification after initiation of hemodialysis.

BACKGROUND: Although mineral metabolism disorder influences cardiac valvular calcification (CVC), few previous studies have examined the effects of non-calcium-containing and calcium-containing phosphate binders on CVC in maintenance hemodialysis patients. The aim of the present study was to compare the effects of lanthanum carbonate (LC) with calcium carbonate (CC) on the progression of CVC in patients who initiated maintenance hemodialysis and to investigate clinical factors related to CVC. METHODS: The current study included 50 subjects (mean age 65 years, 72% males) from our previous randomized controlled trial (LC group, N = 24; CC group, N = 26). CVC was evaluated as CVC score (CVCS) using echocardiography at baseline and 18 months after initiation of hemodialysis. We compared CVCS and the changes between the two groups. We also analyzed the associations between CVCS and any other clinical factors including arterial plaque score (PS) and serum phosphorus levels. RESULTS: Baseline characteristics of study participants including CVCS were almost comparable between the two groups. At 18 months, there were no significant differences in mineral metabolic markers or CVCS between the two groups, and CVCS were significantly correlated with PS (r = 0.39, p < 0.01). Furthermore, changes in CVCS were significantly correlated with average phosphorus levels (r = 0.36, p < 0.05), which were significantly higher in high serum phosphorus and high PS group compared to low serum phosphorus and low PS group (p < 0.05). CONCLUSIONS: In the present study, there were no significant differences between LC and CC with regard to progression of CVC. However, serum phosphorus levels and arterial plaque seem to be important for the progression and formation of CVC in hemodialysis patients.

Antithrombotic and thrombolytic therapy for valvular disease: Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines.

BACKGROUND: Antithrombotic therapy in valvular disease is important to mitigate thromboembolism, but the hemorrhagic risk imposed must be considered. METHODS: The methods of this guideline follow those described in Methodology for the Development of Antithrombotic Therapy and Prevention of Thrombosis Guidelines. Antithrombotic Therapy and Prevention of Thrombosis, 9th ed: American College of Chest Physicians Evidence-Based Clinical Practice Guidelines in this supplement. RESULTS: In rheumatic mitral disease, we recommend vitamin K antagonist (VKA) therapy when the left atrial diameter is > 55 mm (Grade 2C) or when complicated by left atrial thrombus (Grade 1A). In candidates for percutaneous mitral valvotomy with left atrial thrombus, we recommend VKA therapy until thrombus resolution, and we recommend abandoning valvotomy if the thrombus fails to resolve (Grade 1A). In patients with patent foramen ovale (PFO) and stroke or transient ischemic attack, we recommend initial aspirin therapy (Grade 1B) and suggest substitution of VKA if recurrence (Grade 2C). In patients with cryptogenic stroke and DVT and a PFO, we recommend VKA therapy for 3 months (Grade 1B) and consideration of PFO closure (Grade 2C). We recommend against the use of anticoagulant (Grade 1C) and antiplatelet therapy (Grade 1B) for native valve endocarditis. We suggest holding VKA therapy until the patient is stabilized without neurologic complications for infective endocarditis of a prosthetic valve (Grade 2C). In the first 3 months after bioprosthetic valve implantation, we recommend aspirin for aortic valves (Grade 2C), the addition of clopidogrel to aspirin if the aortic valve is transcatheter (Grade 2C), and VKA therapy with a target international normalized ratio (INR) of 2.5 for mitral valves (Grade 2C). After 3 months, we suggest aspirin therapy (Grade 2C). We recommend early bridging of mechanical valve patients to VKA therapy with unfractionated heparin (DVT dosing) or low-molecular-weight heparin (Grade 2C). We recommend long-term VKA therapy for all mechanical valves (Grade 1B): target INR 2.5 for aortic (Grade 1B) and 3.0 for mitral or double valve (Grade 2C). In patients with mechanical valves at low bleeding risk, we suggest the addition of low-dose aspirin (50-100 mg/d) (Grade 1B). In valve repair patients, we suggest aspirin therapy (Grade 2C). In patients with thrombosed prosthetic valve, we recommend fibrinolysis for right-sided valves and left-sided valves with thrombus area < 0.8 cm(2) (Grade 2C). For patients with left-sided prosthetic valve thrombosis and thrombus area ≥ 0.8 cm(2), we recommend early surgery (Grade 2C). CONCLUSIONS: These antithrombotic guidelines provide recommendations based on the optimal balance of thrombotic and hemorrhagic risk.

[Cardiac valves calcifications in dialysis patients]. / Kalcifikacije srcanih zalistaka kod pacijenata na kronicnoj hemodijalizi.

Chronic kidney disease (CKD) patients, especially those with end-stage renal disease (ESRD), are at much higher risk of cardiovascular disease (CVD) than the general population. High serum phosphorus (P) level play important role in pathogenesis of cardiovascular calcifications and is a frequent and important cardiovascular risk factor in patients with CKD. We aimed to investigate the association of serum levels of C-reactive protein (CRP), parathyroid hormon (PTH). calcium phosphorus product (CaxP) with cardiac valves calcifications (VC) in patients on hemodialysis (HD). We investigated for VC using colour Doppler echocardiography. VC were considered present if mitral annular calcifications and/or aortic annular calcifications were visualized. We divided patients in two groups. VC negative group (VC-) were patients with absence of VC. Patients with presence of VC were VC positive (VC+). CRP mean levels in two samples were higher in VC+ group than in VC- group (17.0 vs 3.4mg/L) and (17.1 vs 4.0 mg/L) p<0.0001. CaxP mean level in both samples was higher in VC+ group than in VC- group, 4.8 vs 4.2 (p=0.0219) and 5.0 vs 4.3 (p=0.0078). We also made analysis of absolute highest levels of three samples of CRP (CRPmax) between groups. CRPmax was higher in VC+ group than in VC- group, 19.5 vs 9.7 mg/L, (p=0.0045). We made analysis of absolute higher levels of two samples of Ca x P (CaxPmax) between groups. CaxPmax was higher in VC+ group than in VC- group, 5.2 vs 4.4 (p=0.0014). We found cardiac valve calcifications in 40 percent of patients on hemodialysis. We found that patients with correlation between PTH level, CRP level, CaxP product and cardiac valve calcifications have higher serum levels of PTH and CRP. We also found that CaxP product is higher in patients with cardiac valve calcifications. We didn't find correlation between age, dialysis duration, BMI and cardiac valve calcifications. These findings support careful monitoring of calcium metabolisum in end stage renal disease to reduce valvular cacifications and the risk of cardiovascular disease.

[Ways of reducing donor blood components during reconstructive surgery of the heart valves under extracorporeal circulation].

Blood loss and transfusion tactics were analyzed in 131 patients who had undergone correction of one, two, and three cardiac valves under general balanced anesthesia and extracorporeal circulation. The volume of intraoperative blood loss was 869+/-298 ml with the range of 700 to 2000 ml. Packed red cells (PRC) were transfused to 9% of patients; fresh frozen plasma (FFP) in 10%, PRC and FFP were transfused to 17% patients. Donor blood was not used in 63.5% of patients in order to save the patient's blood. It comprised the preoperative storage of autologous plasma in a quantity of 300-700 ml, the modified intraoperative reservation of autologous blood in a volume of 400-1200 ml, and, in 70% of patients, the use of washed autologous red blood cells. The hemostasis protocol included the use of epsilon-aminocapronic acid, aprotinin (trasilol) not more than 2,000,000 KUE, and packed platelets. For adequate heparin neutralization, after administration of the calculated dose of protamine, it was long administered in a dose of 25 mg/hour for 4-5 hours. The developed and introduced comprehensive program for the patient's blood maintenance and blood loss diminution made it possible to avoid transfusing PRC and FFP in more than 60% of patients with a blood loss volume of as high as 1500 ml; and to maintain adequate oxygen balance and hemostasis in the remaining patients.

[Clinical study on effect of Shenqi Fuzheng Injection on erythrocyte immunity in patients after cardiopulmonary bypass].

OBJECTIVE: To study the effect of Shenqi Fuzheng Injection (SQFZI) on erythrocyte immune function in patients after cardiopulmonary bypass (CPB). METHODS: Twenty patients ready for receiving CPB were randomly assigned to two groups, 10 in each group. Patients in the SQFZI group were treated with 250 mL SQFZI via intravenous dripping starting from 5 days before operation and after ending CPB once a day. Peripheral venous blood samples of all patients were collected at the time points of before anesthesia, and 6 h, 24 h, 72 h and 7 days after CPB, which were anticoagulated with heparin for dynamically detecting the changes of RBC-C3bRR and RBC-ICR. RESULTS: RBC-C3bRR and RBC-ICR in the SQFZI group were significantly higher at 6 h, 24 h, 72 h, and day 7 after operation than those in the control group respectively at the corresponding time points, and they restored to the normal levels at day 7, suggesting the erythrocyte immune function after CPB in the SQFZI group was superior to that in the control group (P < 0.05). CONCLUSION: Application of SQFZI in the peri-operative period can significantly improve the hypo-immunological function of erythrocyte caused by CPB, and promote the recovery of erythrocyte immunity.

Effects of intraoperative autologous blood donation and tepid temperature cardiopulmonary bypass on blood system.

The effects of the intraoperative autologous blood donation and tepid temperature cardiopulmonary bypass (CPB) on blood system were investigated. Twenty-four patients with rheumatic heart valve diseases scheduled for open heart surgery were selected and divided randomly into group A (intraoperative autologous blood donation and tepid temperature, nasopharyngeal temperature was at 32-34 degrees C during CPB) and group B (control, nasopharyngeal temperature was at 25-28 degrees C during CPB). The plasmatic concentrations of GMP-140 and D-Dimer and the plasmatic activities of 6-keto-PGF1 alpha and AT-III were measured by using ELISA or substrate luminescence techniques before operation, at the end of CPB, after discontinuation of CPB and postoperatively. Red blood cell count, platelet count, hematocrit, the amount of blood drainage and the amount of blood transfusion needed were measured or recorded postoperatively. The results showed the plasmatic concentrations of GMP-140 and D-Dimer in group A were significantly less (P < 0.05) than those in group B during and after operation. The activity of 6-keto-PGF1 alpha in group A was higher (P < 0.05) than that in group B during and after operation. The AT-III activity in group A was less (P < 0.05) during CPB but higher 30 min after discontinuation of CPB than that in group B. The amount of postoperative blood loss (283 +/- 166 versus 722 +/- 194 ml, P < 0.01) and amount of blood transfusion (816 +/- 126 versus 1443 +/- 678 ml, P < 0.01) in group A were significantly less than those in group B, respectively. The red blood cell count, platelet count and hematocrit in group A were significantly higher than those in group B after operation. The results suggests intraoperative autologous blood donation and tepid temperature have a good protection on blood system and can reduce postoperative non-surgical bleeding.

[Clinical study on ligustrazine in treating myocardial ischemia and reperfusion injury].

OBJECTIVE: To explore the protective effect of Ligustrazine in treating myocardial ischemia, and reperfusion injury. METHODS: The activities of serum superoxide dismutase (SOD), glutathione peroxidase (GSH-Px), and lactic dehydrogenase (LDH) and the amount of malondialdehyde (MDA) as well as the effects of Ligustrazine (LGT) on them were determined in 16 patients with cardiopulmonary bypass, who were, scheduled for elective cardiac surgery, were randomly divided into control group and LGT group. Ligustrazine was given by intravenous drip within 2-3 minute with a definite speed before occlusion and immediately after release respectively. Their venous blood samples were collected to measure the serum levels of SOD, GSH-Px, LDH and MDA by biochemical methods before the occlusion of aorta, at 30 minutes of occlusion and at 30 minutes after release respectively. RESULTS: There were significantly and very significantly differences between the values of control group and LGT group. CONCLUSION: LGT could effectively protect the myocardium from ischemia and reperfusion injury.

Blood conservation in valve surgery.

Blood utilization in 40 patients undergoing elective valve surgery was prospectively studied. The patients had valvular lesions of rheumatic origin with a mean age of 29.1 years and a mean preoperative hematocrit of 35.23 +/- 4.16. Blood was removed from all patients after induction of anesthesia and reinfused after bypass (mean 365.12 +/- 66.96 ml). Membrane oxygenator was used in all the patients. All discard suction was routed through a regionally heparinised collecting and processing system, and the resulting red cell concentrate was transfused. At the conclusion of bypass, all blood remaining in the pump oxygenator was also processed by cell saver and used for subsequent reinfusion. Normovolemic anemia was accepted in hemodynamically stable patients. Thirty two patients (80%) received no bank blood or blood products during their entire hospital course. A total of twelve units of whole blood was transfused into eight patients.

[Can administration of trasylol in reduced Hammersmith dosage with simultaneous transfusion of autologous blood meet the requirements of open heart surgery?]. / Kann die Gabe von Trasylol in einer verringerten Hammersmith-Dosierung bei gleichzeitiger Applikation von Eigenblutspenden den Ansprüchen der offenen Herzchirurgie entsprechen?

PROBLEM: The general positive effect of the proteinase inhibitor trasylol on blood loss and transfusion demand in cardiac surgery has been demonstrated in several placebo-controlled studies. Given the possibility of cardiac and renal side effects associated with a high dose of trasylol (Hammersmith dosage: 6 x 10(6) kallikrein inactivator units KIU), the question of a dose reduction was raised. METHODS: Being designed as a randomized double-blind comparative group study, the investigation included 120 patients with elective primary cardiac surgery from November 1990 to April 1992. One characteristic aspect of this study was the combined administration of trasylol and autologous blood transfusions. To compare the efficacy and safety of different doses of trasylol, two groups, each with 60 patients, were created: the former with the full Hammersmith dose (high dose group = HD group), the latter with half of the Hammersmith dose (los dose group = LD group). A placebo group had to be excluded for ethical reasons. RESULTS: The trasylol plasma levels showed a good dose correlation for the complete interval. The intra-operative bleeding tendency, as judged by the surgeons in charge, did not show any statistical significant difference between the HD group and the LD group. As to the post-operative blood loss via thoracic drainage, the early collection periods did not show any difference between both study groups. Starting at 6 hours post-operatively, the drainage losses showed a tendency towards lower volumes in the HD group. This difference was statistically significant for the time period "6-12 hours post-operatively". The analysis of the post-operative complications did not show any difference. SUMMARY: In this study with a high percentage of autologous blood transfusions, a lower dose of trasylol seemed to be nearly as effective as a full Hammersmith dose. However, such a reduced dose did not demonstrate any advantage regarding the complication rate in comparison with the conventional high dose.

[Preoperative autologous blood donation in heart surgery patients: laboratory parameters with oral iron substitution]. / Präoperative Eigenblutspende bei herzchirurgischen Patienten: Laborparameter unter oraler Eisensubstitution.

In this study we analyzed some hematologic parameters of 228 autologous blood donors at a cardiosurgic clinic. The standard schedule of drawing autologous blood at our clinic is 4 units whole blood (450 ml) and 1 unit plasma (750 ml) for a time of 5 weeks under iron substitution (equivalent to 240 mg Fe). In younger women this kind of drawing blood leads to an unacceptable decrease of hemoglobin concentration. The preoperative autologous blood donation results in an increase of erythropoiesis on the day of clinical admittance. The best parameters to supervise the hematologic situation of the outpatient autologous blood donors are the hemoglobin concentration and the hematocrit.

[Effect of hyperbaric oxygenation on central hemodynamics and oxygenating function of the lungs in open-heart surgery]. / Vliianie giperbaricheskoi oksiganatsii na tsentral'nuiu gemodinamiku i oksigeniruiushchuiu funktsiiu legkikh pri operatsiiakh na otkrytom serdtse.

The dynamics of some oxygenating pulmonary function (OPF) indices has been studied in 33 patients with coronary cardiac disease and rheumatic lesions of cardiac valves 4-6 hours after surgery in response to a single hyperbaric oxygenation (HBO) session (1.5 ata, 45 min) in the immediate postoperative period. It is found that in the presence of slight or, on the contrary, pronounced arterial hypoxemia, no significant negative OPF changes were observed. At the same time, a temporary increase in the alveolo-arterial gradient has been found in some patients. The comparison of data on the systemic blood flow with the OPF indices permits suggesting the prevalent role of the membrane component in a PaO2 decrease in patients after using assisted circulation.

[Is preservation of erythrocyte concentrates with added solutions an alternative to deep freezing in heart surgery autologous blood donation?]. / Ist die Konservierung von Erythrozytenkonzentraten mittels additiver Lösungen eine Alternative zur Tiefgefrierung bei herzchirurgischen Eigenblutspendern?

In patients undergoing cardiovascular operations the deep freezing of autologous red blood cells (RBC) was compared with the liquid storage in PAGGS-Sorbitol. On an average 3.9 units of blood were predeposited in the group with deep freezing and 3.4 in the group with liquid storage. The number of complications was the same in both groups despite the shorter intervals between the donations in the group with liquid storage. 58 out of 74 patients (= 78%) with deep frozen autologous RBC and 42 out of 65 patients (= 65%) with liquid stored RBC need no homologous blood. 12% of the liquid stored RBC were discared due to unforseen delaying of the operation.

Lack of effect of influenza and pneumococcal vaccines on anticoagulation by warfarin.

The effects on anticoagulation of a purified trivalent sub-unit influenza vaccine and a 14-valent pneumococcal vaccine were investigated in a single-blind controlled study involving 69 well-stabilised warfarin recipients. There were no clinically or statistically significant alterations of anticoagulant control in vaccine recipients as compared with controls at 2, 7 and 21 days after vaccination. On the basis of these data, concern about warfarin-vaccine interaction should not deter practitioners from immunising warfarin recipients against influenza or infection with Streptococcus pneumoniae.

Mitral anular calcification in chronic renal failure.

In order to determine the incidence and pathogenesis of mitral anular calcification (MAC) in chronic renal failure, we analyzed biochemical, hemodynamic and echocardiographic data in 168 patients on long-term hemodialysis. Mitral anular calcification is more common in patients with chronic renal failure than in other patients of similar age. Its pathogenesis appears to be due to abnormal calcium-phosphorus homeostasis in the setting of secondary hyperparathyroidism. Hypertension did not appear to be an important etiologic factor in our patients. Meticulous control of hyperphosphatemia would appear to be the most important therapeutic measure in preventing this complication.

Effects of relaxation therapy on cardiac performance and sympathetic activity in patients with organic heart disease.

Six patients, with surgically implanted tantalum myocardial markers, were trained in deep muscle relaxation therapy. Analysis of individual responses and group means of blood pressure and ventricular dimensions during relaxation showed a decrease in plasma norepinephrine levels and indices of myocardial contractility compared to the control state. Heart rate changes in individuals during relaxation were directly correlated with changes in plasma norepinephrine levels, although group means for heart rate did not change significantly between control and relaxation periods. Base-line plasma norepinephrine levels were directly correlated with systolic blood pressure and were inveresly correlated with a measure of myocardial contractility. These data suggest that physiological changes during relaxation may be mediated through the sympathetic nervous system.