[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.

Heart transplantation and consecutive mitral valve replacement.

A 48-year-old man was diagnosed with progressive mitral insufficiency due to fibrosis of papillary muscles and chordae tendineae, necessitating mitral valve replacement (MVR) 8 months after cardiac transplantation. Donor echocardiography and inspection of the heart at procurement were inconspicuous. The patient is alive, free from valve-related complications and functionally improved six years after MVR. The limited yet successful experiences with left-sided valve repair or replacement in the transplanted heart are reviewed.

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.

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.

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.

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.

Reactive oxygen species and nitric oxide in myocardial ischemia and reperfusion.

Oxygen radicals and reactive oxygen species (ROS) are known to be generated in large amounts under inflammatory conditions and in the first few minutes of postischemic organ reperfusion. Due to the interaction of ROS with nitric oxide (NO), formed constitutively by endothelial cells, two alternatives are feasible. On the one hand, reaction with superoxide radicals may induce toxification (formation of peroxynitrite), and, on the other hand, by reacting with superoxide and hydroxyl radicals, NO can serve as a radical scavenger (formation of the innocuous anions, nitrate and nitrite, respectively). However, NO is considered to play a pivotal role in numerous physiological and pathophysiological processes, with effects arising from both lack and surfeit of this easily diffusible and chemically very reactive molecule. Physiologic contributions to vascular dilatation and inhibition of platelet and leukocyte activation, e.g., are infringed by enhanced inactivation of NO. Such inactivation occurs readily due to spontaneous reaction of NO with the superoxide radical, formed, e.g., by stressed endothelial cells and activated leukocytes. Conversely, overproduction of NO by induced NO synthase (iNOS) may lead to circulatory shock, cell apoptosis or even cell necrosis. Caution would, thus, seem to be warranted when attempting to interfere with homeostasis of NO. We have investigated the ability of NO to act as a radical scavenger during myocardial reperfusion in experimental and clinical settings. In the former, inhibition of angiotensin converting enzyme was employed to generate more endogenous NO (via bradykinin), in the latter, low-dose sodium nitroprusside was used as the donor of exogenous NO in patients undergoing coronary bypass grafting. Inhibition of leukocyte adhesion, attenuation of platelet activation and mitigation of redox-stress and inflammation were observed in both instances. Accordingly, modest enhancement of NO levels should afford cardioprotection during reperfusion.

Reduction of oxygen delivery during post-ischemic reperfusion protects the isolated guinea pig heart.

OBJECTIVE: To further characterise the influence of oxygen delivery during early reperfusion (first 5 min) in the isolated guinea pig heart, three modes of coronary reperfusion were chosen, differing with respect to reperfusion flow and arterial PO2. METHODS: Isolated working guinea pig hearts underwent ischemia and reperfusion (15 min each). Reperfusion was at constant pressure (Group 1, 60 mmHg, n = 7) or at constant flow (Group 2, 5 ml/min, n = 7) with a PO2 of 600 mmHg. Group 3 (n = 8) was reperfused at 5 ml/min with a PO2 of 300 mmHg for 5 min and a PO2 of 600 mmHg thereafter. Lactate release and oxygen consumption were determined during reperfusion. Glutathione release served to assess myocardial oxidative stress. RESULTS: After ischemia, hearts in Group 1 (mean coronary flow 14.4 +/- 1.1 ml/min during the first 5 min of reperfusion) performed external heart work at 31 +/- 2% of the pre-ischemic level. Performance in Group 2 recovered to 50 +/- 3% and in Group 3 to 68 +/- 3%. Myocardial oxygen consumption during early reperfusion (2nd min) was lowest in Group 3 (1.9 micromol/min) and highest in Group 1 (8.3 micromol/min). No difference in lactate release was observed. Release of glutathione during the first 5 min of reperfusion was 43.8 +/- 7.9 nmol in Group 1, but only 3.6 +/- 0.7 in Group 2 (p < 0.05). CONCLUSIONS: In isolated guinea pig hearts, controlled oxygen delivery during post-ischemic reperfusion by both, reduction of coronary flow and PO2, improves recovery of pump function. The effect is accompanied by less oxidative stress, as indicated by lowered rates of glutathione release.

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.

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.

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.