Markers of endothelial dysfunction after cardiac surgery: soluble forms of vascular-1 and intercellular-1 adhesion molecules.

Endothelium forms an inner layer of vascular wall. It plays an important role in inflammatory process, regulation of vascular tone, and synthesis of thromboregulatory substances. Leukocyte and endothelium interactions during inflammation are regulated by different families of adhesion molecules. Increased levels of soluble forms of adhesion molecules have been detected in the circulating blood in conditions such as autoimmune diseases, transplant rejection, ischemia-reperfusion injury in addition to neutrophil- and endothelial membrane-bound forms reflecting the level of endothelial dysfunction. It is known that endothelial dysfunction is a risk factor for ischemic events such as stroke, myocardial infarction, unstable angina pectoris, ventricle fibrillation, necessity of revascularisation procedures, and death from cardiovascular reasons. Clinical studies showed that cardiac surgery has an impact on vascular endothelial function as well. The amount of endothelium-derived soluble forms of vascular-1 and intercellular-1 adhesion molecules increases after cardiopulmonary bypass suggesting endothelial dysfunction. However, further investigations are needed to be done to support the evidence that endothelial dysfunction proceeding heart surgery is one of the reasons of tissue ischemia-reperfusion injury.

Intra-aortic balloon counterpulsation in decompensated cardiomyopathy patients: bridge to transplantation or assist device.

OBJECTIVES: The crucial decision to progress from pharmacological treatment of acute decompensated heart failure to institution of assist device or transplantation begins with evaluation of the chances for a successful recovery. We tested whether the intra-aortic balloon counterpulsation (IABP) could give us the necessary time for clinical decision-making and preserve adequate circulation until it is made. METHODS: We assessed 11 dilated cardiomyopathy patients of NYHA class IV, listed for heart transplantation or a ventricular assist device (VAD), who had conventional IABP placed. Heart function prior to and after IABP insertion as well as hemodynamics, end-organ function (renal and hepatic), frequency of complications and clinical outcomes were assessed. RESULTS: The duration of intra-aortic balloon pump insertion ranged from 72 to 360 h (mean 181.54+/-81.65). After 48 h of intra-aortic balloon pump support, there was a significant increase of mean systemic arterial pressure from 74.5+/-9.6 to 82.3+/-4.7 mmHg (P=0.02), and ejection fraction from 14.7+/-6.4 to 21.0+/-8.6 (P=0.014). Meanwhile improvement of cardiac index, pulmonary wedge pressure and end-organ perfusion markers did not reach statistical significance. Three patients were successfully weaned off the balloon and recovered without additional interventions, two patients were transplanted and three were supported with counterpulsation until the implantation of assist device. Three patients died due to progressive heart failure, two after IABP removal and one after VAD implantation. There was no incidence of infection, limb ischemia, thrombus, or embolic complications. CONCLUSIONS: Our data showed that intra-aortic balloon pump support may be successfully and safely used in the acute decompensated dilated cardiomyopathy patients, as an urgent measure of cardiac support, to stabilize the patient and maintain organ perfusion until transplant is available, VAD is placed or patient is weaned from IABP.

Incidence and precipitating factors of delirium after coronary artery bypass grafting.

OBJECTIVE: To analyze large contemporary patient population, undergoing on-pump coronary artery bypass grafting at our institution, and identify the prevalence and precipitating factors of delirium development. DESIGN: Baseline demographics, operative data and postoperative outcomes of 1367 consecutive patients were recorded prospectively and analysed using multivariate logistic regression analysis, to determine independent predictors of postoperative delirium development. RESULTS: Delirium was detected in 42 (3.07%) patients. Eight factors: age more than 65 years, peripheral vascular disease, Euroscore>/=5, preoperative IABP support, postoperative blood product usage and postoperative low cardiac output syndrome were independently predicting delirium development after coronary artery bypass procedures. Postoperative delirium was associated with significantly higher mortality rate (16.6% vs. 3.9%, p=0.013), prolonged mechanical ventilation time (9.2+/-3.1 vs. 5.05+/-7.6, p=0.04) and increased length of intensive care unit stay (6.8+/-4.9 vs. 2.0+/-2.7 days, p=0.001). CONCLUSIONS: Delirium is a dangerous complication, prolonging intensive care unit stay and postoperative mortality. Factors associated with delirium development are advanced age, peripheral vascular disease, diminished cardiac function and blood product usage.

[Disorders of neurocognitive function after coronary artery bypass grafting]. / Pooperacines neurokognityvines disfunkcijos daznis po miokardo revaskulizavimo operaciju.

OBJECTIVE: Neurocognitive dysfunction still remains a frequent problem after heart surgery, complicating early recovery and strongly affecting postoperative quality of life. The aim of our study was to determine incidence of cognitive dysfunction after coronary artery bypass grafting for patients of low risk group and to find operative and postoperative factors associated with early cognitive impairment. MATERIAL AND METHODS: Using exclusion criteria, which are known as risk factors for postoperative neurological complications we selected a group of 30 coronary artery bypass grafting patients. The day before surgery and 7 to 8 days after operation we evaluated cognitive function of each patient using MMSE and standardized test battery of five neuropsychological tests. The incidence of cognitive decline was evaluated using composite z scores and 1 SD criteria. Preoperative ultrasound screening of asymptomatic carotid artery was performed for each patient. RESULTS: Early postoperative cognitive dysfunction was present in 13 (46.3%) of patients. Patients with cognitive decline more often had asymptomic, hemodynamicly significant carotid artery stenosis. Duration of operation and coronary artery bypass time was longer in cognitive dysfunction group. As well there were more grafts performed to this group of patients. We noticed a relationship between lower temperature during coronary artery bypass and cognitive impairment. CONCLUSIONS: Incidence of cognitive dysfunction for patients of low risk group was 46.3%. Cognitive decline was associated with prolonged coronary artery bypass, operation time and number of grafts.

[Preoperative risk factors and postoperative complications in coronary artery bypass grafting]. / Rizikos veiksniu itaka komplikacijoms rastis po miokardo revaskulizavimo operaciju.

BACKGROUND: Prediction of risk of postoperative complication is necessary for optimal use of available resources and makes possible to compare patient population and postoperative outcomes in different institutions. The goal of the study was to identify preoperative risk factors for morbidity following coronary artery bypass grafting. MATERIAL AND METHODS: Data of 1829 consecutive patients undergoing surgery for coronary artery disease in Clinics of Santariskes of Vilnius University Hospital. Morbidity was defined as the presence of one or more of the following categories of complications: cardiac, pulmonary, neurologic, renal and infectious. RESULTS: The observed crude hospital mortality was 2.57%. Major morbidity events occurred in 14.1% of the patients. The most frequently occurring complications were cardiac (myocardial infarction or low cardiac output syndrome), followed with the need of prolonged mechanical ventilation and stroke. CONCLUSIONS: Older age, diabetic patients, patients with renal dysfunction and reduced contractility of the left ventricle, especially operated on as emergency with uncontrolled heart failure, cardiogenic shock or ongoing infarction are at risk of development one or more complications following coronary artery bypass grafting. Major perioperative complications following coronary artery bypass grafting occur relatively frequently and could be used for quality assessment and quality improvement activities in our institution.