Plasma 25-hydroxyvitamin D2 and D3 levels and incidence of postoperative atrial fibrillation.

Low circulating levels of total 25-hydroxyvitamin D (25(OH)D) have been associated with an increased risk of adverse effects after cardiac surgery. The metabolites, 25(OH)D2 and 25(OH)D3, provide a good index of vitamin D status. In this study, we examined the association between preoperative plasma levels of total 25(OH)D, 25(OH)D2 and 25(OH)D3 and the risk of postoperative atrial fibrillation (POAF) following open heart surgery. The levels of plasma 25(OH)D2 and 25(OH)D3 in 118 patients, who underwent coronary artery bypass grafting and/or valvular surgery, were measured immediately prior to surgery and on postoperative day 3 by liquid chromatography-tandem mass spectrometry. Patients who developed POAF had higher median plasma levels of 25(OH)D2 than those who remained in sinus rhythm (SR) (P = 0·003), but no significant difference was noted in levels of 25(OH)D3 or total 25(OH)D between the two groups (P > 0·05). By univariate analysis, patients with total 25(OH)D and 25(OH)D2 levels above the median had higher frequency of POAF (P < 0·05) and the incidence of POAF increased significantly with each higher quartile of preoperative plasma levels of 25(OH)D2 (P = 0·001), an association that was independent of confounding factors. In both the SR and POAF groups, the median plasma levels of 25(OH)D2, 25(OH)D3 and total 25(OH)D were lower (P < 0·05) on the third postoperative day compared with preoperatively. Our findings demonstrate that higher plasma levels of 25(OH)D2 are associated with increased risk of POAF, while this is not the case for 25(OH)D3 or total 25(OH)D. The reason for these discrepant results is not clear but warrants further study.

Inflammatory response following heart surgery and association with n-3 and n-6 long-chain polyunsaturated fatty acids in plasma and red blood cell membrane lipids.

BACKGROUND: Open heart surgery is associated with a systemic inflammatory response. The n-3 long-chain polyunsaturated fatty acids (LC-PUFA), eicosapentaenoic acid (EPA) and docosahexaenoic acid (DHA), and the n-6 LC-PUFA arachidonic acid (AA) may contribute to modulation of the inflammatory response. OBJECTIVE: We investigated whether the preoperative levels of EPA, DHA and AA in plasma phospholipids (PL) and red blood cell (RBC) membrane lipids in patients (n=168) undergoing open heart surgery were associated with changes in the plasma concentration of selected inflammatory mediators in the immediate postoperative period. RESULTS AND CONCLUSIONS: The postoperative concentration of TNF-ß was lower (P<0.05) and those of hs-CRP, IL-6, IL-8, IL-18 and IL-10 higher (P<0.05) than the respective preoperative concentrations. We observed that the preoperative levels of EPA and AA in plasma PL and RBC membrane lipids were associated with changes in the concentration of pro-inflammatory and anti-inflammatory mediators, suggesting a complex role in the postoperative inflammatory process.

Brain natriuretic peptide is a good predictor for outcome in cardiac surgery.

BACKGROUND AND AIM: The heart secretes brain natriuretic peptide (BNP) in response to myocardial stretch. The aim of this study was to determine whether adverse effects after cardiac surgery were associated with higher serum BNP levels pre-operatively. METHODS: One hundred and thirty-five patients undergoing various cardiac procedures were included in the study, and N-terminal pro-BNP (NT-pro-BNP) was measured pre-operatively. Post-operative complications were defined as follows: (i) a post-operative length of stay in the intensive care unit (ICU) exceeding 48 h; (ii) mortality at 28 days; (iii) the need for inotropic agents and/or intra-aortic balloon pump (IABP); and (iv) renal failure. Serum NT-pro-BNP values were compared for patients with and without complications. The serum NT-pro-BNP level was also correlated with the euroSCORE and ejection fraction (EF). RESULTS: Pre-operative serum NT-pro-BNP levels were significantly higher in patients with an ICU length of stay of more than 2 days or death prior to post-operative day 28 (3118 ng/l vs. 705 ng/l; P < 0.001). Pre-operative serum NT-pro-BNP levels were also significantly higher in patients needing inotropic agents (2628 ng/l vs. 548 ng/l; P < 0.001) or IABP insertion (3705 ng/l vs. 935 ng/l; P = 0.001) or developing renal failure (2857 ng/l vs. 945 ng/l; P < 0.001) post-operatively. The correlation between the serum NT-pro-BNP level and euroSCORE was good (r = 0.658; P < 0.001). The receiver operating characteristic (ROC) curves were used to assess the ability of serum NT-pro-BNP, euroSCORE and EF to predict outcome after cardiac surgery. This revealed an area under the ROC curve for the length of stay in the ICU or mortality at 28 days of 0.829 for serum NT-pro-BNP, 0.814 for euroSCORE and 0.328 for EF assessed by transesophageal echocardiography, indicating that the pre-operative serum NT-pro-BNP level is a good prognostic indicator for outcome after cardiac surgery. CONCLUSION: Serum NT-pro-BNP is a good predictor for complications after cardiac surgery, and is as good as euroSCORE and better than EF.

Is compartment pressure related to plasma colloid osmotic pressure, in patients during and after cardiac surgery?

Haemodilution is always considerable during cardiopulmonary bypass (CPB). If this extra fluid sits in the muscle compartments then a corresponding rise in the compartment pressure (CP) is to be expected. The aim of this study was to measure pressure changes in a body compartment with new equipment, the MTC (Microtransducer). Changes in plasma colloid osmotic pressure (COP) were also measured during and after CPB to find a connection, if any, between CP and plasma COP. Ten elective consecutive CPB patients were studied. A 3-French (3-F) catheter-size electronic MTC was inserted in an anterior tibial compartment before CPB. The CP was monitored for 48 h. Plasma COP was also measured before, during and after CPB. CP increased significantly during and after CPB in all patients (p=0.01). COP decreased significantly in all patients (p=0.005), but no correlation was found between changes in COP and CP values in this study. Most of the patients reached their highest CP just after weaning off bypass. The CP remained elevated for 48 h, even though it then tended to decrease again. None of the patients reached the starting value within 48 h. COP decreased rapidly after going on bypass, but returned towards its starting value approximately 6 h after bypass. It is concluded that CP increases considerably during and after CPB and stays increased for at least 2 days after CPB. COP decreases during CPB, but reaches normal values 6 h after the CPB. No correlation was found between changes in CP and COP The MTC is a safe and easy way to measure intracompartment pressure.

[A left main coronary artery arising from the pulmonary artery. Case report.].

Anomalous origin of the left coronary artery from the pulmonary artery is a rare congenitial heart disease. Most patients are diagnosed shortly after birth but occasionally the anomaly is diagnosed in teenagers or adults. Prognos is dismal without operation. We describe the first case diagnosed and treated in Iceland. The patient, an asymptomatic 14 year old boy, underwent both the socalled Takeuchi's tunnel plastic and a coronary bypass operation.

[Cardiac surgery of the neonate and children in Iceland 1990-1995.].

Over the past three decades Icelandic children with congenital heart defects have been operated abroad. In 1990 the first infant with congenital heart defect underwent surgical correction here in Iceland that otherwise would have been transported to a foreign country. This paper summarizes our experience with children with congenital defects who have been operated in Iceland. There were 26 patients who underwent 28 surgical procedures, the ages were from three days to 18 years, median 10 months. Fourteen patients had coarctation of the aorta, four patients with complex defects underwent shunt operations, four patients had atrial septal defects and four patients underwent other operations. The 30 day mortality rate was 3.8% (one patient with complex defect died after shunt placement). There was one late death from progressive heart failure in spite of successful initial surgical palliation. Cost analysis is presented in the paper. In conclusion the overall results are encouraging and acceptable for correcting congenital heart defects here in Iceland and is cost effective.

Prolonged total extracorporeal lung assistance without systemic heparinization.

A 16-year-old female developed severe ARDS in her single remaining lung following pneumonectomy for blunt trauma. Total extracorporeal lung assist (ECLA) for 40 days using a covalently heparin-coated circuit proved lifesaving. Systemic heparinization was not applied, as the heparinized surface by itself prevented clotting of the extracorporeal circuit. Systemic primary fibrinolysis developed but was not associated with major bleeding. A veno-right ventricular cannulation technique was used and maximum venous drainage for the extracorporeal circulation was achieved by elevating the bed 50 cm from the floor. This allowed extracorporeal blood flow (ECBF) approaching cardiac output (CO) and complete extracorporeal replacement of lung function. After 40 days, lung recovery allowed discontinuation of ECLA. Five days later the patient suffered serious lung collapse and was operated for a bronchopleural fistula. The patient was extubated 4 weeks after terminating ECLA and discharged in good condition 5 weeks later.

Radiologic diagnosis of liver metastases in colo-rectal carcinoma. Prospective evaluation of the accuracy of angiography, ultrasonography, computed tomography and computed tomographic angiography.

To evaluate the accuracy of radiologic methods in liver metastases from colo-rectal carcinoma, a prospective investigation of 71 patients was performed. These patients were examined by angiography, ultrasound (US), computed tomography (CT) and computed tomographic angiography (CTA). The primary aim of the investigation was to determine the accuracy of CTA. The results of these examinations were then compared with the results from inspection and palpation of the liver at laparotomy. An analysis of liver tumor distribution, as well as a lesion-by-lesion analysis, was performed. In 20 patients, tumor growth was found in the liver in 36 lobes/segments at laparotomy. Three patients called false positives (angiography 2, US, CT and CTA 3 patients) turned out to be true positives since the lesions were overlooked at operation. The changes in sensitivity obtained when these patients are considered are given in parentheses. Of the lobes/segments affected by tumor growth at surgery, angiography revealed 47 (48) per cent, US 69 (71) per cent, CT 80 (82) per cent and CTA 83 (84) per cent. At a lesion-by-lesion analysis, angiography showed 33 per cent, US 69 per cent, CT 61 per cent and CTA 76 per cent of the lesions. Because of a larger number of false positives recorded with CTA compared with CT the former examination is not suitable as a single method for evaluating resectability of liver metastases.