Intensive care unit management of the critically ill patient with fluid overload after open heart surgery

Fluid overload is common before, during and after cardiac surgery. The fluid associated with cardiopulmonary bypass (CPB) and cardioplegia is a particularly important source of such fluid overload. In addition, renal dysfunction, which is common in these patients, participates in the pathogenesis of a positive sodium and water balance. Such fluid overload is physiologically undesirable and participates in the pathogenesis of several clinically important complications. Fluid overload can be partly prevented with the use of diuretics. However, in many patients, diuretics do not achieve sufficient sodium and water diuresis. In these patients, the application of hemofiltration (HF) during CPB and also immediately after CPB is an effective and safe approach to the maintenance of fluid homeostasis. If acute renal failure occurs, early intervention with HF may even improve survival.

Geometric endo-ventricular patch repair of inferior left ventricular scars improves mitral regurgitation and clinical outcome

BACKGROUND

The surgical reconstruction of inferior left ventricular (LV) aneurysms and scars has been considered a difficult procedure and there has been little material published about this treatment option. In this study we report on our experience with reconstruction of the inferior wall and compare it to the outcome of anterior LV reconstructions.

METHODS

Seventeen patients (group 1) underwent geometric endo-ventricular patch repair (GER) of inferior LV aneurysms and dyskinetic scars between January 1998 and December 2000. In addition to poor LV function, 5 of these patients had severe mitral valve regurgitation (MR), 8 had moderate MR, and 4 had mild MR preoperatively. These patients also underwent coronary artery bypass graft surgery or valve surgery. The perioperative course, survival, and clinical status were evaluated in this group and was compared to those of 86 patients (group 2) undergoing anterior GER during the same period.

RESULTS

There was 1 early death in group 1 (5.8%) and 6 in group 2 (7%) (p = ns). At the conclusion of the operative procedure, all patients in group 1 were weaned off cardiopulmonary bypass with trivial to mild MR. There was 1 late death in group 1 (6.2%) and 2 in group 2 (2.8%) (p = ns). Eleven patients (73%) in group 1 were in New York Heart Association class 1 compared to 60 in group 2 (77%) (p = ns). Follow-up echocardiography showed that 80% of patients in group 1 had trivial MR.

CONCLUSIONS

The surgical reconstruction of inferior LV aneurysms and scars can be performed safely with the expectation of a reasonable early outcome similar to that achieved with anterior LV scars. When used in this setting GER improves MR, reducing the likelihood of heart failure decompensation.

Carotid artery anastomosis with albumin solder and near infrared lasers: a comparative study

BACKGROUND AND OBJECTIVE

Laser tissue-welding has been used for anastomosis of carotid arteries. During welding, thermal injury sustained by the vessel walls should be minimized to prevent thrombosis. Two different types of lasers were used and effects on tissue damage were studied in vitro and in vivo.

STUDY DESIGN/MATERIALS AND METHODS

End-to-end anastomosis of dog carotid arteries (n = 10) was performed by using a human albumin solder (HAS) in conjunction with Nd:YAG or diode lasers (lambda = 1.32 microm and 1.9 microm, respectively). The arteries were evaluated for patency and evidence of histologic injury after 21 days. Another group of arteries was laser soldered in vitro to measure the intimal and adventitial temperatures by using thermocouples.

RESULTS

The arteries repaired with the diode laser sustained significantly less thermal damage than those repaired with Nd:YAG laser, both in vitro and in vivo. In particular, the intimal temperature was significantly lower (P < 0.05) for the diode than for the Nd:YAG repairs (approximately 35 degrees C and approximately 50 degrees C, respectively). In the latter group, the patency rate was 75%, but thrombosis occurred in 75% of the specimens at 21 days. All diode anastomoses were patent and thrombosis developed in only 17% of the arteries.

CONCLUSION

Use of the diode laser and albumin solders may provide a means to successfully repair carotid arteries with minimal thermal damage.

Effects of adrenergic blockade on the daily rhythms of body temperature and oxygen consumption of the black-tailed tree rat (Thallomys nigricauda) maintained under different photoperiods

(1) Measurements of VO(2) and T(b) daily rhythms in T. nigricauda were conducted. (2) Three different effects on VO(2) and T(b) were assessed: alpha and beta blockade, time of the day, and photoperiod regime. (3) Results show that in T. nigricauda, the response of T(b) and VO(2) differs significantly under the different photoperiod regimes. Rats acclimated to 16L:8D increased T(b) values as a response to beta blockade, while alpha blockade caused a decrease in T(b). (4) VO(2) values of T. nigricauda acclimated to 11.5L:12.5D responded differently to alpha and beta blockade. It can be assumed that the thermoregulatory responses with beta blockade are through a decrease in heat production, rather than through heat dissipation. However, in the case of alpha blockade, it may be assumed that heat dissipation, through vasodilation, is the cause for the decrease in T(b) values.

[Early outcome with the Alfieri mitral valve repair]

OBJECTIVES

Mitral regurgitation in cases of prolapse of the anterior leaflet, posterior leaflet with calcified annulus, or prolapse of both leaflets is thought to be difficult to repair. The Alfieri repair has been developed to address these conditions.

METHODS

Seven patients (four men and three women, mean age 71 +/- 9 years) underwent the Alfieri repair for mitral regurgitation at Austin and Repatriation Medical Centre between January 1999 and December 1999. The mechanism of mitral regurgitation was prolapse of the posterior leaflet with calcified annulus in one patient, prolapse of the anterior leaflet in two, and prolapse of both leaflets in four. Mitral regurgitation before operation was severe in all patients. The Cosgrove ring was used in all patients. Four patients underwent combined operation, coronary artery bypass surgery in three and tricuspid annuloplasty in one.

RESULTS

There was no hospital death. Two patients had postoperative complications, transient ischemic attack in one patient and rapid atrial fibrillation in one. The mean hospital stay was 11.3 +/- 8.7 days. Mitral regurgitation after operation was mild in five patients and trivial in two. Mean pressure gradient of the transmitral valve was 4.0 +/- 1.4 mmHg.

CONCLUSIONS

The Alfieri mitral valve repair is a simple and satisfactory technique to repair mitral regurgitation in selected patients. Long-term follow-up is required to evaluate the durability of this technique.

Early and intensive continuous hemofiltration for severe renal failure after cardiac surgery

BACKGROUND

The aim of this study was to test whether early and intensive use of continuous venovenous hemofiltration (CVVH) achieved a better than predicted outcome in patients with severe acute renal failure undergoing cardiac operations, and whether a simple and yet accurate model could be developed to predict their outcome before starting CVVH.

METHODS

Medical record analysis with collection of demographic, clinical, and outcome information was used.

RESULTS

Sixty-five consecutive patients were treated with early and intensive CVVH (mean operation to CVVH time, 2.38 days; pump-controlled ultrafiltration rate, 2 L/h) after coronary artery bypass grafting (56.9%), single valve procedure (16.9%), or combined operations (26.2%). In 32.3% of patients, intraaortic balloon counterpulsation was required and 20% of patients were emergencies. Sustained hypotension despite inotropic and vasopressor support occurred in 40% of patients and prolonged mechanical ventilation in 58.5%. Using an outcome prediction score specific for acute renal failure, the predicted risk of death was 66%. Actual mortality was 40% (p = 0.003). Using multivariate logistic regression analysis and neural network analysis, patient outcome could be predicted with good levels of accuracy (receiver operating characteristic 0.89 and 0.9, respectively).

CONCLUSIONS

Early and aggressive CVVH is associated with better than predicted survival in severe acute renal failure after cardiac operations. Using readily available clinical data, the outcome of such patients can be predicted before the implementation of CVVH.

Daily torpor in elephant shrews (Macroscelidea: Elephantulus spp.) in response to food deprivation

Patterns of daily torpor were measured in response to photoperiod and food restriction at a constant temperature (18 degrees C) in two species of elephant shrew (Macroscelidea), Elephantulus rozeti (from Morocco) and Elephantulus myurus (from southern Africa). Body temperature was monitored continuously for ca. 3 months using temperature-sensitive telemeters. Under short photoperiods (8:16 L:D), both species entered spontaneous torpor on an ad libitum diet, but showed a higher frequency of induced torpor when food was restricted. Under long photoperiods (16:8 L:D), E. myurus could be induced to enter daily 'summer' torpor. A total of 378 torpor bouts were measured, none of which were longer in duration than 18 h. Under short photoperiods, arousal from torpor was associated with the onset of the photoperiod, whereas the time of entry was variable throughout the scotophase. However, E. myurus tended to phase shift torpor from the photophase to the scotophase under long photoperiods, despite displaying weak circadian amplitudes of body temperature indicative of a photophase rest phase. Both species lacked well-defined circadian amplitudes of body temperature, a pattern thought to be associated with polyphasic activity cycles characteristic of several Elephantuluis species. It was concluded that these and other patterns of torpor shown by Elephantulus show similarities with other small Afrotropical insectivores inhabiting semi-arid habitats or unpredictable environments.

Heterothermy in elephant shrews, Elephantulus spp. (Macroscelidea): daily torpor or hibernation?

The physiological parameters of heterothermy (e.g. minimum body temperature and oxygen consumption, percentage metabolic reduction, and bout length) were measured in two species of Elephantulus elephant shrews (Elephantulus myurus and Elephantulus rozeti; Macroscelidea) as a function of ambient temperature. Both species displayed deep torpor whereby the body temperatures of ca. 5 degrees C and oxygen consumption as low as 2% of basal metabolic rate were attained. Torpor bout length (n = 57 bouts) never exceeded 24 h. These data are characteristic of both hibernation (minimum body temperature and metabolism) and daily torpor (bout length), and argue that these two physiological responses may not necessarily have separate evolutionary origins.

Passive ventricular constraint amends the course of heart failure: a study in an ovine model of dilated cardiomyopathy

OBJECTIVE

Dilated cardiomyopathy (DCM) is associated with a progressive deterioration in cardiac function. We hypothesised that some of the deleterious effects of DCM could be reduced by mechanically limiting the degree of cardiac dilatation.

METHODS

A Transonic 20A cardiac output (CO) flow-probe was implanted in the pulmonary artery of 12 adult (52 +/- 4 kg) sheep. Early heart failure was created by rapid right ventricular (RV) pacing for 21 days at a rate which resulted in an initial 10% decrease in CO (to a maximum of 190 bpm). A custom polyester jacket (Acorn Cardiovascular, St Paul, MN) was then placed, via a partial lower sternotomy, on the ventricular epicardium of all sheep. Animals were randomised either to jacket retention (wrap) or removal (sham). Pacing was recommenced at a higher rate (that initiated a further 10% decrease in CO) for 28 days. Haemodynamic and echocardiographic parameters were determined at baseline, implant and at termination.

RESULTS

At termination, the left ventricular fractional shortening was significantly higher (p = 0.03), the degree of mitral valve regurgitation lower (scaled 0-3) (p = 0.03) and the left ventricular long axis area smaller (p = 0.02) in the wrap animals compared with sham.

CONCLUSIONS

In this model of heart failure, ventricular constraint with a polyester jacket diminished the deterioration in cardiac function associated with progressive dilated cardiomyopathy. These results suggest that maintainance of a more normal cardiac size and shape may be beneficial in patients with dilated cardiomyopathy.

Comparative histopathology of radial artery versus internal thoracic artery and risk factors for development of intimal hyperplasia and atherosclerosis

BACKGROUND

In this study, we examined the comparative histopathology, morphometry, and risk factors for the development of intimal hyperplasia and atherosclerosis in the radial artery (RA) and the internal thoracic artery (ITA).

METHODS AND RESULTS

Paired specimens of RAs and ITAs, obtained from 150 patients who underwent CABG, were evaluated with histopathology; 110 pairs of arteries were suitable for morphometric analysis. The severity of disease was evaluated on the basis of percentage of luminal narrowing, intimal thickness index, and intima-to-media ratio. Risk factors were determined with stepwise linear regression. Intimal hyperplasia was seen in 141 RAs (94%) and 103 ITAs (69%) (P<0.001). Atherosclerosis was seen in 5% of RAs and 0.7% of ITAs (P=0.04). Medial calcification was found only in RAs (20 of 150, 13.3%) (P<0.001). Morphometric analysis showed that compared with ITAs, RAs had a significantly higher intimal area, medial area, percentage of luminal narrowing, intimal thickness index, and intima-to-media ratio (all P<0.001) Factors found to be significant (P<0.05) predictors of the 3 severity indices of intimal hyperplasia, including atherosclerosis, in RAs were peripheral vascular disease, smoking, age, and diabetes. Risk factors for intimal hyperplasia in ITAs were age and smoking.

CONCLUSIONS

The RA is more likely to have atherosclerosis, intimal hyperplasia, and medial calcification than the ITA. Morphometric analysis indices showed marked differences between the RA and the ITA. Care should be taken when selecting the RA as a conduit in CABG, particularly in patients who are elderly, diabetic, smoke, or have peripheral vascular disease.

Effects of left atrial dilatation on the endocardial atrial defibrillation threshold: a study in an ovine model of pacing induced dilated cardiomyopathy

Left atrial (LA) dilation is a common finding in patients with chronic atrial fibrillation (AF). Progressive dilatation may alter the atrial defibrillation threshold (ADFT). In our study, epicardial electrodes were implanted on the LA free wall and right ventricular apex of eight adult sheep. Large surface area, coiled endocardial electrodes were positioned in the coronary sinus and right atrium (RA). LA dilatation was induced by rapid ventricular pacing (190 beats/min) for 6 weeks and echocardiographically assessed weekly along with the ADFT (under propofol anesthesia). LA effective refractory period (ERP) was measured every 2-3 days using a standard extra stimulus technique and 400 ms drive. The AF cycle length (AFCL) was assessed from LA electrograms. During the 6 weeks of pacing the mean LA area increased from 6.1 +/- 1.5 to 21.3 +/- 2.4 cm2. There were no significant changes in the mean ADFT (122 +/- 15 V), circuit impedance (46 +/- 5 omega), or LA AFCL (136 +/- 23 ms). There was a significant increase in the mean LA ERP (106 +/- 10 ms at day 0, and 120 +/- 13 ms at day 42 of pacing). In this study, using chronically implanted defibrillation leads, the minimal energy requirements for successful AF were not significantly altered by ongoing left atrial dilatation. This finding is a further endorsement of the efficiency of the coronary sinus/RA shock vector. Furthermore, the apparent stability of the AF present may be a further indication of a link between the type of AF and the ADFT.

A second-generation enzyme immunoassay for detection of antibodies to IFN-alpha

We have developed a solid-phase enzyme-linked immunoassay (EIA) for detecting antibodies to interferon-alpha2 (IFN-alpha2) in serum or plasma. In this assay, based on the sandwich principle, the capture antigen, IFN-alpha2, is covalently bound to the wells in 96-well plates. This novel procedure offers considerable advantages over the antigen binding by passive adsorption used in most previous EIA. Specific antibodies present in clinical specimens bind to the anchored antigen and are detected by adding peroxidase-labeled IFN-alpha2 and a peroxidase substrate mixture. The resultant color is a function of the concentration of antibody in the sample. The assay has proved to be convenient, precise, and reproducible and can detect as little as 1-5 ng/ml of specific antibody IgG.

Torpor patterns in the pouched mouse (Saccostomus campestris; Rodentia): a model animal for unpredictable environments

Patterns of spontaneous and induced daily torpor were measured in the Afrotropical pouched mouse (77-115 g), Saccostomus campestris, in response to photoperiod, temperature, and food deprivation, using temperature telemetry. Photoperiod had no influence on the incidence, depth, or duration of daily torpor in either males and females. Although the testis size index decreased in response to food deprivation and photoperiod by a maximum of 24%, full testis regression did not occur. Torpor bout duration was, on average, 5.3 h, independent of photoperiod and ambient temperature. Males did not enter torpor in response to food deprivation but did in response to low ambient temperature, though significantly less frequently than females. At normothermia, the body temperatures (daily minimum, mean, maximum) of males were significantly lower than those of females. Minimum body temperatures of both males and females during torpor did not fall below 20 degrees C at an ambient temperature of 15 degrees C. The patterns of torpor measured here differ from those observed in species from strongly seasonal environments. They suggest adaptation to an environment rendered unpredictable by the El Niño Southern Oscillations. As an aseasonal, opportunistic breeder capable of year-round adaptive hypothermia, the pouched mouse represents an excellent model animal for research on physiological and behavioral adaptations to unpredictable environments.

Susceptibility to atrial fibrillation: a study in an ovine model of pacing-induced early heart failure

INTRODUCTION

The development of susceptibility to atrial fibrillation (AF) is a common consequence of many forms of cardiovascular disease, especially heart failure. In this study we used a sheep model of pacing-induced stable early heart failure to describe, quantify, and relate the level of susceptibility to AF to changes in structural and electrophysiologic parameters.

METHODS AND RESULTS

Epicardial electrodes were implanted on the atria and right ventricles of nine sheep. The AF threshold, atrial vulnerability period, atrial effective refractory period (ERP), and interatrial conduction time were examined during control and over a 6-week period of ventricular pacing at 190 beats/min. Left atrial (LA) area and left ventricular (LV) fractional shortening were monitored using echocardiography. There were significant increases in LA susceptibility to AF (P < 0.0003), LA area (P < 0.0002), and LA ERP400 (P < 0.0002). Rate of increase in LA area was related positively to AF susceptibility (P = 0.02) and inversely to LA ERP400 (P = 0.002). LV fractional shortening decreased to approximately 50% of control value (P < 0.00001). No changes were observed in right atrial electrophysiology.

CONCLUSION

In this study, susceptibility (the ability of an extrastimulus to induce AF) was rigorously measured within a predetermined format. Significant relationships were found to exist between susceptibility, certain of the observed changes in atrial electrophysiology and structure.

Prediction of outcome after revascularization in patients with poor left ventricular function

BACKGROUND

In patients with poor left ventricular function, the determinants of outcome after revascularization are unknown.

METHODS

We studied prospectively 57 patients with stable coronary artery disease and poor left ventricular function (left ventricular ejection fraction, 0.28 +/- 0.04) who underwent coronary artery bypass grafting. Clinical variables were assessed as predictors of outcome in all patients, and preoperative stress thallium-201 scintigraphic data were analysed in 37 patients.

RESULTS

The operative mortality was 1.7%. At 12 months after operation, 46 of the 49 survivors were angina-free and 35 had fewer heart failure symptoms, but postoperative left ventricular ejection fraction (0.30 +/- 0.09) did not change significantly. Eighteen survivors had left ventricular ejection fraction improved by 0.05 or more (0.30 +/- 0.03 preoperatively, 0.40 +/- 0.05 postoperatively; p = 0.0001). The adjusted odds ratio of large reversible thallium-201 defects in predicting such outcome was 15 (95% confidence interval, 1.6 to 140), whereas other clinical variables had no predictive value. The transplantation-free 5-year survival was 73%.

CONCLUSIONS

In patients with poor left ventricular function, surgical revascularization can be performed safely, with good symptomatic relief and long-term survival. One-year survival and improvement in left ventricular function is better in patients with large reversible defects on preoperative stress thallium-201 scintigraphy.

Biochemical evaluation of endometrial biopsies by magnetic resonance spectroscopy--preliminary data

Biochemical study of tissue biopsy samples by magnetic resonance spectroscopy involves relatively small capital and running costs and could become a routine diagnostic or screening procedure if its utility were to be adequately demonstrated. We have demonstrated feasibility of evaluation of endometrial biopsy samples by magnetic resonance previous to histopathologic examination. Preliminary comparisons of magnetic resonance spectra with histopathologic evaluation indicates that in at least some instances, magnetic resonance may be the more sensitive indicator of disease.

Freeze-dried microarterial allografts

Rehydrated freeze-dried microarterial allografts were implanted to bridge arterial defects using New Zealand White rabbits as the experimental model. Segments of artery from the rabbit ear and thigh were harvested and preserved for a minimum of 2 weeks after freeze-drying. These allografts, approximately 1 mm in diameter and ranging from 1.5 to 2.5 cm in length, were rehydrated and then implanted in low-pressure and high-pressure arterial systems. Poor patency was noted in low-pressure systems in both allografts and autografts, tested in 12 rabbits. In the high-pressure arterial systems, allografts that were freeze-dried and reconstituted failed in a group of 10 rabbits with an 8-week patency rate of 30 percent. Gamma irradiation in an effort to reduce infection and antigenicity of grafts after freeze-drying was associated with a patency rate of 10 percent at 8 weeks in this system in another group of 10 rabbits. Postoperative cyclosporin A therapy was associated with a patency rate of 22.2 percent in the high-pressure arterial system in a 9-rabbit group. Control autografts in this system in a group of 10 rabbits showed a 100 percent patency at 8 weeks. Microarterial grafts depend on perfusion pressure of the vascular bed for long-term patency. Rehydrated freeze-dried microarterial allografts do not seem to function well in lengths of 1 to 2.5 cm when implanted in a high-pressure arterial system. Freeze-dried arterial allografts are probably not antigenic.

Coronary artery surgery in Asian patients

We studied retrospectively, 412 consecutive Asian patients undergoing coronary artery bypass grafting between January 1st, 1982 and June 30th, 1987. The mean age was 55 +/- 9 years at operation with a 70.5% male predominance. Patients of Chinese origin accounted for 60.9%, Indonesian for 26.4%, Indian 9.9% and Malaysian 2.6%. Chronic stable angina was the most consistent presenting symptom in 71% and 49% had at least one myocardial infarction in the past. Fifty percent were hypertensive and 26% diabetic. Left main stem coronary artery obstruction was evident in 21.6% and the coronary arteries diffusely diseased in 53%. An average of 3.8 +/- 0.4 grafts were performed per patient using reversed saphenous vein, and endarterectomies were necessitated in 27.1%. The small calibre of coronary arteries in Asian patients was reflected by 54% of grafted vessels having a luminal diameter of 1.5 mm. The early mortality rate and the peri-operative myocardial infarction rate was 1.2% in each instance. A mean follow-up of 30 months revealed a late mortality of 1.9% and 76% of patients were in NYHA Functional Class I. This study suggests that despite a high incidence of hypertension, diabetes and diffuse coronary artery disease Asian patients tolerate coronary artery bypass graft surgery well and obtain significant benefit from it.