Transesophageal two-dimensional echocardiographic analysis of right ventricular systolic performance indices during coronary artery bypass grafting

Sixteen patients (aged 59 +/- 14 years) undergoing coronary artery bypass surgery were evaluated to delineate the intraoperative course of transesophageal echocardiographic right ventricular (RV) systolic performance indices. Pre-induction data included thermodilution RV ejection fraction (RVEFTD), 0.43 +/- 0.13, RV end-diastolic volume index (EDVI), 110 +/- 33 mL/m2, cardiac index (CI), 3.4 +/- 1.0 L/min/m2, RV end-diastolic pressure (EDP), 7.1 +/- 4.2 mmHg, and mean pulmonary artery pressure (PAP), 21 +/- 6 mmHg. Eleven patients had significant right coronary artery (RCA) disease (> 70% occlusion). Five patients arrived with an ongoing nitroglycerin infusion (1 to 3 micrograms/kg/min), which was maintained intraoperatively. Echocardiographic measurements included longitudinal-axis (LA) and short-axis (SA) planimetered area excursion fractions (2DLA and 2DSA, respectively) and LA maximal major and minor axis shortening fractions (max majorLA and max minorLA, respectively). Hemodynamic measurements included RVEFTD, EDVI, CI, EDP, and PAP. Measurements were determined following induction/endotracheal intubation, following sternotomy/pericardiotomy, and after cardiopulmonary bypass (CPB) with the chest open. All patients were maintained on vasodilator therapy post-CPB (nitroglycerin, 1 to 3 micrograms/kg/min [N = 16] and nitroprusside, 0.5 to 4.5 microgram/kg/min [N = 4]) post-CPB. Two patients received inotropic support (epinephrine, 0.2 to 0.3 microgram/kg/min). CPB was associated with significant decreases in max major axisLA and 2DLA (P < 0.05) as compared to measurements determined prior to CPB. Maximum major axisLA values pre-CPB were 0.35 +/- 0.06 and 0.33 +/- 0.08 versus post-CPB values of 0.24 +/- 0.08.(ABSTRACT TRUNCATED AT 250 WORDS)

Thermodilution right ventricular ejection fraction measurement reproducibility--a study in patients undergoing coronary artery bypass graft surgery

OBJECTIVE

To assess the effects of heart rate, right ventricular systolic performance (ejection fraction), chamber dimensions, and flow rate (cardiac index) on the reproducibility of algorithm-derived triplicate thermodilution right ventricular ejection fraction measurements.

DESIGN

Prospective study; combined hemodynamic and echocardiographic clinical evaluation.

SETTING

Operating room in a university hospital.

PATIENTS

Twenty-one coronary artery bypass graft patients.

MEASUREMENTS AND MAIN RESULTS

The right atrial delivery site was positioned by analysis of transduced pressure waveform and echocardiographic imaging of tracer agitated saline cavitations. Measurement reproducibility was quantified by determining the variation (standard deviation) within 101 triplicate thermodilution measurement sets. There was no significant relationship between measurement reproducibility and estimates of right atrial area (21.6 +/- 6.9 cm2), diameter (5.1 +/- 0.8 cm) and supero-inferior length (5.1 +/- 0.9 cm) and right ventricular maximal minor axis diastolic diameter (4.21 +/- 1.05 cm). Reproducibility was also unrelated to right ventricular end-diastolic volume index (97.9 +/- 32.7 mL/m2) and cardiac index (2.9 +/- 0.9 L/min/m2). Measurement reproducibility was directly related to mean right ventricular ejection fraction (0.39 +/- 0.14) and inversely related to heart rate (80.8 +/- 18.6 beats/min) (p < .01 and < .001, respectively).

CONCLUSIONS

Thermodilution-derived right ventricular ejection fraction measurement reproducibility was unrelated to estimates of right atrial and ventricular dimensions and cardiac index. Measurement reproducibility was a direct function of right ventricular systolic performance and an indirect function of heart rate. Measurement should be interpreted with these constraints in mind.

The effect of calcium on pulmonary vascular resistance and right ventricular function

Calcium chloride is frequently administered to patients immediately after separation from cardiopulmonary bypass to improve the contractile state of the myocardium. Animal studies suggest that calcium chloride may produce increases in pulmonary vascular resistance, which can precipitate right ventricular failure. In an attempt to determine the effect of calcium chloride administration after cardiopulmonary bypass on right ventricular function, this study was designed to evaluate patients with normal and elevated pulmonary vascular resistance. Fifty patients scheduled for elective cardiac surgery were prospectively studied for changes in ionized calcium levels before and after bypass. The impact of calcium administration on right ventricular function was assessed by a pulmonary artery catheter modified for the measurement of right ventricular ejection fraction. In all patients the level of ionized calcium decreased during bypass from a mean of 4.91 to 4.29 mg.dl-1. However, the infusion of calcium chloride (10 mg.kg-1) after bypass resulted in increasing the ionized calcium levels to prebypass levels. Administration of calcium chloride after bypass to patients with normal right ventricular function resulted in a transient increase in both cardiac output and right ventricular ejection fraction without any change in pulmonary vascular resistance. Eight patients with both elevated pulmonary vascular resistance and depressed right ventricular function were evaluated to determine the effect of calcium chloride after bypass on pulmonary vascular resistance and right ventricular ejection fraction. Administration of calcium chloride (10 mg.dl-1) to these patients did not result in any significant increase in pulmonary vascular resistance or depression of right ventricular performance. More important, in these patients, right ventricular ejection fraction and cardiac output were significantly increased after calcium chloride administration. In summary, the results of this study fail to demonstrate any increase in pulmonary vascular resistance or deterioration of right ventricular function with the administration of calcium chloride (10 mg.kg-1) after bypass in patients with elevated pulmonary vascular resistance.

Childhood psychological trauma correlates with unsuccessful lumbar spine surgery

In a retrospective study of 86 patients who underwent lumbar spine surgery, patients who had three or more of a possible five serious childhood psychological traumas (risk factors) had an 85% likelihood of an unsuccessful surgical outcome. Conversely, in patients with a poor surgical outcome, the incidence of these traumas was 75%. In the group of 19 patients with no risk factors, there was only a 5% incidence of failure. This study shows that a highly significant correlation exists between unsuccessful lumbar spine surgery and a history of childhood traumas. Although recognition of predictors for unsuccessful outcome can be useful in avoiding surgery in patients whose indications for surgery are borderline, the greater challenge is to help the patient who, despite being at high psychological risk for negative outcome, has severe spinal pathology that will likely require surgery. In such cases, psychiatric treatment is critical. In the group of 19 patients with no risk factors, single-level laminectomies and discectomies were performed on 6 patients. The other 13 cases were complex, involving a combination of repeat surgeries (n = 4) fusions (n = 3), and/or multilevel laminectomies and discectomies (n = 11).

Complications occurring in the postanesthesia care unit: a survey

To identify and quantitate complications occurring in the postanesthesia care unit (PACU), a prospective study evaluated 18,473 consecutive patients entering a PACU at a university teaching hospital. Using a standardized collection form, the incidence of intraoperative and PACU complications was determined. The combined PACU and intraoperative complication rate was 26.7%. Data showed a PACU complication rate of 23.7%, with an overall intraoperative complication rate of 5.1%. Nausea and vomiting (9.8%), the need for upper airway support (6.9%), and hypotension requiring treatment (2.7%) were the most frequently encountered PACU complications. Patients in whom PACU complications developed were analyzed by ASA physical status. Of all patients experiencing nausea and vomiting (n = 1571), the highest percentage were ASA physical status II patients (n = 831). Likewise, in the group of 1450 patients who demonstrated a need for upper airway support, 792 were ASA physical status II. In patients experiencing a major cardiovascular complication, for example, variables associated with a greater risk of developing any PACU complications were ASA physical status (status II), duration of anesthesia (2-4 h), anesthetic technique, emergency procedures, and certain types of surgical procedures (orthopedic or abdominal). For patients admitted with a temperature of less than 35 degrees C the duration of the PACU stay was 152 +/- 46 min compared with 116 +/- 65 min for patients with a temperature greater than or equal to 36 degrees C (P less than 0.01). In conclusion, events occurring during the PACU period continue to be a source of patient morbidity.

Cardiopulmonary bypass induces leukocyte-platelet adhesion

Cardiopulmonary bypass (CPB) has been demonstrated to activate platelets, producing an increased number of circulating platelets that have undergone alpha-granule release and express granule membrane protein-140 (GMP-140) on their surface. In vitro, GMP-140 mediates activated platelet adhesion to neutrophils (PMN) and monocytes, causing the formation of leukocyte-platelet conjugates. Using a newly developed assay that measures the percentage of circulating leukocyte-platelet conjugates in whole blood, we studied 17 patients undergoing CPB and have determined that (1) monocyte-platelet conjugates increased significantly during CPB, from 18% +/- 1.5% to 44% +/- 4.5% (mean +/- SEM) by the end of CPB, while PMN-platelet conjugates increased only slightly and lymphocyte-platelet conjugates decreased; (2) the time course of the increase in monocyte- and PMN-platelet conjugates paralleled that of the increase in circulating activated platelets, as determined by the presence of surface GMP-140; and (3) monocyte activation, as assessed by increased surface expression of CD11b, showed a gradual increase similar to the increase in monocyte-platelet conjugates, while PMN surface CD11b peaked immediately after the start of CPB. We conclude that CPB, through increased platelet GMP-140 expression, causes formation of monocyte-platelet, and to a lesser extent, PMN-platelet conjugates. The activation of monocytes and PMN on CPB, as evidenced by CD11b expression, occurs with differing time courses.

Right ventricular function and failure: a review

The importance of right ventricular (RV) function in maintaining global cardiac performance is the focus of this discussion. The physiological determinants of normal right ventricular function will be discussed, with particular emphasis on the afterload and contractility characteristics of the right ventricle. Numerous clinical conditions have been shown to affect RV performance. These conditions include positive-pressure ventilation, ischemia, pulmonary hypertension, and cardiac surgery. Present methods for the perioperative evaluation of RV function include angiography, radionuclide techniques, thermodilution techniques, echocardiography, and magnetic resonance imaging. Traditional modalities for the treatment of RV dysfunction consist of pharmacological interventions (i.e., vasodilators and inotropes) and/or mechanical assist devices. Newer pharmacological strategies for the treatment of RV failure and associated pulmonary hypertension include the phosphodiesterase fraction III inhibitors and the prostaglandins, specifically PGE1. In summary, the accurate evaluation of perioperative RV performance combined with new treatment options will ensure maximal preservation of RV performance.

A Veterans Administration Cooperative Study of biphasic calcium phosphate ceramic in periodontal osseous defects

One hundred thirty-seven V.A. patients were randomized to one of three treatment groups to evaluate the efficacy of biphasic calcium phosphate (BCP) ceramic in the treatment of periodontal osseous defects. This material was tested against both autogenous bone implant and open flap curettage procedures. Baseline probing attachment level, Navy plaque index, and gingival index were recorded for all patients. These parameters were monitored for 3 years. At the end of this period, 101 patients had completed the study. Although the plaque and gingival indices steadily increased with time, there were no statistically significant differences among the treatment groups. Patients in the ceramic group had a gain in attachment level of 1.0 mm; those in the curettage group, 0.9 mm; and 0.4 mm for those in the bone implant group. Although the BCP patients had a greater gain, the difference was not statistically significant. In this veteran population, not only did BCP patients fail to outperform those in the control groups, all three treatment groups were similarly ineffective.

Immunochemical and molecular biological studies on human placental cigarette smoke-inducible cytochrome P-450-dependent monooxygenase activities

The induction of specific forms of cytochrome P-450 and P-450-associated xenobiotic-metabolizing monooxygenase activities by maternal cigarette smoking was characterized in human placenta employing polyclonal and monoclonal antibodies and recombinant DNA probes. The anti-BNF-B2 (prepared against rat liver P-450 induced by beta-naphthoflavone) inhibited about 60 per cent of aryl hydrocarbon hydroxylase (AHH) and 7-ethoxyresorufin O-deethylase activities (ERDE) in placental tissues from smoking mothers, whereas the anti-PB-B2 (to phenobarbital-induced rat liver P-450) was without significant inhibitory effect. Inhibition of 7-ethoxycoumarin O-deethylase (ECDE) by the anti-BNF-B2 was dependent on maternal smoking: the enzyme from non-smokers was not significantly inhibited, whereas the enzyme from smokers was variably inhibited by 15-60 per cent. The monoclonal antibodies towards the major 3-methylcholanthrene-inducible and phenobarbital-inducible rat liver P-450s (Mab 1-7-1 and 2-66-3, respectively) behaved similarly, except the inhibition was somewhat stronger if present. Antibody raised against rat liver NADPH-cytochrome P-450 oxido-reductase did not inhibit any activity studied. In immunoblotting experiments, the anti-reductase recognized the protein in human placental microsomes. However, neither anti-BNF-B2, anti-PB-B2 or Mab 1-7-1 or Mab 2-66-3 detected any proteins in human placental microsomes, regardless of smoking status. Northern blot hybridization analysis of placental RNA samples showed that only P-450IA1 mRNA existed in the placentas of smoking mothers with detectable ERDE activity. Despite the discrepancy between protein blotting and immunoinhibition data all other findings support the conclusion that maternal cigarette smoking induces the expression of the CYPIA1 gene (and not CYPIA2), resulting in an increased synthesis of P-450IA1 protein and increased AHH, ERDE and ECDE activities in human placenta.

Preservation of platelet function during trimethaphan infusion

The effect of trimethaphan (Arfonad) infusion on platelet function was prospectively evaluated in 38 (n = 38) patients (28 patients receiving trimethaphan, ten control patients) undergoing elective cardiac surgery. Any patient with a positive history for the ingestion of medication known to interfere with platelet function was excluded from the study. Following induction of anesthesia with fentanyl (and prior to cardiopulmonary bypass) 28 patients (n = 28) received trimethaphan as clinically indicated to maintain a mean blood pressure of 80 mmHg. The infusion rate and total dose of trimethaphan delivered was recorded for each patient. The evaluation of platelet function was performed via adenosine diphosphate (ADP) and epinephrine-induced platelet aggregation tests. The administration of trimethaphan failed to result in any detrimental effect on platelet function as assessed via these aggregation studies. Template bleeding times were also performed on all study patients. Bleeding time measurements performed in patients following trimethaphan administration were unchanged from baseline values. Platelet aggregation studies and bleeding time performed in control group following the administration of fentanyl (30 micrograms/kg) plus enflurane (inspired concentration 0.5-1%) did not reveal any deviation from baseline values. These results are in contrast to a previous study that demonstrated a negative effect upon platelet function following sodium nitroprusside administration (at clinically acceptable doses). These data demonstrate that trimethaphan provides control of arterial pressure with preservation of platelet function.

Clinical applications of amrinone

A bipyridine derivative, amrinone is a noncatecholamine, nonglycoside alternative in the treatment of perioperative myocardial dysfunction. A type-3 phosphodiesterase enzyme inhibitor, amrinone combines positive inotropic support with systemic and pulmonary vasodilation. In patients with heart failure undergoing cardiac or noncardiac surgery, the absence of tachycardia and dysrhythmias is of particular clinical benefit. In these patients, amrinone's ability to augment cardiac performance without increasing heart rate or myocardial oxygen consumption offers significant clinical advantages during the perioperative period.

The Escherichia coli dam gene is expressed as a distal gene of a new operon

DNA containing the Escherichia coli dam gene and sequences upstream from this gene were cloned from the Clarke-Carbon plasmids pLC29-47 and pLC13-42. Promoter activity was localized using pKO expression vectors and galactokinase assays to two regions, one 1650-2100 bp and the other beyond 2400 bp upstream of the dam gene. No promoter activity was detected immediately in front of this gene; plasmid pDam118, from which the nucleotide sequence of the dam gene was determined, is shown to contain the pBR322 promoter for the primer RNA from the pBR322 rep region present on a 76 bp Sau3A fragment inserted upstream of the dam gene in the correct orientation for dam expression. The nucleotide sequence upstream of dam has been determined. An open reading frame (ORF) is present between the nearest promoter region and the dam gene. Codon usage and base frequency analysis indicate that this is expressed as a protein of predicted size 46 kDa. A protein of size close to 46 kDa is expressed from this region, detected using minicell analysis. No function has been determined for this protein, and no significant homology exist between it and sequences in the PIR protein or GenBank DNA databases. This unidentified reading frame (URF) is termed urf-74.3, since it is an URF located at 74.3 min on the E. coli chromosome. Sequence comparisons between the regions upstream of urf-74.3 and the aroB gene show that the aroB gene is located immediately upstream of urf-74.3, and that the promoter activity nearest to dam is found within the aroB structural gene. This activity is relatively weak (about 15% of that of the E. coli gal operon promoter). The promoter activity detected beyond 2400 bp upstream of dam is likely to be that of the aroB gene, and is 3 to 4 times stronger than that found within the aroB gene. Three potential DnaA binding sites, each with homology of 8 of 9 bp, are present, two in the aroB promoter region and one just upstream of the dam gene. Expression through the site adjacent to the dam gene is enhanced 2- to 4-fold in dnaA mutants at 38 degrees C. Restriction site comparisons map these regions precisely on the Clarke-Carbon plasmids pLC13-42 and pLC29-47, and show that the E. coli ponA (mrcA) gene resides about 6 kb upstream of aroB.

Infusion of sodium nitroprusside induces platelet dysfunction in vitro

The effect of sodium nitroprusside (SNP) infusion on platelet function was prospectively evaluated in 29 patients undergoing cardiac surgical procedures requiring cardiopulmonary bypass. Any patient receiving preoperative medication known to interfere with platelet function was excluded from this study. Platelet function was evaluated by measurement of platelet aggregation with both adenosine diphosphate (ADP) and epinephrine-induced aggregation tests. Ten patients served as a control population receiving fentanyl anesthesia and no SNP. Nineteen patients received SNP, as clinically indicated, following the induction of anesthesia (and prior to cardiopulmonary bypass) to maintain a mean blood pressure of 80 mmHg. The infusion rate and total dose of SNP delivered was recorded for each patient. Infusion rates of SNP greater than or equal to 3 micrograms.kg.-1 min-1 resulted in a dose-related decrease in platelet aggregation (P less than 0.05). This reduction in platelet function was accompanied by a concomitant increase in bleeding time from 5.8 +/- 0.6 to 9.3 +/- 0.4 min in the patients receiving SNP (P less than 0.05). In addition, with the administration of a total dose of SNP greater than or equal to 16 mg, a significant reduction in platelet aggregation (P less than 0.05) was observed. Platelet aggregation studies and bleeding time performed in the control group (following the administration of fentanyl (30 micrograms/kg) did not reveal any deviation from baseline values. The results from this in vivo study support previous in vitro data demonstrating a detrimental effect upon platelet function following SNP infusion.

A study of iron complexation in a swine model

The treatment of iron poisoning consists of supportive care and efforts to remove or retard the absorption of iron from the gastrointestinal tract. A standard but rarely challenged treatment is to render the unabsorbed iron less soluble by complexing it with bicarbonate or phosphate solution. Another therapy is the use of oral deferoxamine. Bicarbonate and phosphate therapy are known to be associated with adverse outcomes if used inappropriately. Is their use justified? To closely simulate a potentially toxic iron overdose in a 24-month-old child, a swine model was used. Twenty fasted castrated male pigs weighing an average of 14.6 kg (+/- 3.0 kg) were orally dosed with 300 mg/kg FeSO4 (60 mg Fe/kg) and randomly placed into 1 of 4 treatment groups receiving 50 ml of distilled water (control), 5% sodium bicarbonate, 5% sodium dihydrogen phosphate, or deferoxamine (10 g). Sequential serum iron levels were obtained at 0, 1, 2, 4, and 6 hr. There were no significant differences in the absorption of iron, as reflected by serum iron concentrations, in the bicarbonate and phosphate groups when compared to the control group (p greater than 0.05). Deferoxamine therapy reduced iron serum concentrations, ie iron absorption, significantly (p less than 0.05) when compared to the control, bicarbonate and phosphate groups. This study provides evidence that efforts to form digestive tract complexation of iron with bicarbonate or phosphate are of no value.

Induction of cytochrome P-450IA1 gene expression in human breast tumour cell lines

The induction of cytochrome P-450IA1 by 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) was studied in eight human breast tumour cell lines. The cells were treated with various concentrations of TCDD for 24 h, and total RNA was isolated. The level of P-450IA1 RNA induced by 1 nM TCDD followed the order: MCF-7 greater than T47-D greater than ZR-75-1 greater than 3909 greater than 3522. AL-1, BT-20 and CAMA-1 did not respond to TCDD at the concentrations used. Northern blot analysis revealed 2 bands at 2.7 and 2.0 Kb, respectively, with the larger band being 6-fold more intense. The ratio was not changed by the TCDD treatment. TCDD induction did not change the benzo[a]pyrene-7,8-diol (BP-7,8-diol) metabolite profile compared with control cells, when cells were incubated with [3H]BP-7,8-diol for 24 h following the treatment with TCDD. These results demonstrate that different breast tumour cell lines vary greatly with respect to the basal expression levels of P-450IA1 RNA and its inducibility by TCDD. Furthermore, TCDD treatment does not change the relative distribution of BP-7,8-diol metabolites.