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Grocott HP. Rational choices for chest wall interfascial plane blocks in cardiac surgery: where should we focus our research efforts? Anaesthesia 2020; 76:423-424. [PMID: 33170510 DOI: 10.1111/anae.15307] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/08/2020] [Indexed: 12/27/2022]
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Duncan KC, Grocott HP. Three-dimensional echocardiography to confirm persistent intracardiac air bubbles after mitral valve surgery. Anaesth Rep 2020; 8:20-21. [PMID: 32206758 DOI: 10.1002/anr3.12032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 12/09/2019] [Indexed: 11/07/2022] Open
Affiliation(s)
- K C Duncan
- Department of Anaesthesia University of Manitoba Winnipeg MB Canada
| | - H P Grocott
- Department of Anaesthesia University of Manitoba Winnipeg MB Canada
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Ho LTS, Lenihan M, McVey MJ, Karkouti K, Wijeysundera DN, Rao V, Crowther M, Grocott HP, Pinto R, Scales DC, Achen B, Brar S, Morrison D, Wong D, Bussières JS, Waal T, Harle C, Médicis É, McAdams C, Syed S, Tran D, Waters T. The association between platelet dysfunction and adverse outcomes in cardiac surgical patients. Anaesthesia 2019; 74:1130-1137. [PMID: 30932171 DOI: 10.1111/anae.14631] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/18/2019] [Indexed: 11/30/2022]
Abstract
Haemostatic activation during cardiopulmonary bypass is associated with prothrombotic complications. Although it is not possible to detect and quantify haemostatic activation directly, platelet dysfunction, as measured with point-of-care-assays, may be a useful surrogate. In this study, we assessed the association between cardiopulmonary bypass-associated platelet dysfunction and adverse outcomes in 3010 cardiac surgical patients. Platelet dysfunction, as measured near the end of the rewarming phase of cardiopulmonary bypass, was calculated as the proportion of non-functional platelets after activation with collagen. Logistic regression and multivariable analyses were applied to assess the relationship between platelet dysfunction and a composite of in-hospital death; myocardial infarction; stroke; deep vein thrombosis or pulmonary embolism; and acute kidney injury (greater than a two-fold increase in creatinine). The outcome occurred in 251 (8%) of 3010 patients. The median (IQR [range]) percentage platelet dysfunction was less for those without the outcome as compared with those with the outcome; 14% (8-28% [1-99%]) vs. 19% (11-45% [2-98%]), p < 0.001. After risk adjustment, platelet dysfunction was independently associated with the composite outcome (p < 0.001), such that for each 1% increase in platelet dysfunction there was an approximately 1% increase in the composite outcome (OR 1.012; 95%CI 1.006-1.018). This exploratory study suggests that cardiopulmonary bypass-associated platelet dysfunction has prognostic value and may be a useful clinical measure of haemostatic activation in cardiac surgery.
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Affiliation(s)
- L T S Ho
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M Lenihan
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada
| | - M J McVey
- Department of Anesthesia and Pain Medicine, Hospital for Sick Children, University of Toronto, ON, Canada
| | - K Karkouti
- Department of Anesthesia and Pain Management, Toronto General Hospital, University Health Network, University of Toronto, ON, Canada.,Toronto General Research Institute and the Peter Munk Cardiac Centre, Toronto General Hospital, University Health Network, ON, Canada
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Grocott HP. Safety assessments in the avoidance of preoperative α-receptor blockade in phaeochromocytoma surgery: the pitfalls of a zero numerator. Br J Anaesth 2018; 119:545-546. [PMID: 28969333 DOI: 10.1093/bja/aex286] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
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Grocott HP. Addressing burnout in anaesthetic trainees. Anaesth Intensive Care 2018; 46:341. [PMID: 29716497] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/08/2023]
Affiliation(s)
- H P Grocott
- Dept of Anesthesia & Perioperative Medicine, University of Manitoba
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Grocott HP. The limitations of using baseline cerebral tissue oxygen saturation to stratify perioperative risk. Anaesth Intensive Care 2017; 45:525. [PMID: 28673226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/07/2023]
Affiliation(s)
- H P Grocott
- Dept of Anesthesia & Perioperative Medicine, University of Manitoba
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Grocott HP. Cerebral oxygenation and vascular resistance changes during cardiopulmonary bypass - where is the proof? Anaesthesia 2017; 72:663-664. [PMID: 28401546 DOI: 10.1111/anae.13867] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
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Bottle A, Mozid A, Grocott HP, Walters MR, Lees KR, Aylin P, Sanders RD. Preoperative risk factors in 10 418 patients with prior myocardial infarction and 5241 patients with prior unstable angina undergoing elective coronary artery bypass graft surgery. Br J Anaesth 2013; 111:417-23. [PMID: 23592695 DOI: 10.1093/bja/aet107] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND The EuroSCORE associates coronary artery bypass graft (CABG) surgery with higher perioperative risk in the first 3 months after a myocardial infarction (MI). The optimal scheduling of CABG surgery after unstable angina (UA) is unknown. We investigated the preoperative predictors of adverse outcomes in patients undergoing CABG with prior MI or UA and investigated the importance of time interval between the cardiac event and CABG. METHODS The Hospital Episode Statistics database (April 2006-March 2010) was analysed for elective admissions for CABG. Independent preoperative patient factors influencing length of stay, readmission rates, and mortality, were identified by logistic regression and presented as adjusted odds ratios (ORs). RESULTS A total of 10 418 patients with prior MI (mortality 1.8%) and 5241 patients with prior UA (mortality 2.2%) were included in the respective cohorts. Multiple risk factors were identified in each population including liver disease and renal failure. The time interval from cardiac event (MI or UA) to elective CABG surgery did not influence perioperative outcomes when analysed as a continuous measure or using the arbitrary 3-month threshold [MI, OR 1.1 (0.78-1.57) and UA, OR 0.65 (0.39-1.09)]. CONCLUSIONS Our hypothesis generating data suggest that the increased risk currently allocated in the EuroSCORE for an interval of 3 months between MI and CABG should be critically re-evaluated. Furthermore, prior MI should not be discounted as a risk factor if it is more than 3 months old.
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Affiliation(s)
- A Bottle
- School of Public Health, Imperial College London, London, UK
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Podgoreanu MV, White WD, Morris RW, Mathew JP, Stafford-Smith M, Welsby IJ, Grocott HP, Milano CA, Newman MF, Schwinn DA. Inflammatory gene polymorphisms and risk of postoperative myocardial infarction after cardiac surgery. Circulation 2006; 114:I275-81. [PMID: 16820586 PMCID: PMC1945056 DOI: 10.1161/circulationaha.105.001032] [Citation(s) in RCA: 78] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND The inflammatory response triggered by cardiac surgery with cardiopulmonary bypass (CPB) is a primary mechanism in the pathogenesis of postoperative myocardial infarction (PMI), a multifactorial disorder with significant inter-patient variability poorly predicted by clinical and procedural factors. We tested the hypothesis that candidate gene polymorphisms in inflammatory pathways contribute to risk of PMI after cardiac surgery. METHODS AND RESULTS We genotyped 48 polymorphisms from 23 candidate genes in a prospective cohort of 434 patients undergoing elective cardiac surgery with CPB. PMI was defined as creatine kinase-MB isoenzyme level > or = 10x upper limit of normal at 24 hours postoperatively. A 2-step analysis strategy was used: marker selection, followed by model building. To minimize false-positive associations, we adjusted for multiple testing by permutation analysis, Bonferroni correction, and controlling the false discovery rate; 52 patients (12%) experienced PMI. After adjusting for multiple comparisons and clinical risk factors, 3 polymorphisms were found to be independent predictors of PMI (adjusted P<0.05; false discovery rate <10%). These gene variants encode the proinflammatory cytokine interleukin 6 (IL6 -572G>C; odds ratio [OR], 2.47), and 2 adhesion molecules: intercellular adhesion molecule-1 (ICAM1 Lys469Glu; OR, 1.88), and E-selectin (SELE 98G>T; OR, 0.16). The inclusion of genotypic information from these polymorphisms improved prediction models for PMI based on traditional risk factors alone (C-statistic 0.764 versus 0.703). CONCLUSIONS Functional genetic variants in cytokine and leukocyte-endothelial interaction pathways are independently associated with severity of myonecrosis after cardiac surgery. This may aid in preoperative identification of high-risk cardiac surgical patients and development of novel cardioprotective strategies.
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Affiliation(s)
- M V Podgoreanu
- Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA.
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Grocott HP, Sato Y, Homi HM, Smith BE. The influence of xenon, nitrous oxide and nitrogen on gas bubble expansion during cardiopulmonary bypass. Eur J Anaesthesiol 2005; 22:353-8. [PMID: 15918383 DOI: 10.1017/s0265021505000608] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
Abstract
BACKGROUND AND OBJECTIVE Xenon may have favourable applications in the setting of cardiac surgery. Its advantages include a desirable haemodynamic profile as well as potential cardiac and neuroprotective properties. However, its low solubility may lead to enhanced diffusion into enclosed gas spaces. The purpose of this study was to compare the effects of xenon (Xe), nitrous oxide (N2O) and nitrogen (N2) on gas bubble size during cardiopulmonary bypass (CPB). METHODS Rats were randomized to receive 70% Xe, 26% oxygen (O2), 4% carbon dioxide (CO2) (xenon group); 70% N2O, 26% O2, 4% CO2 (nitrous oxide group) or 70% N2, 26% O2, 4% CO2 (nitrogen group) during 90 min of normothermic CPB. Small gas bubbles (300-500 microL; n = 12 per group) were injected into a bubble chamber on the venous side of the bypass circuit. After 10 min of equilibration, they were removed for volumetric analysis. RESULTS The increase in bubble size was 2 +/- 2% with nitrogen, 17 +/- 6% with xenon (P = 0.0192 vs. nitrogen) and 63 +/- 23% with nitrous oxide (P = 0.0001 vs. nitrogen). The nitrous oxide group had significantly increased bubble size compared to the xenon group (P = 0.0001). CONCLUSIONS During CPB, xenon anaesthesia produced a small increase in gas bubble size compared to nitrogen. Nitrous oxide resulted in significantly larger bubbles compared to both nitrogen and xenon.
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Affiliation(s)
- H P Grocott
- Duke University Medical Center, Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Durham, NC 27710, USA.
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Mackensen GB, Ti LK, Phillips-Bute BG, Mathew JP, Newman MF, Grocott HP. Cerebral embolization during cardiac surgery: impact of aortic atheroma burden. Br J Anaesth 2003; 91:656-61. [PMID: 14570786 DOI: 10.1093/bja/aeg234] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Aortic atheromatous disease is known to be associated with an increased risk of perioperative stroke in the setting of cardiac surgery. In this study, we sought to determine the relationship between cerebral microemboli and aortic atheroma burden in patients undergoing cardiac surgery. METHODS Transoesophageal echocardiographic images of the ascending, arch and descending aorta were evaluated in 128 patients to determine the aortic atheroma burden. Transcranial Doppler (TCD) of the right middle cerebral artery was performed in order to measure cerebral embolic load during surgery. Using multivariate linear regression, the numbers of emboli were compared with the atheroma burden. RESULTS After controlling for age, cardiopulmonary bypass time and the number of bypass grafts, cerebral emboli were significantly associated with atheroma in the ascending aorta (R2=0.11, P=0.02) and aortic arch (P=0.013). However, there was no association between emboli and descending aortic atheroma burden (R2=0.05, P=0.20). CONCLUSIONS We demonstrate a positive relationship between TCD-detected cerebral emboli and the atheromatous burden of the ascending aorta and aortic arch. Previously demonstrated associations between TCD-detectable cerebral emboli and adverse cerebral outcome may be related to the presence of significant aortic atheromatous disease.
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Affiliation(s)
- G B Mackensen
- Division of Cardiothoracic Anesthesiology and Critical Care Medicine, Department of Anesthesiology, Box 3094, Duke University Medical Center, Durham, NC 27710, USA
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Mackensen GB, Sato Y, Nellgård B, Pineda J, Newman MF, Warner DS, Grocott HP. Cardiopulmonary bypass induces neurologic and neurocognitive dysfunction in the rat. Anesthesiology 2001; 95:1485-91. [PMID: 11748410 DOI: 10.1097/00000542-200112000-00031] [Citation(s) in RCA: 54] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND Neurocognitive dysfunction is a common complication of cardiac surgery using cardiopulmonary bypass (CPB). Elucidating injury mechanisms and developing neuroprotective strategies have been hampered by the lack of a suitable long-term recovery model of CPB. The purpose of this study was to investigate neurologic and neurocognitive outcome after CPB in a recovery model of CPB in the rat. METHODS Fasted rats (n = 10) were subjected to 60 min of normothermic (37.5 degrees C) nonpulsatile CPB using a roller pump and a membrane oxygenator. Sham-operated controls (n = 10) were not subjected to CPB. Neurologic outcome was assessed on days 1, 3, and 12 after CPB using standardized functional testing. Neurocognitive outcome, defined as the time (or latency) to finding a submerged platform in a Morris water maze (an indicator of visual-spatial learning and memory), was evaluated daily from post-CPB days 3-12. Histologic injury in the hippocampus was also evaluated. RESULTS Neurologic outcome was worse in the CPB versus the sham-operated controls at all three measurement intervals (P < 0.001). The CPB group also had longer water maze latencies compared with the sham-operated controls (P = 0.004), indicating significant neurocognitive dysfunction after CPB. No difference in histologic injury between groups was observed. CONCLUSIONS CPB caused both neurologic and neurocognitive impairment in a rodent recovery model. This model could potentially facilitate the investigation of CPB-related injury mechanisms and possible neuroprotective interventions.
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Affiliation(s)
- G B Mackensen
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Newman MF, Grocott HP, Mathew JP, White WD, Landolfo K, Reves JG, Laskowitz DT, Mark DB, Blumenthal JA. Report of the substudy assessing the impact of neurocognitive function on quality of life 5 years after cardiac surgery. Stroke 2001; 32:2874-81. [PMID: 11739990 DOI: 10.1161/hs1201.099803] [Citation(s) in RCA: 244] [Impact Index Per Article: 10.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The importance of perioperative cognitive decline has long been debated. We recently demonstrated a significant correlation between perioperative cognitive decline and long-term cognitive dysfunction. Despite this association, some still question the importance of these changes in cognitive function to the quality of life of patients and their families. The purpose of our investigation was to determine the association between cognitive dysfunction and long-term quality of life after cardiac surgery. METHODS After institutional review board approval and patient informed consent, 261 patients undergoing cardiac surgery with cardiopulmonary bypass were enrolled and followed for 5 years. Cognitive function was measured with a battery of tests at baseline, discharge, and 6 weeks and 5 years postoperatively. Quality of life was assessed with well-validated, standardized assessments at the 5-year end point. RESULTS Our results demonstrate significant correlations between cognitive function and quality of life in patients after cardiac surgery. Lower 5-year overall cognitive function scores were associated with lower general health and a less productive working status. Multivariable logistic and linear regression controlling for age, sex, education, and diabetes confirmed this strong association in the majority of areas of quality of life. CONCLUSIONS Five years after cardiac surgery, there is a strong relationship between neurocognitive functioning and quality of life. This has important social and financial implications for preoperative evaluation and postoperative care of patients undergoing cardiac surgery.
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Affiliation(s)
- M F Newman
- Department of Anesthesiology, Division of Neurology, Duke University Medical Center, Durham, NC, USA.
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Grigore AM, Mathew J, Grocott HP, Reves JG, Blumenthal JA, White WD, Smith PK, Jones RH, Kirchner JL, Mark DB, Newman MF. Prospective randomized trial of normothermic versus hypothermic cardiopulmonary bypass on cognitive function after coronary artery bypass graft surgery. Anesthesiology 2001; 95:1110-9. [PMID: 11684979 DOI: 10.1097/00000542-200111000-00014] [Citation(s) in RCA: 110] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Despite significant advances in cardiopulmonary bypass (CPB) technology, surgical techniques, and anesthetic management, central nervous system complications occur in a large percentage of patients undergoing surgery requiring CPB. Many centers are switching to normothermic CPB because of shorter CPB and operating room times and improved myocardial protection. The authors hypothesized that, compared with normothermia, hypothermic CPB would result in superior neurologic and neurocognitive function after coronary artery bypass graft surgery. METHODS Three hundred patients undergoing elective coronary artery bypass graft surgery were prospectively enrolled and randomly assigned to either normothermic (35.5-36.5 degrees C) or hypothermic (28-30 degrees C) CPB. A battery of neurocognitive tests was performed preoperatively and at 6 weeks after surgery. Four distinct cognitive domains were identified and standardized using factor analysis and were then compared on a continuous scale. RESULTS Two hundred twenty-seven patients participated in 6-week follow-up testing. There were no differences in neurologic or neurocognitive outcomes between normothermic and hypothermic groups in multivariable models, adjusting for covariable effects of baseline cognitive function, age, and years of education, as well as interaction of these with temperature treatment. CONCLUSIONS Hypothermic CPB does not provide additional central nervous system protection in adult cardiac surgical patients who were maintained at either 30 or 35 degrees C during CPB.
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Affiliation(s)
- A M Grigore
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Bainbridge DT, Mackensen GB, Newman MF, Landolfo KP, Grocott HP. Off-pump coronary artery bypass surgery in a patient with C1 esterase inhibitor deficiency. Anesthesiology 2001; 95:795-6. [PMID: 11575557 DOI: 10.1097/00000542-200109000-00037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Affiliation(s)
- D T Bainbridge
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Grocott HP, Newman MF, El-Moalem H, Bainbridge D, Butler A, Laskowitz DT. Apolipoprotein E genotype differentially influences the proinflammatory and anti-inflammatory response to cardiopulmonary bypass. J Thorac Cardiovasc Surg 2001; 122:622-3. [PMID: 11547323 DOI: 10.1067/mtc.2001.115152] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA.
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Ti LK, Mathew JP, Mackensen GB, Grocott HP, White WD, Reves JG, Newman MF. Effect of apolipoprotein E genotype on cerebral autoregulation during cardiopulmonary bypass. Stroke 2001; 32:1514-9. [PMID: 11441194 DOI: 10.1161/01.str.32.7.1514] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE The presence of the apolipoprotein E epsilon4 (apoE4) allele has been associated with cognitive decline after cardiac surgery. We compared autoregulation of cerebral blood flow (CBF), cerebral metabolic rate for oxygen (CMRO(2)), and arterial-venous oxygen content difference [C(A-V)O(2)], during cardiopulmonary bypass (CPB) in patients with and without the apoE4 allele to help define the mechanism of association with cognitive decline. METHODS One hundred fifty-four patients underwent coronary artery bypass grafting with CPB, nonpulsatile flow, and alpha-stat management. CBF was measured by using (133)Xe washout methods. C(A-V)O(2), CMRO(2), and oxygen delivery were calculated. Pressure-flow autoregulation was tested by using 2 CBF measurements at stable hypothermia: the first at stable mean arterial pressure (MAP) and the second 15 minutes later, when MAP had increased or decreased >/=20%. Metabolism-flow autoregulation was tested by varying the temperature and measuring the coupling of CBF and CMRO(2). RESULTS In patients with (n=41) or without (n=113) the apoE4 allele, there were no differences in CBF, CMRO(2), C(A-V)O(2), pressure-flow and metabolism-flow autoregulation corrected for age, gender, non-insulin-dependent diabetes, hemoglobin, CPB time, and temperature. CONCLUSIONS We conclude that apoE genotype does not affect global CBF and oxygen delivery/extraction during CPB, which suggests that other mechanisms are responsible for the apoE isoform-related neurocognitive dysfunction seen in patients undergoing CPB.
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Affiliation(s)
- L K Ti
- Division of Cardiothoracic Anesthesiology and Critical Care, Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Newman MF, Laskowitz DT, White WD, Kirchner JL, Grocott HP, Stafford-Smith M, Sketch MH, Jones RH, Reves JG, Saunders AM. Apolipoprotein E polymorphisms and age at first coronary artery bypass graft. Anesth Analg 2001; 92:824-9. [PMID: 11273909 DOI: 10.1097/00000539-200104000-00006] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
UNLABELLED Apolipoprotein E (apoE) polymorphisms are heritable determinants of total and low-density lipoprotein cholesterol. The impact of apoE4 genotypes on the severity of atherosclerosis has been debated; however, recent studies have identified a correlation between apoE4 genotype and atherosclerosis. We assessed the impact of apoE4 genotype on age at first coronary artery bypass graft (CABG), hypothesizing that patients with the apoE4 allele are predisposed to coronary artery disease and present earlier for coronary revascularization. We assessed individual apoE genotypes and age in 560 patients undergoing primary CABG, by using analysis of variance (ANOVA) and controlling for gender. Because of the small number of patients in individual genotype groups, we compared patients with one or more copies of the apoE4 allele with those having no copies of the allele, again controlling for gender. A comparison of patients with one or more copies of the apoE4 allele with patients without the allele showed an earlier age at first CABG for those with the allele (P: = 0.032). Gene-dose analysis was also significant (P: = 0.012); patients with two copies of the allele presented at 54.2 +/- 6.9 yr. We report that the apoE4 allele is linked to age at first CABG. Identifying at-risk individuals may help prevent atherosclerosis. Further study is needed to define the mechanism of this association, and to define which coronary intervention is appropriate, based on long-term outcome. IMPLICATIONS A correlation exists between apolipoprotein E (apoE) genotypes and the severity of atherosclerosis. We hypothesized that patients with the apoE4 allele are predisposed to coronary artery disease and present earlier for coronary artery bypass graft (CABG). Individuals with the apoE4 allele presented earlier for CABG, and the apoE4 allele is linked to age at first CABG.
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Affiliation(s)
- M F Newman
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Grocott HP, Arrowsmith JE. Serum S100 protein as a marker of cerebral damage during cardiac surgery. Br J Anaesth 2001; 86:289-90. [PMID: 11573680] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/21/2023] Open
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Panten RR, Harrison JK, Warner J, Grocott HP. Aortic dissection after angioplasty and stenting of an aortic coarctation: detection by intravascular ultrasonography but not transesophageal echocardiography. J Am Soc Echocardiogr 2001; 14:73-6. [PMID: 11174440 DOI: 10.1067/mje.2001.110784] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
In this case report, an iatrogenic dissection of the descending aorta occurred during balloon angioplasty and stenting of a recurrent coarctation. The dissection was not seen by transesophageal echocardiography, but intravascular ultrasonography, performed routinely during such procedures at this institution, identified the dissection and guided further therapeutic stent placement.
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Affiliation(s)
- R R Panten
- Department of Anesthesiology, The Heart Center, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
Cerebral injury is a well-known complication of cardiac surgery. Investigations of both injury mechanisms and neuroprotective strategies have partially been limited by the lack of an adequate preclinical model of small animal cardiopulmonary bypass (CPB). We sought to determine if neurological injury could be demonstrated in a recovery model of complete CPB in the rat. Rats (n = 5) underwent 45 min of normothermic CPB followed by 24 h of recovery. Compared to sham-operated rats (n = 5), the CPB group showed a worse neurological outcome score (median, 25-75th percentile) compared to controls (5, 4-7 vs 9, 8-9, p = 0.016). This rat model of CPB may allow for the study of CPB-associated neurological injury.
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Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Affiliation(s)
- A M Grigore
- Department of Anesthesiology, Duke Heart Center, Durham, NC, USA
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Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center, and the Durham Veterans Affairs Medical Center, NC 27710, USA
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Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center, and Durham Veterans Affairs Medical Center, Durham, North Carolina 27710, USA
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Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Kilts JD, Gerhardt MA, Richardson MD, Sreeram G, Mackensen GB, Grocott HP, White WD, Davis RD, Newman MF, Reves JG, Schwinn DA, Kwatra MM. Beta(2)-adrenergic and several other G protein-coupled receptors in human atrial membranes activate both G(s) and G(i). Circ Res 2000; 87:705-9. [PMID: 11029407 DOI: 10.1161/01.res.87.8.705] [Citation(s) in RCA: 106] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
Cardiac G protein-coupled receptors that couple to Galpha(s) and stimulate cAMP formation (eg, beta-adrenergic, histamine, serotonin, and glucagon receptors) play a key role in cardiac inotropy. Recent studies in rodent cardiac myocytes and transfected cells have revealed that one of these receptors, the beta(2)-adrenergic receptor (AR), also couples to the inhibitory G protein Galpha(i) (activation of which inhibits cAMP formation). If beta(2)ARs could be shown to couple to Galpha(i) in the human heart, it would have important ramifications, because levels of Galpha(i) increase with age and in failing human heart. Therefore, we investigated whether beta(2)ARs in the human heart activate Galpha(i). By photoaffinity labeling human atrial membranes with [(32)P]azidoanilido-GTP, followed by immunoprecipitation with antibodies specific for Galpha(i), we found that Galpha(i) is activated by stimulation of beta(2)ARs but not of beta(1)ARs. In addition, we found that other Galpha(s)-coupled receptors also couple to Galpha(i), including histamine, serotonin, and glucagon. When coupling of these receptors to Galpha(i) is disrupted by pertussis toxin, their ability to stimulate adenylyl cyclase is enhanced. These data provide the first evidence that beta(2)AR and many other Galpha(s)-coupled receptors in human atrium also couple to Galpha(i) and that abolishing the coupling of these receptors to Galpha(i) increases the receptor-mediated adenylyl cyclase activity.
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MESH Headings
- Adenylate Cyclase Toxin
- Adenylyl Cyclases/metabolism
- Adrenergic beta-1 Receptor Antagonists
- Adrenergic beta-2 Receptor Antagonists
- Adrenergic beta-Agonists/pharmacology
- Aged
- Atrial Appendage/chemistry
- Atrial Appendage/metabolism
- Cell Membrane/chemistry
- Dobutamine/pharmacology
- Ethanolamines/pharmacology
- GTP-Binding Protein alpha Subunits, Gi-Go/metabolism
- GTP-Binding Protein alpha Subunits, Gs/metabolism
- Humans
- Isoproterenol/pharmacology
- Middle Aged
- Myocardial Contraction/physiology
- Pertussis Toxin
- Photoaffinity Labels
- Precipitin Tests
- Receptors, Adrenergic, beta-1/analysis
- Receptors, Adrenergic, beta-1/metabolism
- Receptors, Adrenergic, beta-2/analysis
- Receptors, Adrenergic, beta-2/metabolism
- Receptors, Cell Surface/analysis
- Receptors, Cell Surface/metabolism
- Receptors, Glucagon/metabolism
- Receptors, Histamine/metabolism
- Receptors, Serotonin/metabolism
- Signal Transduction/drug effects
- Signal Transduction/physiology
- Virulence Factors, Bordetella/pharmacology
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Affiliation(s)
- J D Kilts
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Sharma AD, Bittner HB, Sreeram G, Grocott HP, Slaughter TF. Interesting right ventricular transesophageal echocardiography findings. J Cardiothorac Vasc Anesth 2000; 14:617-9. [PMID: 11052452 DOI: 10.1053/jcan.2000.9495] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center, and the Durham Veteran's Affairs Medical Center, NC 27710, USA
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Sharma AD, Grocott HP. Platelet transfusion reactions: febrile nonhemolytic reaction or bacterial contamination? Diagnosis, detection, and current preventive modalities. J Cardiothorac Vasc Anesth 2000; 14:460-6. [PMID: 10972618 DOI: 10.1053/jcan.2000.7962] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center and the Durham Veterans Affairs Medical Center, NC 27710, USA
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Chew ST, Newman MF, White WD, Conlon PJ, Saunders AM, Strittmatter WJ, Landolfo K, Grocott HP, Stafford-Smith M. Preliminary report on the association of apolipoprotein E polymorphisms, with postoperative peak serum creatinine concentrations in cardiac surgical patients. Anesthesiology 2000; 93:325-31. [PMID: 10910477 DOI: 10.1097/00000542-200008000-00008] [Citation(s) in RCA: 58] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
BACKGROUND Renal dysfunction after cardiac surgery occurs in up to 8% of patients and is associated with major increases in morbidity, mortality, and cost. Genetic polymorphisms have been implicated as a factor in the progression of chronic renal disease, but a genetic basis for the development of acute renal impairment has not been investigated. The authors therefore tested the hypothesis that apolipoprotein E alleles are associated with different postoperative changes in serum creatinine after cardiac surgery. METHODS The authors performed a prospective observational study with use of data from 564 coronary bypass surgical patients who were enrolled in an ongoing investigation of apolipoprotein E genotypes and organ dysfunction at a university hospital between 1989-1999. Renal function was assessed among apolipoprotein E genotype groups by comparisons of preoperative (CrPre), peak in-hospital postoperative (CrMax) and perioperative change (DCr) in serum creatinine values. RESULTS The epsilon4 allele grouping (E2 = 2/2,2/3,2/4; E3 = 3/3; E4 = 3/4,4/4) was associated with a smaller increase in postoperative serum creatinine (perioperative change: E4, +0.17; E3, +0.26; E4, +0.27 mg/dl) and a lower peak postoperative creatinine than the epsilon2 and epsilon3 in univariate and multivariate analysis (peak in-hospital postoperative serum creatinine multivariate P = 0.015 vs. epsilon3, P = 0.038 vs. epsilon2). There was no difference in baseline creatinine among allele groups. CONCLUSIONS Inheritance of the apolipoprotein epsilon4 allele is associated with reduced postoperative increase in serum creatinine after cardiac surgery, compared with the epsilon3 or epsilon2 allele. This is the first report of a possible genetic basis for acute renal impairment. These data may contribute to renal risk stratification for cardiac surgery and raise questions regarding apolipoprotein E and the pathophysiology of acute renal injury.
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Affiliation(s)
- S T Chew
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Sharma AD, Sreeram G, Erb T, Grocott HP, Slaughter TF. Leukocyte-reduced blood transfusions: perioperative indications, adverse effects, and cost analysis. Anesth Analg 2000; 90:1315-23. [PMID: 10825313 DOI: 10.1097/00000539-200006000-00010] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- A D Sharma
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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van Wermeskerken GK, Lardenoye JW, Hill SE, Grocott HP, Phillips-Bute B, Smith PK, Reves JG, Newman MF. Intraoperative physiologic variables and outcome in cardiac surgery: Part II. Neurologic outcome. Ann Thorac Surg 2000; 69:1077-83. [PMID: 10800797 DOI: 10.1016/s0003-4975(99)01443-5] [Citation(s) in RCA: 64] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
BACKGROUND The impact of alterable physiologic variables on neurologic outcome after coronary artery bypass grafting procedures is unknown. The purpose of this study was to determine whether minimum intraoperative hematocrit, maximum glucose concentration, or mean arterial pressure during cardiopulmonary bypass influences risk-adjusted neurologic outcome after coronary artery bypass grafting. METHODS Outcome data from 2,862 patients undergoing coronary artery bypass grafting were merged with intraoperative physiologic data. A preoperative stroke risk index was calculated for each patient. Variables found significant by univariate logistic regression were tested in a multivariable model to determine association with outcome. RESULTS The incidence of stroke or coma in the study population was 1.3%. After controlling for stroke risk and bypass time, only an index of low mean arterial pressure during bypass retained a significant inverse association with outcome (p = 0.0304). CONCLUSIONS This study found no evidence that glucose concentration or minimum hematocrit are associated with major adverse neurologic outcome. The association between lower pressure during bypass and decreased incidence of stroke or coma persisted in all risk groups. This points to mechanisms other than hypoperfusion as the primary cause of neurologic injury associated with cardiac surgery.
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Affiliation(s)
- G K van Wermeskerken
- Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA
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Mackensen GB, Grocott HP, Smith MS. An interesting finding during transesophageal echocardiographic assessment of the mitral valve. J Cardiothorac Vasc Anesth 2000; 14:227-8. [PMID: 10794350 DOI: 10.1016/s1053-0770(00)90026-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Affiliation(s)
- G B Mackensen
- Department of Anesthesiology, The Heart Center, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
The neurological complications of cardiac surgery are associated with significantly increased mortality, morbidity and resource utilization. The use of new surgical techniques, introduction of wider indications for surgery and increased public expectation has led to an increase in the average age of cardiac surgical patients and an increased incidence of repeat procedures. With these changes has come an increased risk of neurological complications. The likelihood of perioperative stroke varies between 1% and 5% in most published series and is dependent on a multitude of risk factors. Of these, patient age, aortic atheroma, symptomatic cerebrovascular disease, diabetes mellitus and the type of surgery appear to be most important. Cognitive deterioration after cardiac surgery is far more common, affecting as many as 80% of patients a few days after surgery and persisting in one-third. Despite an increase in the age of the cardiac surgical population, the reported incidence of cognitive dysfunction after cardiac surgery seems to have fallen in recent years. Whether this is a real phenomenon or the result of changes in the use of psychometric testing and the definition of cognitive decline remains unclear. Recognition that certain equipment, surgical practices and patient factors contribute to neurological morbidity has prompted 'neuroprotective' interventions. Some of these (e.g. arterial line filtration and alpha-stat management) have been shown to improve outcome. Despite these measures, a small number of patients will inevitably sustain cerebral injury during otherwise successful cardiac surgery. Although pharmacological neuroprotection may, in the future, offer some of these patients an improved outcome, it is unlikely that any single agent will prevent neurological injury. In the meantime, the CNS complications of cardiac surgery remain a fertile area of research.
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Affiliation(s)
- J E Arrowsmith
- Department of Anaesthesia, Papworth Hospital, Papworth Everard, Cambridge, UK
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Affiliation(s)
- A M Grigore
- Department of Anesthesiology, Duke Heart Center, Duke University Medical Center, Durham, NC 27710, USA
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Mackensen GB, Nellgård B, Sarraf-Yazdi S, Dexter F, Steffen RP, Grocott HP, Warner DS. Post-ischemic RSR13 amplifies the effect of dizocilpine on outcome from transient focal cerebral ischemia in the rat. Brain Res 2000; 853:15-21. [PMID: 10627303 DOI: 10.1016/s0006-8993(99)02212-x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
In a recent study of focal cerebral ischemia in rats, pre-ischemic administration of the synthetic allosteric hemoglobin modifier RSR13 (2-[4-[[3,5-dimethylanilino) carbonyl] methyl] phenoxy]-2-methylproprionic acid) reduced cerebral infarct size when combined with the NMDA receptor antagonist dizocilpine (MK-801) but not when given alone. We hypothesized that post-ischemic RSR13 administration would enhance neuroprotection afforded by NMDA receptor antagonism in a rat model of transient middle cerebral artery occlusion (MCAO). Fasted normothermic Wistar rats underwent 75 min of temporary MCAO. At onset of reperfusion, rats randomly received: (1) 0.9% NaCl (vehicle) i.v. alone (n=16); (2) 0.9% NaCl+dizocilpine (0.25 mg/kg) i.v. (n=16); or (3) RSR13 (150 mg/kg)+dizocilpine (0.25 mg/kg) i.v. (n=17). Seven days later, neurologic deficit and cerebral infarct size were determined. Dizocilpine alone compared to vehicle reduced mean+/-S.D. subcortical (52+/-24 mm(3) vs. 122+/-64 mm(3), P=0.003) and cortical (35+/-35 mm(3) vs. 125+/-72 mm(3), P=0.00074) infarct volumes. When compared to dizocilpine alone, the combination of RSR13+dizocilpine further reduced subcortical (37+/-14 mm(3) vs. 52+/-24 mm(3), P=0. 034) and cortical (8+/-19 mm(3) vs. 35+/-35 mm(3), P=0.018) infarct size. RSR13+dizocilpine improved neurologic scores vs. either dizocilpine alone (P=0.0014) or vehicle (P=10(-7)). The combination of NMDA receptor antagonism and a RSR13 mediated rightward shift of the oxy-hemoglobin dissociation curve improved outcome from MCAO. Because this occurred after reperfusion, our results suggest that the post-ischemic brain continues to suffer from hypoperfusion defects, which are amenable to therapy by enhanced O(2) delivery. The results also support the concept that neuroprotective strategies, which combine drugs with different mechanisms of action, may yield cumulative benefits.
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Affiliation(s)
- G B Mackensen
- Department of Anesthesiology, Klinikum rechts der Isar, Technische Universität München, Munich, Germany.
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Affiliation(s)
- J E Arrowsmith
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Garduno C, Chew S, Forbess J, Smith PK, Grocott HP. Persistent left superior vena cava and partial anomalous pulmonary venous connection: incidental diagnosis by transesophageal echocardiography during coronary artery bypass surgery. J Am Soc Echocardiogr 1999; 12:682-5. [PMID: 10441226 DOI: 10.1053/je.1999.v12.a98795] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
Transesophageal echocardiography plays an important role in the intraoperative treatment of the heart surgery patient. Its utility in the description of both known and unexpected cardiac pathology is well established. We describe a patient with a previously undiagnosed partial anomalous pulmonary venous connection along with a persistent left superior vena cava scheduled for routine coronary artery bypass graft surgery (CABG).
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Affiliation(s)
- C Garduno
- Department of Anesthesiology, Duke Heart Center, Durham, NC, USA
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Garduno C, Chew S, Grocott HP. Microbubble intravenous contrast during transesophageal echocardiography: agitated 0.9% saline versus agitated 0.9% saline with benzyl alcohol. J Cardiothorac Vasc Anesth 1999; 13:513. [PMID: 10468277 DOI: 10.1016/s1053-0770(99)90251-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Sarraf-Yazdi S, Sheng H, Grocott HP, Bart RD, Pearlstein RD, Steffen RP, Warner DS. Effects of RSR13, a synthetic allosteric modifier of hemoglobin, alone and in combination with dizocilpine, on outcome from transient focal cerebral ischemia in the rat. Brain Res 1999; 826:172-80. [PMID: 10224294 DOI: 10.1016/s0006-8993(99)01233-0] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
This study examined the effect of a pharmacologically induced rightward shift in the partial pressure of oxygen at which 50% of hemoglobin is saturated (P50) on outcome from transient focal cerebral ischemia in the rat. Halothane anesthetized rats (n=20 per group) were given saline or a single 15-min infusion of 150 mg/kg RSR13 (2-[4-[[3,5-dimethylanilino) carbonyl]methyl]phenoxy]-2-methylproprionic acid) intravenously before or 30 min after onset of 75 min of middle cerebral artery filament occlusion (MCAO). Seven days later, severity of hemiparesis and cerebral infarct size were examined. RSR13 alone did not significantly improve outcome. Conscious normothermic rats (n=12 per group) were also given RSR13 (150 mg/kg) or 0.9% NaCl intravenously and subjected to 75 min of MCAO with 7 days of recovery. Again, RSR13 alone did not significantly reduce infarct size or improve neurologic score. A dose-response curve for dizocilpine (MK-801) was then constructed in conscious normothermic rats subjected to 75 min of MCAO. Dizocilpine (0.5 mg/kg i.v.) caused a 90% reduction in mean infarct size while 0.25 mg/kg reduced infarct size by 48%. Other rats were then subjected to 75 min of MCAO after being given dizocilpine (0.25 mg/kg i.v.; n=18) or RSR13 (150 mg/kg i.v. )+dizocilpine (0.25 mg/kg i.v.; n=15). RSR13+dizocilpine resulted in smaller cortical infarct volume (8+/-14 mm3 vs. 34+/-37 mm3, p<0.02) and total cerebral infarct volume (46+/-28 mm3 vs. 81+/-60 mm3, p<0. 05) compared to dizocilpine alone, respectively. We conclude that a pre-ischemic peak increase in P50 of approximately 25 mmHg alone is insufficient to reduce focal ischemic injury, but may be advantageous when used in conjunction with other neuroprotective agents.
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Affiliation(s)
- S Sarraf-Yazdi
- Duke University School of Medicine, Duke University Medical Center, Durham, NC 27710, USA
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Abstract
UNLABELLED The administration of aprotinin has been associated with a reduction in cardiac surgery-related stroke. Intrinsic neuroprotective properties of this drug have not been evaluated in laboratory outcome models of cerebral ischemia. The purpose of this study was to determine whether aprotinin exhibits neuroprotective effects against either global or focal cerebral ischemia in the rat. Fasted rats were administered aprotinin (30,000 or 60,000 KIU/kg) or vehicle (0.9% NaCl) IV before global ischemia (10 min bilateral carotid occlusion with mean arterial pressure 30 mm Hg) or focal ischemia (75 min of transient middle cerebral artery occlusion [MCAO]). Five days after global ischemia, the percentage of dead hippocampal CA1 neurons (mean +/- SD) was similar among the groups (small-dose aprotinin: 49+/-31, n = 15; large-dose aprotinin: 55+/-31, n = 13; vehicle: 47+/-31, n = 16; P = 0.74). After 7 days' recovery from MCAO, no difference among the groups was observed for either neurologic score (P = 0.99) or cerebral infarct volume (small-dose aprotinin: 136+/-80 mm3, n = 23; large-dose aprotinin: 132+/-101 mm3, n = 11; vehicle: 121+/-81 mm3, n = 21; P = 0.87). IMPLICATIONS Aprotinin offers no neuroprotection against either global or focal cerebral ischemia in the rat when administered as a single preischemic bolus.
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Affiliation(s)
- H P Grocott
- Neuroanesthesia Research Laboratory, Department of Anesthesiology, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Weiss L, Grocott HP, Rosania RA, Friedman A, Newman MF, Warner DS. Case 4--1998. Cardiopulmonary bypass and hypothermic circulatory arrest for basilar artery aneurysm clipping. J Cardiothorac Vasc Anesth 1998; 12:473-9. [PMID: 9713741 DOI: 10.1016/s1053-0770(98)90206-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Affiliation(s)
- L Weiss
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27710, USA
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Miura Y, Grocott HP, Bart RD, Pearlstein RD, Dexter F, Warner DS. Differential effects of anesthetic agents on outcome from near-complete but not incomplete global ischemia in the rat. Anesthesiology 1998; 89:391-400. [PMID: 9710398 DOI: 10.1097/00000542-199808000-00016] [Citation(s) in RCA: 92] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND It has been postulated that anesthetic agents that reduce cerebral metabolic rate will protect the brain against ischemia when electroencephalographic (EEG) activity is persistent, but will provide no protection when ischemia is severe enough to cause EEG isoelectricity. No outcome studies have addressed this issue. The authors studied anesthetic agents to determine if they provide differential effects on outcome from global cerebral ischemic insults that cause either an attenuated or isoelectric EEG. METHODS Fasted rats were subjected to either (1) incomplete ischemia (attenuated EEG; 20 min of mean arterial pressure [MAP] = 50 mmHg and bilateral carotid occlusion) or (2) near-complete ischemia (isoelectric EEG; 10 min of MAP = 30 mmHg and bilateral carotid occlusion) while anesthetized with 1.4% isoflurane, 1 mg x kg(-1) x min(-1) ketamine, or 25 microg x kg(-1) x h(-1) 70% nitrous oxide and fentanyl. The brain was maintained at normothermia during ischemia and for 22 h after ischemia. Five days later, hippocampal CA1 and cortical injury were measured. RESULTS There was no difference among anesthetic agents during incomplete ischemia for mean +/- SD percentage dead CA1 neurons (fentanyl, 38%+/-20%; isoflurane, 31%+/-10%; ketamine, 40%+/-19%; P = 0.38). During near-complete ischemia, there was a difference among anesthetic agents (fentanyl, 88%+/-9%; isoflurane, 37%+/-20%; ketamine, 70%+/-28%; P = 0.00008). Isoflurane was protective compared with fentanyl (P = 0.00007) and ketamine (P = 0.0061). There was no difference between fentanyl and ketamine (P = 0.143). Similar observations were made in the cortex. Neurologic function correlated with histologic damage. CONCLUSIONS Outcome from near-complete but not incomplete cerebral ischemia depended on the anesthetic agent administered during the ischemic insult.
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Affiliation(s)
- Y Miura
- Department of Anesthesiology and Resuscitation, Yamagata University, Japan
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Grocott HP, Bart RD, Sheng H, Miura Y, Steffen R, Pearlstein RD, Warner DS. Effects of a synthetic allosteric modifier of hemoglobin oxygen affinity on outcome from global cerebral ischemia in the rat. Stroke 1998; 29:1650-5. [PMID: 9707208 DOI: 10.1161/01.str.29.8.1650] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Neuronal injury results from an insufficient supply of oxygen to the brain. This experiment examined whether a pharmacologically induced rightward shift of the partial pressure of oxygen at which 50% of hemoglobin is saturated (P50) would improve outcome from either incomplete and/or near-complete forebrain ischemia-induced hypoxia in the rat. METHODS For incomplete ischemia (attenuated electroencephalogram), fasted rats (n = 17 to 19 per group) were given a synthetic allosteric modifier of hemoglobin affinity for oxygen (RSR13; 150 mg/kg IV) before or immediately after 20 minutes of bilateral carotid occlusion combined with a decrease in mean arterial pressure to 40 mm Hg. For near-complete ischemia (isoelectric electroencephalogram), rats (n = 15 per group) were given RSR13 (150 mg/kg) at onset of reperfusion after 10 minutes of bilateral carotid occlusion combined with a decrease in mean arterial pressure to 30 mm Hg. In both experiments, control rats were given vehicle (0.9% NaCl IV) only. Outcome (defined as percent dead hippocampal CA1 neurons) was determined at 5 days after ischemia. RESULTS RSR13 (150 mg/kg) produced a 68% rightward shift of P50 (34+/-3 to 57+/-8 mm Hg). RSR13 reduced CA1 damage resulting from incomplete ischemia by 28% (P=0.02), but only when administered at the onset of reperfusion. RSR13 had no effect on outcome from near-complete ischemia. CONCLUSIONS A postischemic pharmacologically induced increase in P50 may improve outcome from incomplete global cerebral ischemia. More severe (near-complete) ischemia negates this benefit.
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Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke University Medical Center, Durham, NC 27705, USA.
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47
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Abstract
BACKGROUND The glial protein S100beta has been used to estimate cerebral damage in a number of clinical settings. The purpose of this investigation was to determine the correlation between cerebral microemboli and S100beta levels during cardiac operations. METHODS Transcranial Doppler ultrasonography was used to measure emboli in the right middle cerebral artery. Emboli counts (n = 111) were divided into five time periods: (1) incision to aortic cannulation; (2) aortic cannulation to cross-clamp onset; (3) cross-clamp onset to cross-clamp release; (4) cross-clamp release to decannulation; and (5) decannulation to chest closure. The level of S100beta (n = 156) was measured at baseline, at the end of cardiopulmonary bypass, then 150 and 270 minutes after cross-clamp release. RESULTS The level of S100beta correlated with age, cardiopulmonary bypass time, cross-clamp time, and number of emboli at time period 2. Although cardiopulmonary bypass time was univariately associated with S100beta level, it became nonsignificant in a multivariable model that included age and cross-clamp time. CONCLUSIONS The correlation of S100beta level with emboli measured during cannulation (time period 2) supports the hypothesis that cannulation is a high-risk time period for cerebral injury.
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Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke Heart Center, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Croughwell ND, Reves JG, White WD, Grocott HP, Baldwin BI, Clements FM, Davis RD, Jones RH, Newman MF. Cardiopulmonary bypass time does not affect cerebral blood flow. Ann Thorac Surg 1998; 65:1226-30. [PMID: 9594842 DOI: 10.1016/s0003-4975(98)00113-1] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
BACKGROUND A time-dependent decline in cerebral blood flow (CBF) has been reported in cardiac surgical patients despite stable pump flows and arterial carbon dioxide tension. Other studies have failed to support these hypothermic cardiopulmonary bypass (CPB) results, showing preservation of CBF during CPB. The purpose of the study was to define the influence of mildly hypothermic CPB duration on CBF. METHODS Cerebral blood flow was measured using xenon-133 washout and alpha-stat blood gas management during nonpulsatile CPB. Cerebral blood flow measurements were made after the initiation of CPB and near the end of bypass during pump flows of 2.4 L.min-1.m-2. RESULTS Fifty-two coronary artery bypass patients were studied. The average time between CBF measurements was 54 +/- 20 minutes (mean +/- standard deviation), with a range of 10 to 100 minutes. Temperature and arterial carbon dioxide tension were controlled: after the initiation of CPB, temperature was 35.5 degrees +/- 0.4 degree C and carbon dioxide tension was 37 +/- 2.8 mm Hg; whereas near the end of bypass temperature was 35.6 degrees +/- 0.5 degree C and carbon dioxide tension was 36 +/- 2.3 mm Hg. We found no correlation between CBF and time on CPB (p = 0.47; r = 0.101), in contrast to other studies suggesting that CPB duration may intrinsically affect CBF. CONCLUSIONS Our experimental results include the following: (1) during mildly hypothermic bypass, CBF does not decrease in relation to time and (2) cerebral flow-metabolism coupling is intact at 35 degrees C.
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Affiliation(s)
- N D Croughwell
- Department of Anesthesiology, Duke Heart Center, Duke University Hospital, Durham, North Carolina, USA
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Grocott HP, Smith MS, Glower DD, Clements FM. Endovascular aortic balloon clamp malposition during minimally invasive cardiac surgery: detection by transcranial Doppler monitoring. Anesthesiology 1998; 88:1396-9. [PMID: 9605702 DOI: 10.1097/00000542-199805000-00033] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Affiliation(s)
- H P Grocott
- Department of Anesthesiology, Duke Heart Center, Duke University Medical Center, Durham, North Carolina 27710, USA.
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Chew STH, Tardiff BE, Conlon PJ, White WD, Newman MF, Landolfo K, Grocott HP, Smith MS. APOLIPOPROTEIN E PHENOTYPE DOES NOT PREDICT RISK OF RENAL IMPAIRMENT AFTER CABG SURGERY. Anesth Analg 1998. [DOI: 10.1213/00000539-199804001-00057] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
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