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This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief, Professor Hugh Hemmings, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at the University. This is further described in 'Further Retractions of Articles by Joachim Boldt', https://doi.org/10.1016/j.bja.2020.02.024.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief, Professor Hugh Hemmings, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at the University. This is further described in 'Further Retractions of Articles by Joachim Boldt', https://doi.org/10.1016/j.bja.2020.02.024.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief, Professor Hugh Hemmings, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at the University. This is further described in 'Further Retractions of Articles by Joachim Boldt', https://doi.org/10.1016/j.bja.2020.02.024.

This article has been retracted: please see Elsevier Policy on Article Withdrawal (https://www.elsevier.com/about/our-business/policies/article-withdrawal). This article has been retracted at the request of the Editor-in-Chief, Professor Hugh Hemmings, based on the recommendations of Justus-Liebig-University Giessen following an internal review of research conducted by Joachim Boldt at the University. This is further described in 'Further Retractions of Articles by Joachim Boldt', https://doi.org/10.1016/j.bja.2020.02.024.

To attain satisfactory results in aortic arch surgery a reliable method of cerebral protection, avoidance of emboli, and control of hemorrhage is mandatory. Deep hypothermic circulatory arrest is the most common technique at present but gives only a limited period of protection, whereas a complicated aortic arch operation may require more time than anticipated. Therefore the selective cannulation and perfusion of the innominate artery has not been widely used until now because it is uncertain whether the left hemisphere of the brain is adequately perfused. Between 1990 and 1995, 21 of 69 patients within the last 36 months, consisting of 15 men and 6 women averaging 45 +/- 13.4 years, underwent operative treatment for aneurysm (n = 9) or type A dissection (n = 12) involving the aortic valve and aortic arch; selective innominate perfusion (SCP [i]) in moderate hypothermia (28 degreesC) for brain protection was used. Extended perioperative monitoring included bilateral somatosensory-evoked potentials (SEP), transcranial Doppler sonography (TCD), a computer-aided topographical electro-encephalometry (CATEEM), and analysis of the arterial and venous oxygen saturation and desaturation. Mean time periods were 229.7 +/- 56.5 minutes for extracorporeal circulation, 151.7 +/- 34.1 minutes for aortic cross-clamping, and 67.05 +/- 34.03 for selective cerebral perfusion via the innominate artery. Not once did the intraoperative monitoring reveal hints of cerebral damage due to inadequate perfusion. All patients survived surgery but two could not be weaned from the respirator; one died 2 days and the other 6 days after the operation due to multiple organ failure (MOF). Another two patients died after 13 days due to untreatable septic syndrome with pulmonary insufficiency. All four patients died within 30 days, during which time they had aortic dissection involving the complete aortic arch and severe aortic valvular incompetence (grade IV). There was no late death and follow-up time of 19.76 +/- 8.04 months revealed an overall mortality rate of 19%. Only temporary neurological affections (left-sided hemiparesis) were found in two patients (9.5%). Additionally, we observed neuropsychological disturbances in one of these. Our first experience with selective cerebral perfusion via innominate artery and the attendant CATEEM monitoring for assessment of adequate bilateral cerebral perfusion suggests that this method is a useful addition to the armamentarium in complicated aortic arch surgery.

AIM The effects on cerebral function of premedication with the benzodiazepine flunitrazepam and with morphine were studied on the evening of the preoperative day (2 mg flunitrazepam p.o.) and 90 minutes before induction of anaesthesia (2 mg flunitrazepam plus 15 mg morphine i.m.). DESIGN The EEG was analysed topographically (17 electrodes) and quantitatively. RESULTS As a typical effect of benzodiazepines, increases in electrical activity in the frequency band beta-1 of the power spectrum were observed, and could be demonstrated 10 minutes after oral application, mainly in the frontal and central parts of the cortex. Increases in the powerbands delta and theta indicated induction of sleep approximately 15-20 minutes after application and were not looked upon as an effect of the benzodiazepine exclusively. These increases were noticed first in the central, occipital and temporal areas and after 30 minutes in the frontal parts of the cortex. Flunitrazepam plus morphine showed qualitatively similar but quantitatively less pronounced results. Topographical differences were similar to the results of an application of flunitrazepam alone. DISCUSSION The results demonstrate the importance of a topographical as well as quantitative evaluation in studies on complex interactions of sedative or narcotic drugs and their clinical effects on cerebral function.

Objectives We sought to determine both the procedural performance and safety of percutaneous implantation of the second (21-French [F])- and third (18-F)-generation CoreValve aortic valve prosthesis (CoreValve Inc., Irvine, California). Background Percutaneous aortic valve replacement represents an emerging alternative therapy for high-risk and inoperable patients with severe symptomatic aortic valve stenosis. Methods Patients with: 1) symptomatic, severe aortic valve stenosis (area 2 ); 2) age ≥80 years with a logistic EuroSCORE ≥20% (21-F group) or age ≥75 years with a logistic EuroSCORE ≥15% (18-F group); or 3) age ≥65 years plus additional prespecified risk factors were included. Introduction of the 18-F device enabled the transition from a multidisciplinary approach involving general anesthesia, surgical cut-down, and cardiopulmonary bypass to a truly percutaneous approach under local anesthesia without hemodynamic support. Results A total of 86 patients (21-F, n = 50; 18-F, n = 36) with a mean valve area of 0.66 ± 0.19 cm 2 (21-F) and 0.54 ± 0.15 cm 2 (18-F), a mean age of 81.3 ± 5.2 years (21-F) and 83.4 ± 6.7 years (18-F), and a mean logistic EuroSCORE of 23.4 ± 13.5% (21-F) and 19.1 ± 11.1% (18-F) were recruited. Acute device success was 88%. Successful device implantation resulted in a marked reduction of aortic transvalvular gradients (mean pre 43.7 mm Hg vs. post 9.0 mm Hg, p Conclusions Treatment of severe aortic valve stenosis in high-risk patients with percutaneous implantation of the CoreValve prosthesis is feasible and associated with a lower mortality rate than predicted by risk algorithms.

Background— The morbidity and mortality of surgical aortic valve replacement are increased in elderly patients with multiple high-risk comorbid conditions. Therefore, a prospective, single-center, nonrandomized study was performed in high-risk patients with aortic valve disease to evaluate the feasibility and safety of percutaneous implantation of a novel self-expanding aortic valve bioprosthesis (CoreValve). Methods and Results— Symptomatic high-risk patients with an aortic valve area 2 were considered for enrollment. CoreValve implantation was performed under general anesthesia with extracorporeal support using the retrograde approach. Clinical follow-up and transthoracic echocardiography were performed after the procedure and at days 15 and 30 after device implantation to evaluate short-term patient and device outcomes. A total of 25 patients with symptomatic aortic valve stenosis (mean gradient before implantation, 44.2±10.8 mm Hg) and multiple comorbidities (median logistic EuroScore, 11.0%) were enrolled. Device success and procedural success were achieved in 22 (88%) and 21 (84%) patients, respectively. Successful device implantation resulted in a marked reduction in the aortic valve gradients (mean gradient after implantation, 12.4±3.0 mm Hg; P Conclusions— Percutaneous implantation of the self-expanding CoreValve aortic valve prosthesis in high-risk patients with aortic stenosis with or without aortic regurgitation is feasible and, when successful, results in marked hemodynamic and clinical improvement.

To investigate whether generation and liberation of bradykinin and histamine contribute to generalized edema formation in pediatric cardiopulmonary bypass surgery.Prospective observational study.Pediatric heart surgery of a university hospital.Forty-one neonates, infants, and children undergoing cardiopulmonary bypass to correct congenital cardiac anomalies.Plasma concentrations of bradykinin and histamine were determined before, during, and after cardiopulmonary bypass. Fluid balance was evaluated by control of fluid intake and output.The susceptibility to generalized edema formation increased significantly (r = -.457; p.005) with decreasing age. Approximately three times higher plasma concentrations of bradykinin (p.001) were found at the onset of anesthesia and during the total observation period in patients with a fluid retention of6% of body weight compared with patients with a lower retention rate. Plasma bradykinin reached significantly (p.01) higher peak concentrations of 237.9 +/- 58.6 fmol/mL during cardiopulmonary bypass and of 227.5 +/- 90.7 fmol/mL during the early postoperative period in patients with severe edema formation in contrast to only 86.6 +/- 10.9 and 65.5 +/- 26.8 fmol/mL in patients with minor fluid retention. A tendency (p =.06) to slightly increasing histamine concentrations from 2.07 +/- 0.13 nmol/L at baseline to 3.32 +/- 1.41 nmol/L during 90 mins of cardiopulmonary bypass was only observed in patients with high fluid retention.Bradykinin seems to be essentially involved in the enhancement of microvascular permeability in pediatric cardiopulmonary bypass surgery, although a dominant causal role cannot be claimed by this study. Histamine, however, doesn't appear to play a major role and may only contribute as a cofactor. To what extent an increased expression of bradykinin-1 and bradykinin-2 receptors or a reduced potential of bradykinin-degrading enzymes is involved is the object of a further clinical study.

Cardiopulmonary bypass (CPB) is associated with an injury that may cause pathophysiological changes such as systemic inflammatory response syndrome, multiple organ dysfunction syndrome, and mediator-induced multiorgan failure. Systemic endotoxinaemia, release of proinflammatory cytokines, and interactions between neutrophils and endothelium have been reported to correlate with a high incidence of organ dysfunction, infection and sepsis following cardiac surgery. This review discusses the dysregulation of the immune response as a major reason for the higher susceptibility to infections following cardiac surgery, various treatment strategies to reduce CPB-induced inflammation, and especially the prophylactic use of immunoglobulins in cardiac surgery.

BACKGROUND: Cardiovascular surgery with cardiopulmonary bypass (CPB) leads to activation of a variety of inflammatory pathways, including the release of cytokines and selectins. METHODS: In 20 patients undergoing elective coronary artery bypass grafting, plasma levels of interleukins IL-2, -6, -8, -10, -12 and of P-, E-, and L-selectins were measured at eight time points before, during, and after CPB using a standardized ELISA technique. RESULTS: IL-2 plasma levels decreased significantly after the start of CPB and remained low until the second postoperative day. IL-6 and IL-8 levels increased significantly after weaning off CPB, with mean peak values six hours postoperatively. Very low IL-10 plasma levels were detectable preoperatively. They remained low during CPB and peaked significantly after weaning off CPB until skin closure. The IL-12 levels decreased after weaning off CPB (p < 0.05) until 6 hours postoperatively. The plasma levels of P-selectin showed no alterations, but concentrations of E- and L-selectin decreased after the start of CPB (p < 0.05). There were no adverse postoperative events. CONCLUSIONS: The results of our study demonstrate a dysregulation of cytokine and selectin production during and up to 48 h after CPB, which may be a "normal" stress reaction to CPB.

Continuous measurement of somatosensory evoked potentials (SEP) by means of characteristic changes in the signal pattern makes it possible to identify cerebral or spinal cord ischemia during critical phases of the operative procedure. A correct interpretation of the measurements is only possible, however, if the influence of drugs acting on the central nervous system is known. The authors were able to show that inhaled anesthetics have an impact on latencies and response amplitudes. This study examined the influence of various concentrations of desflurane on the conduction of SEP of the Median nerve. In addition, the authors determined how the supplementation of nitrous oxide (N2O) influences the stimulus response of the medianus nerve's SEP. Desflurane has been shown to produce dose-dependent increases in SEP latency (data in part for latency N2O: 0.5 minimum alveolar concentration [MAC] = 20.8 +/- 0.9; 1.5 MAC = 22.2 +/- 1.5; 1.5 MAC/N2O= 23.8 +/- 1.5) and decreases in amplitude, whereas cervically recorded subcortical SEP components are minimally influenced by desflurane. When nitrous oxide is added, there were marked reductions in amplitude (p

The cardiovascular effects of Org 9487 during isoflurane anaesthesia have been evaluated using three doses around its ED90 for neuromuscular blockade, i.e. 1 mg kg-1, 2 mg kg-1 and 3 mg kg-1. Heart rate increased to 110%, 115% and 118% in patients receiving 1 mg kg-1, 2 mg kg-1 and 3 mg kg-1 respectively. There were no significant effects on systolic and diastolic blood pressures for the two lower dose groups. Patients receiving Org 9487 3 mg kg-1 displayed significant decreases in systolic and diastolic blood pressures (91% and 82% of the control values respectively). Except for heart rate in the group receiving 3 mg kg-1, all measurements returned to baseline after a maximum of 15 min. Six patients experienced a transient increase in airway pressure after administration of Org 9487, which was accompanied by a decrease in oxygen saturation in two out of six subjects, but there was no audible wheezing. These episodes were self-limiting and required no treatment. There were no other adverse reactions to this drug during this study.

Objective: Orthotopic heart transplantation has become an accepted therapeutic concept for adult patients with endstage heart disease. In newborns and infants this procedure is still a matter of discussion because of unknown long-term results and the lack of donor organs. Methods: Since March 1988 we have performed 40 orthotopic heart transplantation in 39 infants who were from 1 to 280 days of age. Indications for transplantation included hypoplastic left-heart syndrome ( n = 28), dilative cardiomyopathy (n = 4), endocardial fibroelastosis (n = 4) and other complex structural anomalies (n = 3). The mean waiting period for transplantation was 53 days. A donor‐recipient weight ratio up to 4.0 was accepted. Profound hypothermic circulatory arrest was used for graft implantation in all those patients who required extensive aortic arch reconstruction (71%). The initial immunomodulation was based on Cyclosporine, Azathioprine and Prednisolone. Patients who underwent transplantation during the first 6 weeks of life received a chronic single-drug therapy with Cyclosporine after 1 year. Results: There were six peri-operative deaths caused by drug-resistant right-heart failure in three cases, humoral rejection (n = 1), CMV infection (n = 1) and multi organ failure (n = 1). One infant died late, due to rejection. The actuarial survival rate for the entire group is now 82%. There is a remarkable influence of increasing experience. Whereas six of 15 infants who had heart transplantation between 1988 and 1993 died early post-operatively (survival rate: 60%), only one late death occurred among 24 recipients in the period from 1994 to April 1997 (survival rate: 96%). Episodes of rejection occurred once or several times in about half of the patients in this series (48%). All surviving children are living at home in excellent condition. Conclusions: Heart transplantation during early infancy is a rational and durable therapy for heart diseases with irreversible myocardial failure or severe structural anomalies. The intermediate-term results have been encouraging in many centers, but more data must be accumulated to determine the sequelae of chronic immunosuppression. The lack of donor organs remains one of the major problems in pediatric heart transplantation. © 1998 Elsevier Science B.V. All rights reserved

Von Juni 1988 bis Dezember 1996 wurden am Kinderherzzentrum Giesen 36 Patienten, im Alter von weniger als einem Jahr, einer Herztransplantation zugefuhrt. Zugrundeliegende Diagnosen waren ein hypoplastisches Linksherzsyndrom (n = 26), Endokardfibroelastose (n = 4), Kardiomyopathie (n = 3) und komplexe Vitien (n = 3). Die mittlere Wartezeit von Transplantation betrug 52 Tage, das Verhaltnis der Korpergewichte von Spender zu Empfanger lag im Mittel bei 1,8. Sieben Patienten (19%) verstarben nach Transplantation, uberwiegend innerhalb des ersten Monats nach der Transplantation. Die kumulative Uberlebenswahrscheinlichkeit liegt im Geamtkollektiv bei 79%. Der Einflus zunehmender Erfahrung zeigt sich beim Vergleich der Patienten mit Transplantationen von 1988 bis 1993 (n ? 15) und von 1994 bis 1996 (n = 21). Wahrend im ersten Zeitraum lediglich 50% uberlebten, betrug die Uberlebensrate der spater transplantierten Kinder 92%, die 1-Jahres-Uberlebensrate lag bei 100%. Bei 20 Patienten traten insgesamt 31 Abstosungsepisoden auf, wobei 2 Sauglinge verstarben. 71% aller Abstosungen traten innerhalb des ersten Monats nach der Transplantation auf. Die Nierenfunktion ist ein Jahr nach der Transplantation nur masiggradig eingeschrankt ohne Tendenz zur Verschlechterung. Die somatische Entwicklung verlauft bei nahezu allen Kindern perzentilengerecht. Die Lebensqualitat der Patienten nach der Transplantation ist ausgezeichnet. Alle Patienten leben ohne Einschrankungen zu Hause. Bei zwei Patienten liegt allerdings ein neurologisches Defizit vor. Bislang gibt es im Gesamtkollektiv keine Anzeichen fur eine Transplantatvaskulopathie oder eine maligne Erkrankung. Eine Herztransplantation stellt nach diesen Ergebnissen eine uberdenkenswerte Alternative in der Behandlung sehr komplexer Vitien und Kardiomyopathien im Neugeborenen- und Sauglingsalter dar.

Maintaining an adequate cerebral oxygen supply is a serious problem in aortic arch surgery. Deep hypothermic circulatory arrest is the most common method used for cerebral protection, but guarantees only a time-limited safety period. Based on experimental investigations, we applied selective cerebral perfusion via the innominate artery alone with only moderate hypothermia (28 degrees C) and without circulatory arrest in 25 consecutive patients undergoing surgical treatment of an aneurysm (n = 10) or acute type-A dissection (n = 15) involving the aortic valve and arch. In every case a test perfusion was carried out to assess whether the cerebral perfusion achieved would be adequate for the whole operation. In no case was the perfusion inadequate. As a new perioperative monitoring system, we used computer-aided topographical electroencephalometry (CATEEM). There were 18 male and 7 female patients, their age was 47.0 +/- 15.1 years (mean +/- SD). Mean time periods were 155.1 +/- 37.3 min for aortic cross-clamping, and 69.3 +/- 35 min for selective cerebral perfusion. Postoperatively, two patients (8%) revealed a temporary left-sided hemiparesis, and 4 patients (16%) died within 30 days. The overall mortality rate was 16% in a follow-up period of 24.2 +/- 9.5 months. In this small group the CATEEM monitoring enabled an intraoperative selection of patients with sufficient bihemispheric collateral circulation and therefore suitable for simple innominate artery perfusion.

To develop an improved regimen of antibiotic prophylaxis in cardiac surgery, three antibiotic prophylactic regimens for patients scheduled to have elective cardiothoracic surgery involving a median sternotomy were evaluated.A prospective, randomized, unblinded study.A university teaching hospital.Sixty-nine men scheduled for elective coronary artery bypass grafting (CABG) with extracorporeal circulation (ECC) were included in the study.The patients were selected at random to receive 2 g of cefamandole (CM) at induction of anesthesia (group 1, n = 24), or 2 g of CM at the beginning of anesthesia followed by an additional dose (2 g) immediately after onset of cardiopulmonary bypass (CPB) (group 2, n = 22), or 4 g of CM just at the initiation of anesthesia (group 3, n = 23). Samples from the mammary artery, sternum, and plasma were obtained at various intervals after injection of the antibiotic (10 minutes intravenously) to compare antibiotic levels, assayed for CM concentrations, with high-pressure liquid chromatography (HPLC) and plasma bactericidal activity as well as infectious complications in these sites as a function of time for the three groups.There were no significant differences in biometric data, duration of hospitalization, or management of cardiopulmonary bypass, including urinary tract drainage and infusion volume. The mean plasma t1/2 (distributive or alpha-phase) before bypass was 51.7 +/- 16.7 minutes for group 1 and 2 patients and 54.9 +/- 15.9 minutes for group 3 patients. CM plasma values were significantly higher in group 2 (170.3 +/- 105.8 micrograms/mL) than in groups 1 and 3 (111.8 +/- 42.2 micrograms/mL, 101.2 +/- 57.2 micrograms/mL) at the end of bypass periods (p0.05). The antibiotic contents of mammary artery and sternum samples of group 2 (15.6 +/- 4.7 micrograms/mL, 9.5 +/- 4.7 micrograms/mL) were significantly higher after completion of CPB compared with group 1 (5.7 +/- 1.9 micrograms/mL, 3.8 +/- 2.9 micrograms/mL) and group 3 (6.3 +/- 3.5 micrograms/mL, 3.6 +/- 1.8 micrograms/mL) (p0.05). There were no significant differences in distribution of micro-organisms among the three groups, but two patients of groups 1 and 3 with plasma and tissue CM levels below minimal inhibitor concentration (MIC90) for Hemophilus influencea, E coli, Proteus ssp and Klebsiella ssp after completion of CPB, respectively, developed a pneumonia postoperatively caused by Hemophilus influencea (1), E coli (1) and Klebsiella ssp (2) (p0.05).It would be preferable to infuse the antibiotic shortly before the operative procedure. However, to keep tissue and plasma CM values more than MIC90 for common pathogens during the time period studied, a second infusion of 2 g of CM administered after onset of CPB suggests better protection against the risk of microbial infections. Therefore, the findings might be important for the choice of antibiotic prophylaxis, particularly for high-risk patients.

OBJECTIVE: Objective of this investigation was to compare the effects of the new inhalation agent desflurane with equipotent doses of isoflurane and halothane on hepatic blood flow (tHBF). METHODS: 36 Patients scheduled for elective aortocoronary bypass grafting were enrolled to the study. tHBF was assessed by plasma clearance and hepatic extraction of indocyanine green, and standard haemodynamic parameters were measured by thermodilution technique. The measurements were performed awake and after intubation at equilibration of 1 MAC. All measurements were terminated before skin incision. RESULTS: We found a significant decrease of tHBF in all patients regardless of the inhalation agent used (H 918 ml/min +/- 107 to 625 ml/min +/- 181, I 930 ml/min +/- 195 to 637 ml/min +/- 137, D 940 ml/min +/- 129 to 677 ml/min +/- 122). The tHBF in relation to cardiac output also decreased significantly (H 17% +/- 5 to 14% +/- 3, I 16% +/- 3 to 14% +/- 5, D 20% +/- 5 to 18% +/- 6). No difference was seen between the groups according to tHBF and haemodynamics. CONCLUSION: The results of this study suggest that all inhalation agents included in the study significantly decreased tHBF during anaesthesia with the concentration of 1 MAC.

A survey was conducted among British, French and German anaesthetists to evaluate possible national differences in the peri-operative use of muscle relaxants and their reversal agents. The same non-depolarizing relaxants are used in all three countries, with the exception of d-tubocurarine, which is only available in Great Britain, and alcuronium which is mainly used in Germany. The French anaesthetists seem to use significantly less succinylcholine than their peers in Great Britain or Germany for both elective and emergency intubation. Monitoring of neuromuscular blockade still relies mainly on "clinical judgement'. Reversal of non-depolarizing muscle relaxants is performed routinely in Great Britain, while a substantial number of French anaesthetists avoid the use of a reversal. Dose regimes for neostigmine vary largely, with German anaesthetists administering the lowest, and British anaesthetists administering the highest doses. Side effects of reversal agents are reported by colleagues from all three countries in too high a percentage to justify uncritical administration of these drugs. In Germany there seems to be a noteworthy lack of recovery facilities.

The value of preoperative and early postoperative microbiologic testing of tracheal aspirates as a prognostic indicator of the development of pneumonia was evaluated in a prospective study of 213 cardiac surgical patients. Tracheal aspirates were obtained immediately after intubation and after the patient's arrival at the intensive care unit. Diagnosis of pneumonia was accepted if at least three of the following criteria were fulfilled: leukocytosis >15,000 cells/mm 3 , body temperature >38.5° C, positive results of auscultation, positive results of radiography (new infiltrates that seemed to be consistent with pneumonia), and increased core-reactive protein for more than 2 days after operation. Potentially pathogenic microorganisms were found in 54 (25.4%) of the preoperative tracheal aspirates and in 27 (12.7%) of the early postoperative tracheal aspirates. Positive microbiologic findings correlated with pneumonia in the postoperative course in 24.1% ( p < 0.001) if the preoperative culture results were positive, in 48.2% ( p < 0.001) if the postoperative culture results were positive, and in 44.0% ( p < 0.001) if both were positive. The risk of pneumonia was increased in male patients ( p < 0.05) and in patients with chronic obstructive pulmonary disease ( p < 0.05). Demographic variables, smoking, acute pulmonary symptoms, temperature, leukocyte count at the day of the operation, and data on the operation and the extracorporeal circulation were not significantly related to pneumonia in the early postoperative course. The risk of development of postoperative pneumonia is significantly higher among patients with colonization of the lower respiratory tract. Positive culture results in routine microbiologic monitoring of tracheal aspirates are predictive of pulmonary complications after cardiac operations. (J THORAC CARDIOVASC SURG 1996;111:1213-8)

Der rechte Ventrikel ist durch extrakorporale Zirkulation (EKZ) mehr gefahrdet als der linke. Eine beeintrachtigte rechtsventrikulare Funktion kann von einer Senkung der Nachlast profitieren. Durch Inhalation von Stickstoffmonoxid (NO) kann ein pulmonaler Hypertonus ohne Auswirkungen auf den Systemkreislauf gesenkt werden. In der vorliegenden Arbeit wurde deshalb der Einflus einer NO-Inhalation auf pulmonalarteriellen Druck (PAP), pulmonalvaskularen Widerstand (PVR) und Rechtsherzparameter unmittelbar nach EKZ untersucht. An der Studie nahmen 20 Patienten mit masiggradigem pulmonalen Hochdruck teil. 10 Patienten inhalierten 30 ppm NO, die anderen dienten als Kontrollgruppe. Meszeitpunkte lagen 10 min nach EKZ (Ausgangswerte), 3, 10 und 20 min nach Start sowie 10 min nach Beendigung der NO-Inhalation. Es fand sich ein signifikanter Abfall von PAP und PVR ohne begleitende Verbesserung der Rechtsherzfunktion. In der Kontrollgruppe wurden Veranderungen von PAP und PVR in vergleichbarer Grosenordnung beobachtet. Es ist somit fraglich, ob die beobachteten Effekte spezifisch fur die NO-Inhalation sind. Hohe endogene NO-Konzentrationen in dieser Phase, wie im Tierexperiment gefunden, konnten dieses Verhalten erklaren. Eine klinische Verbesserung der Rechtsherzfunktion nach EKZ konnte bei unseren Patienten durch NO-Inhalation nicht erreicht werden.

Objective. Our objective was to quantify the effects of intravenous anesthetics on values measured by or derived from transcranial Doppler sonography (TCD) during induction of general anesthesia.Methods. We recorded blood flow velocity in the middle cerebral artery (V-MCA) before, during, and after induction of general anesthesia in six groups of young patients without intracranial pathology (n=10 each) using TCD. Patients were randomized to receive either 2 mg/kg propofol, 1.5 mg/kg methohexital, 5 mg/kg thiopental, 0.3 mg/kg etomidate, 2 µg/kg fentanyl and 0.15 mg/kg midazolam, or 1.5 mg/kg ketamine and 0.15 mg/kg midazolam intravenously. At 2 min after injection, each patient was intubated and given isoflurane 0.8% and nitrous oxide 66% in oxygen. Ventilation was set to achieve an end-tidalPco2 of 40 mm Hg. V-MCA, arterial blood pressure, heart rate, hematocrit, andPco2 (venous samples) were measured before and 1, 3, 5, 10, and 30 min after induction of anesthesia.Results. The preinduction data were not different between groups. At 1 min after injection, propofol, thiopental, methohexital, and etomidate significantly decreased V-MCA. TCD values were only slightly affected following fentanyl/midazolam. Ketamine/midazolam induced a modest rise in V-MCA. After endotracheal intubation, V-MCA increased in all groups, and slowly declined thereafter.Conclusions. Under the circumstances of our study, values derived from TCD measurements responded differently to the agents used to induce general anesthesia in nonneurosurgical patients.

Background In patients with carotid artery disease, poor intracerebral collateralization is reflected by impaired cerebrovascular reactivity to carbon dioxide inhalation, which will improve after endarterectomy. The relationship between preoperative reactivity to carbon dioxide using transcranial Doppler sonography (TCD) and intraoperative changes of somatosensory evoked potentials (SEP) and TCD parameters were investigated. Methods In 94 patients, preoperative carbon dioxide reactivity was examined and defined impaired if mean blood flow velocity in the middle cerebral artery (Vm-MCA) increased less than 1.5% mmHg during carbon dioxide challenge. Patients then underwent 100 carotid operations under general anesthesia with both SEP and TCD monitoring. Shunts were placed if SEP amplitude decreased to less then 50% of control or central conduction time increased by 20% after clamping (critical SEP changes). TCD changes were defined as critical in case of a postclamping/preclamping Vm-MCA ratio < or = 0.4. The incidence of critical SEP and TCD changes was compared to preoperative carbon dioxide testing using Fisher's exact test with P < 0.05 considered significant. Postoperatively, neurologic state and carbon dioxide responsiveness were re-examined. Results Twelve patients showed impaired preoperative carbon dioxide reactivity on the side of operation, which improved markedly after surgery. The incidence of critical SEP changes in these cases (8.3%) was not significantly different from that in the remaining patients (14.8%). Critical SEP changes were significantly correlated with critical TCD changes (P < 0.0001). Conclusions Patients with poor carbon dioxide reactivity (preoperative TCD testing) did not have an increased risk of cerebral ischemia during carotid surgery, as assessed by intraoperative SEP recording.

Hypertonic saline solution appears to be an attractive method of volume expansion. In 45 patients undergoing elective aorto-coronary bypass grafting, endocrinologic and circulatory responses to volume loading with hypertonic saline solution prepared in low molecular weight (MW) hydroxyethyl starch (HES) solution (72 g/L NaCl, HES concentration: 6%; MW: 200,000 D; degree of substitution [DS]: 0.5) (HS-HES) was compared randomly to patients who had received low molecular weight HES solution (LMW-HES). A group of patients without volume loading served as a control. Volume was infused to double the low pulmonary capillary wedge pressure (PCWP < 5 mmHg) after induction of anesthesia. Plasma levels of atrial natriuretic peptide (ANP), endothelin, vasopressin, and catecholamines were measured before, during, and after cardiopulmonary bypass (CPS) until the first postoperative day. In addition to systemic circulatory changes, capillary skin blood flow was measured by laser Doppler flowmetry. ANP plasma concentration increased in both volume groups (HS-HES: +79%; HES: +32%), whereas it decreased in the control (−20%). Infusion of HS-HES resulted in an increase in plasma endothelin concentration before and after CPS (from 3 to 6 pg/mL). Five hours after CPB, both treatment groups had higher endothelin plasma concentrations than the control patients (P < 0.05). Epinephrine and norepinephrins plasma levels increased most markedly in the control patients and were highest in the postbypass period in these patients. Cl increased most after infusion of HS-HES (+65%) (P < 0.05). In the postbypass period, Cl remained significantly higher in both volume groups than in the controls. SVR decreased most in the HS-HES patients (−44%) and was lowest after CPS in these patients. Laser Doppler flow was most increased in the HS-HES patients before as well as after CPS. It is concluded that both kinds of volume given before CPS resulted in an improvement in hemodynamics into the postbypass period. Infusion of HSHES led to the most improved systemic and microcirculatory perfusion, which cannot be explained by the endocrinologic response alone.

Thirty consecutive children scheduled for pediatric cardiac operation with cardiopulmonary bypass were included in the study. Before the operation, the patients were randomly divided into two groups: with aprotinin ( n = 15, 30,000 U/kg after induction of anesthesia, 30,000 U/kg added to the prime of the cardiopulmonary bypass system followed by additional 30,000 U/kg every hour until the end of cardiopulmonary bypass or without aprotinin ( n = 15). Thrombomodulin, (free) protein S, protein C, and thrombin/antithrombin III complex were measured from arterial blood samples taken after induction of anesthesia (at baseline, before aprotinin) and before, during, and after cardiopulmonary bypass until the first postoperative day. Standard coagulation parameters (antithrombin III, fibrinogen, platelet count, and partial thromboplastin time) were without differences between the groups. Thrombomodulin plasma concentrations were within normal range (

Ziel: Die Frage zu beantworten, ob die parenterale Substitution von Eisen Vorteile gegenüber der bisher üblichen oralen Gabe bei Eigenblutspendern bietet. Design: Prospektiv, randomisierte Studie. Rahmen und Patienten: 30 männliche und 30 weibliche Patienten, getrennt in zwei Gruppen, vor einer elektiven Hüftgelenksoperation. Interventionen: Patienten der Gruppe·erhielten oral 6 × 50 mg Fe2+-Aspartat/Tag und Patienten der Gruppe P bekamen 0,75 mg/kg KG komplexgebundenes Fe3+ ein-mal wöchentlich nach der Eigenblutspende (EBS) infundiert. In beiden Gruppen wurde die Substitution 2 Wochen vor Beginn der ersten Spende begonnen und über 6 Wochen bis zur Operation fortgeführt. Insgesamt wurden bei jedem Patienten drei EBS durchgeführt. Die Therapiekontrolle erfolgte durch Messung des Hämoglobin-gehaltes, der Ferritin-Plasmakonzentration und der Retikulozytenzahl. Das Auf-treten von Nebenwirkungen wurde durch einen Fragebogen ermittelt. Ergebnisse: Im Hämoglobin-Verlauf beider Gruppen bestand kein Unterschied. Deutlich unterschiedlich waren die Ergebnisse bezüglich der Retikulozytenzahl und des Ferritinverlaufs. Hier kam es in Gruppe P zu einem signifíkanten Anstieg im Vergleich zur Gruppe O. 38,9% der Patienten in Gruppe·zeigten unerwünschte Nebenwirkungen der Eisentherapie, wie Obstipation oder Diarrhoe. Bei Patienten der Gruppe P wurden keine Nebenwirkungen der Eisensubstitution beobachtet. Schluβfolgerungen: Da die Anzahl der zu gewinnenden Eigenblutkonserven zu einem groβen Teil vom Füllungszustand der Eisenspeicher abhängt, ist eine frühzeitige, suffiziente Eisengabe sinnvoll. Da die orale Eisengabe häufig mit unerwünschten Nebenwirkungen einhergeht, kann bei diesen Patienten eine parenterale Gabe er-wogen werden, die jedoch unter strenger ärztlicher Kontrolle zu erfolgen hat, da in seltenen Fällen mit schweren anaphylaktischen Reaktionen gerechnet werden muβ.

The effects of three different fluid regimes administered before surgery on stress-related hormones were studied in 36 patients undergoing elective aortocoronary bypass grafting. Low-dose Ringer's solution (10 ml/kg; low-dose crystalloid group [LDC]), high-dose Ringer's solution (20 ml/kg; high-dose crystalloid group [(HDC]). or a combination of Ringer's solution (10 ml/kg) with high-molecular weight hydroxyethylstarch (HES) (10 ml/kg) (crystalloid-HES group [C-HES]) were randomly administered prior to operation. Haemodynamic variables and plasma concentrations of ADH, ACTH, renin, aldosterone, cortisol and catecholamines were studied before volume load, before commencement of cardiopulmonary bypass (CPB), and immediately after weaning from CPB. Cardiac index and stroke volume index in the C-HES group increased by 20% and 18% respectively, systemic vascular resistance decreased by 25% after volume infusion. This was associated with a decrease in the plasma concentrations of ADH, renin and aldosterone. In contrast to this, in the LDC and HDC groups, haemodynamic parameters remained almost unchanged after volume load. This was associated with an increase in aldosterone (LDC 20%; HDC 58%) and renin (LDC 110%; HDC 44%). In all groups, plasma concentrations of catecholamines increased progressively during the time of surgery and were not influenced by the nature or volume of fluid administered. We conclude that the administration of a combination of crystalloid and colloid solutions during induction of anaesthesia effectively improves haemodynamics and attenuates the increase of the plasma levels of ADH, renin and aldosterone often associated with surgery.

The influence of four different kinds of intravascular volume replacement on platelet function was investigated in 60 patients undergoing elective aortocoronary bypass grafting using cardiopulmonary bypass (CPB). In a randomized sequence, high-molecular weight hydroxyethyl starch solution (HMW-HES, mean molecular weight [Mw] 450,000 d), low-molecular weight HES (LMW-HES, Mw 200,000 d), 3.5% gelatin or 5% albumin were infused preoperatively to double reduced filling pressure (pulmonary capillary wedge pressure [PCWP] < 5 mm Hg). Fifteen untreated patients served as a control. Platelet function was assessed by aggregometry using turbidometric technique (inductors: ADP, epinephrine, collagen). Maximum aggregation, maximum gradient of aggregation, and platelet volume were measured before, during, and after CPB until the first postoperative day. HMW-HES 840 +/- 90 mL, LMW 850 +/- 100 mL, gelatin 950 +/- 110 mL, and albumin 810 +/- 100 mL were given preoperatively. Maximum platelet aggregation (ranging from -23% to -44% relative from baseline value) and maximum gradient of platelet aggregation (ranging from -26% to -45% relative from baseline values) were reduced only in the HMW-HES patients. After CPB, aggregometry also was impaired most markedly in these patients. The other volume groups showed less reduction in platelet aggregation and were similar to the untreated control. On the first postoperative day, aggregation variables had returned almost to baseline in all patients. Platelet volume was the same among the groups within the investigation period. Postbypass blood loss was highest in the HMW-HES group (890 +/- 180 mL). There was significant (P < 0.04) correlation in this group between blood loss and change in platelet aggregation.(ABSTRACT TRUNCATED AT 250 WORDS)

Excessive hemorrhage secondary to cardiopulmonary bypass may be encountered after pediatric cardiac operations. Platelet dysfunction appears to be especially responsible for this problem. The proteinase inhibitor aprotinin is suggested to possess platelet preservation properties and reduce blood loss in this situation. The effects of aprotinin (25,000 U/kg after induction of anesthesia, 25,000 U/kg added to the prime, 25,000 U/kg every hour of cardiopulmonary bypass) on platelet function were randomly studied in 12 children with a weight of less than 10 kg (group 2) and 12 children weighing more than 10 kg (group 4), who were compared with two groups of children without aprotinin (group 1,10 kg; group 3,10 kg). Twelve children undergoing major vessel operations without cardiopulmonary bypass and aprotinin served as a control. Platelet function was assessed using aggregometry (turbidometric technique with adenosine diphosphate, 2.0 mumol/L; collagen, 4 micrograms/mL; epinephrine, 25 mumol/L; NaCl [control]). Platelet function was not altered in the control patients within the entire investigation period. Maximum aggregation in the small children was already lower at baseline in comparison with that of the children10 kg. Cardiopulmonary bypass was followed by a significant reduction in platelet aggregation in all groups. Treatment with aprotinin did not improve platelet function (maximum aggregation and maximum gradient of aggregation) in any group. On the first postoperative day, maximum aggregation in the small children exceeded baseline values, whereas in both groups of children10 kg baseline values had almost been established. Postoperative blood loss was not reduced by treatment with aprotinin.(ABSTRACT TRUNCATED AT 250 WORDS)

Only a few studies have reported on the effects of aprotinin in pediatric cardiac surgery, and the correct dose is controversial. In a prospective, randomized study, three groups of children weighing less than 20 kg were investigated. In group 1 (n = 14): aprotinin 20,000 U/kg was given after induction of anesthesia, 20,000 U/kg was added to the prime, and another 20,000 U/kg was given every hour of cardiopulmonary bypass (low-dose regimen). In group 2 (n = 14) aprotinin 35,000 U/kg was given after induction followed by an infusion of 10,000 U/kg · min until the end of the operation and 35,000 U/kg was added to the prime (high-dose regimen). In group 3 (n = 14) no aprotinin was used (control). Platelet function was evaluated by aggregometry (maximum platelet aggregation, maximum gradient of platelet aggregation) by means of turbidometric technique (inductors: adenosine diphosphate, collagen, and epinephrine) before and after cardiopulmonary bypass until the first postoperative day. Platelet aggregation was significantly reduced during and after bypass, values ranging from −29% to −54% (maximum aggregation) and −25% to −75% (maximum gradient of aggregation) with regard to baseline values. In the further postoperative course, platelet function recovered and mostly exceeded baseline values on the first postoperative day. Platelet aggregation variables were without any differences among aprotinin-treated and control patients. Blood loss was similar for all three groups and added up to approximately 28 ml/kg until the first postoperative day. The use of packed red cells was also comparable for the three groups, whereas the use of fresh frozen plasma was highest in group 1 (1680 ml until the first postoperative day). We conclude from this study that aprotinin did not improve platelet function and did nor reduce blood loss or the need for homologous blood transfusion in pediatric cardiac surgery, regardless of whether a low-dose or a high-dose regimen was used.

Hypothermic cardiopulmonary bypass (CPB) has been associated with both coagulation defects and hemorrhage. The influence of temperature on platelet function and the benefits of aprotinin in this situation were studied in 60 patients undergoing elective aortocoronary bypass grafting. The patients were randomly divided into four groups (15 patients per group): group 1, normo-thermic CPB (nasopharyngeal temperature > 34 °C); group 2, normothermic bypass and administration of high-dose aprotinin (2 million IU before CPB, 500,000 lU/h until the end of the operation, and 2 million IU added to the prime); group 3, hypothermic CPB (nasopharyngeal temperature

Intravenous infusion of glucose/insulin in combination with potassium (GIK) is an often used technique to improve myocardial preservation in cardiac surgery. In a randomized study in 50 patients undergoing elective aortocoronary bypass grafting with good ventricular function, the influence on glucose homeostasis and hormonal response to four different glucose/insulin regimes were compared to an untreated control: 1) 50 g of glucose mixed with 100 U of human insulin (HI/100); 2) 50 g of glucose mixed with 100 U of bovine insulin (BI/100); 3) 50 g of glucose mixed with 50 U of human insulin (HI/50); and 4) 50 g of glucose mixed with 50 U of bovine insulin (BI/50) [corrected]. Glucose/insulin were given in combination with 70 mmol of potassium 40 min before beginning the operation. In addition to blood glucose concentrations various endocrine variables were studied before, during and after cardiopulmonary bypass (CPB). Hemodynamic data (arterial blood pressure, heart rate, cardiac index, systemic vascular resistance) were similar in all five groups. Inotropic support after CPB was necessary in none of the patients. Blood glucose levels showed no differences among all GIK groups (groups 1-4) but were significantly higher than in the control patients. The incidence of severely reduced (50 mg/dL) or elevated blood glucose level (300 mg/dL) did not differ between HI- and BI-treated patients but was significantly lower in the untreated control. Insulin plasma level increased significantly after infusion of GIK with higher levels in HI- than BI-treated patients (P0.05).(ABSTRACT TRUNCATED AT 250 WORDS)

Aims The purpose of the present analysis was to identify predictors of procedural success of percutaneous transcatheter aortic valve implantation (TAVI). Methods and results We prospectively assessed in-hospital outcome of patients undergoing TAVI at two institutions. We analysed clinical, morphological, and procedural parameters using univariate and multivariate regression models. Between 2005 and 2008, a total of 168 consecutive patients with symptomatic aortic valve stenosis underwent TAVI using the self-expanding CoreValve Revalving prosthesis. Patients (93%) were highly symptomatic with a New York Heart Association grade III/IV and a mean aortic valve area of 0.66 ± 0.21 cm2. Acute and in-hospital procedural success rates were 90.5 and 83.9%, respectively, with an in-hospital mortality, myocardial infarction, and stroke rate of 11.9, 1.8, and 3.6%, respectively. Predictors of in-hospital procedural success were type of access (OR 0.33, 95% CI 0.13-0.82, P = 0.017), prior coronary intervention (OR 5.3, 95% CI 1.20-23.41, P = 0.028) and pre-procedural Karnofsky index using univariate regression. Pre-procedural Karnofsky index emerged as the only independent predictor (OR 1.04, 95% CI 1.00-1.08, P = 0.032) in the multivariate analysis. Conclusion Pre-procedural functional performance status predicts the in-hospital outcome after TAVI. Patients with a good functional status are likely to benefit more from TAVI than previously reported high-risk patients

Extracorporeal circulation is known to have profound effects upon platelets. Changes in platelet function were assessed in 20 patients undergoing elective coronary artery bypass grafting (CABG) who stopped taking aspirin (100 mg per day) 5-7 days before the operation compared with 20 patients undergoing aortic valve replacement (AVR) who had never taken anticoagulants or aspirin. Platelet aggregometry was carried out using the turbidimetric technique (inducing agents: adenosine diphosphate (ADP) 1.0 and 2.0 mumol/l; collagen 4 micrograms/ml; epinephrine 25 mumol/l), and maximum aggregation as well as the maximum gradient of aggregation were monitored before, during, and after cardiopulmonary bypass (CPB) until the 1st postoperative (p.o.) day. Until the 1st p.o. day blood loss was significantly higher in the CABG (890 +/- 160 ml) than in the AVR patients (420 +/- 120 ml). A total of 8 units of packed red cells (PRC) were given in the CABG group, whereas no homologous blood was necessary in the AVR patients (P < 0.05). The aggregation variables of the CABG patients were lower than in the AVR patients as early as after the induction of anesthesia (difference in maximum aggregation ranged from 13-29%). During CPB and immediately thereafter, all aggregation variables were significantly reduced in the CABG patients (reduction in maximum aggregation ranged from -32 to -49%) and were significantly different from the platelet aggregation in the AVR patients. Five hours after CPB and on the 1st p.o. day platelet aggregation in the CABG group almost returned to baseline values, however, without reaching the values of the AVR patients.(ABSTRACT TRUNCATED AT 250 WORDS)

To investigate whether plasma catecholamines influence blood flow on the microcirculatory level, forehead and forearm skin blood flow was measured by a two-channel laser Doppler blood flux monitor in 50 patients undergoing aortocoronary bypass grafting. Macrohaemodynamics, plasma viscosity, and skin temperatures were additionally monitored. Plasma catecholamines (adrenaline [AD] and noradrenaline [NOR] ) were determined using high-pressure liquid chromatography (HPLC) from arterial blood samples. In the prebypass period, blood concentrations of both catecholamines increased slightly showing a wide range of values (AD ranging from 3 to 955 pg/ml; NOR ranging from 27 to 5326 pg/ml). In spite of the tremendous increase in plasma catecholamines before and after bypass, laser Doppler flow (LDF) remained almost stable in this period. Neither LDF nor macrocirculatory parameters were correlated to plasma catecholamines. Cardiopulmonary bypass (CPB) resulted in a significant increase in catecholamines (AD ranging from 80 to 2480 pg/ml; NOR ranging from 188 to 9898 pg/ml). Although haematocrit and plasma viscosity were significantly reduced during CPB, LDF decreased in comparison to baseline values (LDF forehead: -25%; LDF forearm: -35%) ( p It is concluded that plasma catecholamine levels were markedly changed during cardiac surgery showing a wide range of concentrations. Microcirculatory flow assessed by laser Doppler remained almost unaffected by these alterations and was not correlated to AD or NOR plasma concentrations. However, during CPB a significant increase in catecholamines can contribute to the risk of microperfusion abnormalities which can be assessed by laser Doppler technique.

Some phosphodiesterase (PDE)-inhibitors are believed to alter platelet count and function due to changes in intracellular cAMP. Whether newly developed (specific) PDE-inhibitors negatively influence platelet function in cardiac surgery should be investigated in a randomized study.Eighty patients undergoing aorto-coronary bypass grafting were divided into 4 groups and received either the new PDE-III-inhibitor piroximone (group 1), the PDE-III-inhibitor enoximone (group 2), epinephrine (group 3) or no inotropic support (control). PDE-III-inhibitors were given as a bolus followed by infusion until starting of cardiopulmonary bypass (CPB). In addition to platelet count and a thrombelastogram, platelet function was assessed by aggregometry (ADP, epinephrine, collagen). Measurements were done before, during and after CPB until the 1st postoperative day.Platelet count and postoperative blood loss did not differ between the groups within the entire investigation period. Maximum aggregation and maximum gradient of platelet aggregation to all stimuli were not changed by either PDE-inhibitor enoximone or piroximone. CPB resulted in a significant decrease of all aggregation variables which was without differences due to treatment. Platelet aggregation recovered in the post-bypass period and exceeded baseline values on the 1st postoperative day.It is concluded that enoximone and the new PDE-III-inhibitor piroximone do not affect platelet function and can be used before CPB without risking platelet-related bleeding in cardiosurgical patients in the perioperative period.

After cardiopulmonary bypass (CPB), some patients may require circulatory support. This study examined the role of the phosphodiesterase-III inhibitor, enoximone, in cardiac surgery. Eighty patients selected by chance were allocated randomly to two groups: 40 patients received enoximone 1.0 mg kg-1 approximately 10 min before weaning from CPB and 40 served as a control group. Additional pharmacological therapy (adrenaline, noradrenaline, nitroglycerin) was given, when necessary, by anaesthetists who were not involved in the study. In addition to standard monitoring, skin capillary blood flow was assessed using a laser Doppler technique before, during and after CPB until 2 h after the end of the operation. In the period after bypass, cardiac index was always significantly greater in the enoximone than in the control group. Systemic and pulmonary vascular resistance were less in the enoximone-treated patients, indicating a reduction in right and left ventricular wall stress. Oxygen consumption in the enoximone patients was significantly greater after CPB, whereas intrapulmonary shunting was comparable in the two groups. In comparison with baseline values, skin capillary blood flow in the enoximone patients was always greater than that in the control group. In comparison with the control patients, significantly fewer enoximone patients needed adrenaline, and in a smaller dose, even 2 h after operation, whereas more enoximone patients required noradrenaline therapy for a short period. We conclude that the use of enoximone before weaning from CPB improved overall cardiac function, reduced the need of catecholaminergic inotropic support, and provided increased organ perfusion up to 2 h after operation.

The effects of aortic stenosis (AS) on right ventricular function during cardiac surgery are not fully understood. Forty patients undergoing aortic valve replacement with either a systolic transvalvular gradient of less than 100 mm Hg (82.1 +/- 5.5 mm Hg; group 1, n = 20) or greater than 120 mm Hg (131.1 +/- 6.9 mm Hg, group 2, n = 20) were investigated with regard to right ventricular function in the perioperative period. Right ventricular ejection fraction (RVEF), right ventricular end-systolic volume (RVESV), and right ventricular end-diastolic volume (RVEDV) were measured by means of the thermodilution technique. Before cardiopulmonary bypass (CPB), RVEF was significantly lower in group 2 patients (34% +/- 6%) than in group 1 (45% +/- 5%). After CPB, RVEF increased significantly in group 2 (28% +/- 4% to 49% +/- 5%), and no further differences were noted between the groups. In the patients with a higher systolic transvalvular gradient, RVEDV and RVESV were lower at the start of surgery, but increased after opening the pericardium. Cardiac index was also lower in these patients. Pericardiotomy resulted in a decrease in right ventricular end-systolic pressure (RVESP) only in the patients of group 2. In these patients more epinephrine was necessary to maintain stable hemodynamics during the post-bypass period. It is concluded that patients with AS are at risk of reduced right ventricular function when the systolic transvalvular pressure gradient is more than 120 mmHg. Knowledge of the complex interaction between the two sides of the heart may enable anesthesiologists to optimize management during the perioperative period.

Systolic, diastolic, and mean blood flow velocity in the middle cerebral artery (Vs,mca; Vd,mca; Wm,mca) and pulsatility (Vs - Vd)/Vm of the waveform obtained were recorded in 51 patients before, during and after general anaesthesia. Transcranial Doppler (TCD) sonographic variables were measured in the awake patient and after induction of anaesthesia with thiopentone 5–6 mg kg−1. After tracheal intubation, 17 patients received 0.8% halothane and 66% nitrous oxide in oxygen for 30 min (15min normoventilation; 15min hyper-ventilation). The inspired halothane concentration was then increased to 1.6% for 45min (15min normoventilation; 15 min hyperventilation; 15 min normoventilation with nitrous oxide replaced by oxygen). Enflurane (1.7% for 30 min and 3.4% for 45 min) was given to another 17 patients; 17 other patients received isoflurane (1.2% and 2.4%). Mean arterial pressure (MAP), nasopharyngeal temperature, end-tidal carbon dioxide concentration, inspired and end-tidal anaesthetic agent concentrations, haemoglobin concentration, PVC and TCD variables were measured at the end of each 15 min period. After recovery from anaesthesia, TCD variables were measured again. There were no intergroup differences in changes in MAP, nasopharyngeal temperature, haemoglobin concentration and PCV. Halothane, enflurane and isoflurane at low doses and normoventilation had little influence on TCD variables compared with awake values. In large concentrations with nitrous oxide in oxygen and normoventilation, there were differences between the volatile agents. Halothane increased blood flow velocities, but enflurane and isoflurane caused little change. Hyperventilation always decreased blood flow velocities and increased pulsatility. Six of 17 patients undergoing hyperventilation with 2.4% isoflurane and nitrous oxide in oxygen showed zero diastolic flow. This phenomenon was not observed in any patient receiving halothane or enflurane. With high doses of the volatile agents and normoventilation, blood flow velocities decreased in all groups after discontinuation of nitrous oxide. Our TCD results are compatible with the known effects of halothane, enflurane and isoflurane on cerebral blood flow (CBF). However, the relative changes in blood flow velocity and CBF may not be proportional with large doses of volatile agents, as a constant diameter of basal cerebral arteries may not be assumed under these conditions.

The ideal choice of a priming solution of the cardiopulmonary bypass (CPB) and its influence on the hemostatic system are not clear. Addition of albumin was reported to inhibit platelet damaging by blood-surface interactions ("coating"). To explore this possibility in 60 consecutive male patients undergoing elective aortocoronary bypass grafting, five different priming solutions were randomly used: (1) 1000 mL of 5% dextrose + 1000 mL of Ringer's solution (RS) + 250 mL of 5% human albumin (HA); (2) 1850 mL of RS + 400 mL of 20% HA; (3) 1750 mL of RS + 500 mL of 10% low molecular weight hydroxyethyl starch (molecular weight average: 200,000; molar substitution ratio: 0.5); (4) 1750 mL of RS + 500 mL of 3.5% gelatin; (5) 2250 mL of RS. Platelet function was studied by aggregometry (= turbidometric technique; 1.0 and 2.0 mumol/L of adenosine diphosphate (ADP), 4 microL/mL of collagen, 25 mumol/L of epinephrine) before, during, and after CPB until the first postoperative day. Blood loss and need for homologous blood was not different between the groups. During CPB, maximum platelet aggregation induced by ADP was least compromised in group 1 and group 4. At the end of the operation ADP-induced aggregation increased in group 1 (+27%), whereas aggregation was decreased in the other priming solution groups. A significant increase in maximum aggregation was found in group 1 even on the first postoperative day (+132% +/- 16%). Collagen-induced aggregation was also least compromised in group 1. Epinephrine-induced platelet aggregation did not change and was similar for all groups. Maximum gradient of aggregation was influenced in an identical way as maximum aggregation.(ABSTRACT TRUNCATED AT 250 WORDS)

Background— Percutaneous aortic valve replacement is a new emerging technology for interventional treatment of severe aortic valve stenosis in surgical high-risk patients. This study was intended to provide a summary of the development and current safety and efficacy status of the self-expanding CoreValve Revalving prosthesis. Method and Results— Between 2005 and 2008, we have enrolled 136 consecutive patients with percutaneous aortic valve replacement using the CoreValve prosthesis. In this prospective nonrandomized, single-center trial, we analyzed procedural outcome, complications and clinical status up to 1 year. First, second, and third generation of the CoreValve prosthesis were implanted in 10, 24, and 102 consecutive high-risk patients (logistic EuroScore: 23.1�15.0%) with severe symptomatic aortic valve stenosis. Mean transvalvular pressure gradient was 41.5�16.7 mm Hg. The procedural success rate increased from generation 1/2 to 3 from 70.0%/70.8% to 91.2% ( P =0.003). The 30-day combined rate of death/stroke/myocardial infarction was 40.0%/20.8%/14.7% ( P =0.11) for generation 1, 2, and 3, with no procedural death in generation 3. Pressure gradients improved significantly with a final mean gradient of 8.1�3.8 mm Hg. Overall functional status assessed by New York Heart Association class improved from 3.3�0.5 (pre) to 1.7�0.7 (post) ( P Conclusion— In experienced hands, percutaneous aortic valve replacement with the CoreValve system for selected patients with severe aortic valve stenosis has a high acute success rate associated with a low periprocedural mortality/stroke rate as well as remarkable clinical and hemodynamic improvements, which persist over time. Additional studies are now required to confirm these findings, particularly head-to-head comparisons with surgical valve replacement in different risk populations.

Heart transplantation (HTX) is a relatively new therapy that is gaining popularity for the treatment of end-stage myocardial failure in adults. This report focuses on our anaesthetic experiences in management of heart transplantation in children. Ten patients ranging in age from 5 days to 5 years and in weight from 3 to 16 kg were studied. Transplantation was successful in six cases (60%), two children died intra-operatively, most likely due to an acute right heart failure, one patient died in the post-operative period, and one child died after 2 months due to pulmonary emboli. Catecholamines were administered to eight of the patients before induction of anaesthesia. Inotropic support during and after weaning off cardiopulmonary bypass was necessary in all cases using either dobutamine and/or adrenaline. Phosphodiesterase inhibitor, enoximone, was administered in five patients. Prostaglandin E1 was used in four patients to reduce afterload of the right ventricle. Cardiac transplantation offers a challenge for the anaesthetist in the pre-bypass period as well as in the weaning and early post-bypass period. Experience is necessary to optimize anaesthetic management of these children.

We have studied the effects of two types of volume replacement on the microcirculation in an open, controlled study in 45 patients undergoing aorto-coronary bypass grafting whose pulmonary capillary wedge pressure (PCWP) was less than 5 mm Hg. Hypertonic saline prepared in hydroxyethylstarch solution (HS-HES, n = 15) and 6% HES 200/0.5 solution (6% HES; n = 15) were infused randomly before operation in order to double the PCWP. Patients not given an infusion served as controls (n = 15). Skin microcirculatory blood flow was investigated by laser Doppler flow (LDF) measured simultaneously at the forearm and forehead before and after cardiopulmonary bypass (CPB). Less HS-HES (3.8 (SD 0.3) ml kg-1) than 6% HES-solution (9.7 (1.5) ml kg-1) was necessary to double baseline PCWP. There were no differences in heart rate and mean arterial pressure (MAP) between the groups. Cardiac index (CI) increased significantly in both volume groups (HS-HES max. +54%; 6% HES max. +30%). Systemic vascular resistance (SVR) decreased after infusion of HS-HES (-30%) and after 6% HES(-19%) and remained almost unchanged in the control group. Plasma viscosity decreased after infusion of HS-HES and increased slightly in control patients (+4%). In comparison with the 6% HES and particularly with the control group, LDF was significantly greater after infusion of HS-HES (forearm +80%; forehead +28%). LDF during CPB and thereafter was always greater than baseline values in the HS-HES group, whereas after bypass LDF was reduced in the 6% HES (-5%) and particularly in the control patients (-30%).(ABSTRACT TRUNCATED AT 250 WORDS)

Hemofiltration devices and the Cell Saver are the most often used techniques to reduce homologous blood requirements in cardiac surgery. In a controlled, randomized study, 105 patients underwent elective aortocoronary bypass grafting. Six different hemofilters (HF-80, HFT 14, CPB 7000, Cobe 1200, UF-205, BC-140) were tested and compared with the Cell Saver (Cell Saver 4) for blood concentration during and after cardiopulmonary bypass. Efficacy, practicality, and laboratory indices including coagulation variables were documented through the morning of the first postoperative day. The HF-80 and UF-205 were the most effective devices for blood concentration. At the end of the operation, the number of platelets was least reduced in these two groups (HF-80, -7%; UF-205, -6%). Moreover, both devices had a significantly higher filtration rate than the other hemofilters. Use of the Cell Saver resulted in the lowest values in coagulation variables (AT-III, fibrinogen, number of platelets) and the most pronounced deterioration in protein homeostasis (colloid osmotic pressure, albumin). In this group, the AT-III concentration was reduced until the morning of the first postoperative day. No negative effects were seen in regard to hemofiltration (free hemoglobin and polymorphonuclear elastase; the Cell Saver group had similar values for these variables). We conclude that blood salvage with hemofiltration devices is superior to that with the Cell Saver. There were, however, significant differences among the hemofilters. The HF-80 and UF-205 were the most effective devices in this study.