Heart and vessels
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Cardiopulmonary bypass (CPB) is associated with an inflammatory response, mainly caused by the trauma of surgery, contact of blood with the artificial surface of the circuit, and reperfusion injury, resulting in increased capillary permeability, respiratory distress, low cardiac output, and multiorgan failure. The inflammatory reaction includes an activation of the humoral and cellular immune system with enhanced release of cytokines. The present study focused on the effect of CPB on the time course of pro- and anti-inflammatory cytokines. ⋯ IL-4 and IL-10, respectively, revealed maximal concentrations of approximately 2 pg/ml (0/39 pg/ml; lower/upper quartiles, respectively) and 208 pg/ml (76 pg per ml/380 pg per ml; lower/upper quartiles, respectively) immediately after protamine administration, preceding the maximal concentration of IL-6. The degree of the observed modulation of cytokine patterns during and after CPB seemed to be patient-dependent, since large interindividual variations in cytokine levels were observed, not only preoperatively, but especially during and following CPB. However, IL-6 and IL-10 showed the least interindividual variations, suggesting that these cytokines may give reliable information regarding modulation of the immune response following CPB and its consequences for the patient's outcome.
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Intraluminal movements of pulmonary artery catheters are seldom considered, although they may have a significant impact on flow measurement and safety. The purpose of this study was to document the movements of these catheters within the heart cycle, and to establish whether any patterns existed. We analyzed two-dimensional real time echocardiography cross-sectional images of the human pulmonary artery in 20 patients, plotting the position of the intra-arterial catheter frame-by-frame onto a standardized template. ⋯ We observed significant movement of the pulmonary artery catheter throughout the heart cycle, without any predictable pattern. Although we did not specifically investigate the effect of these movements on cardiac output, they imply that intra-arterial Doppler flow measurements from the pulmonary artery may be inaccurate, since a stable catheter position, and hence, a sample volume, cannot be ensured. Further speculation can be made on the implications of these movements in regard to thermodilution cardiac output and safety.
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Randomized Controlled Trial Comparative Study Clinical Trial
Centrifugal and roller pumps--are there differences in coagulation and fibrinolysis during and after cardiopulmonary bypass?
A number of hemostatic parameters reflecting the activation of coagulation and fibrinolysis were investigated in a prospective study of 24 patients undergoing cardiopulmonary bypass (CPB) during heart surgery. The patients were randomized to a group in which either a roller (group 1) or a centrifugal pump (group 2) was used. Blood samples were taken preoperatively, at the onset of and every 20 min during CPB, after the administration of protamine, and 4, 20, 44, and 68 h postoperatively. ⋯ Significant differences in favor of group 2 during and after CPB were found in prothrombin fragment F1 + 2, plasmin-antiplasmin complex (PAP), thrombin-antithrombin complex (TAT), and D-dimer (F1 + 2 P < 0.01 after 80-min CPB, PAP P < 0.005 after 40-min CPB, TAT and D-dimer P < 0.05 after 100-min CPB, D-dimer and PAP P < 0.05 after protamine administration, TAT and F1 + 2 4 h after CPB). These findings indicate the activation of fibrinolysis preceding thrombin generation during cardiopulmonary bypass. In addition, we conclude that centrifugal blood pumping is beneficial in avoiding excessive activation of both coagulation and fibrinolysis.
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Comparative Study
Comparison of hemodynamic data before and after corrective surgery for Down's syndrome and ventricular septal defect.
Left ventricular function and the extent of pulmonary vascular disease were studied in 18 children with Down's syndrome and 20 children without Down's syndrome who underwent corrective surgery for ventricular septal defect (VSD) and severe pulmonary hypertension. This study was conducted between 1985 and 1993. All patients underwent routine cardiac catheterization preoperatively and postoperatively (mean, 11.4 months after surgery). ⋯ Some degree of irreversible pulmonary vascular disease was present after repair of VSD in patients with Down's syndrome. In the Down group, there were no significant changes in left ventricular function after surgery, despite the relief of volume overload. These results suggest that early diagnosis and surgical repair are key elements in the management of patients with Down's syndrome and VSD.
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The objective of the study was to develop a non-invasive method for the quantitative evaluation of cardiovascular performance and ventricular-arterial (VA) coupling during varying physiological states. VA-coupling was represented by the ratio between the arterial and ventricular elastances-Ea/Ees. Approximate indices of the relative change of Ees and VA-coupling during stress were developed and tested. ⋯ All three groups showed similar relative increases in Ees and heart rate, but relative Ea increased in P2 and decreased in H, while the opposite was found for the end-diastolic volume. The relative VA-coupling index in P2 was significantly larger than that in P3 and H (P < 0.05). The present non-invasively based indices can be used to quantitatively monitor the individual cardiovascular response to stress testing or drug interventions and to evaluate the importance of VA-coupling in the clinical setting.