Leukocyte depletion results in improved lung function and reduced inflammatory response after cardiac surgery

AbstractLeukocyte depletion during cardiopulmonary bypass has been demonstrated in animal experiments to improve pulmonary function. Conflicting results have been reported, however, with clinical depletion by arterial line filter of leukocytes at the beginning of cardiopulmonary bypass. In this study, we examined whether leukocyte depletion from the residual heart-lung machine blood at the end of cardiopulmonary bypass would improve lung function and reduce the postoperative inflammatory response. Thirty patients undergoing elective heart operations were randomly allocated to a leukocyte-depletion group or a control group. In the leukocyte-depletion group ( n = 20), all residual blood (1.2 to 2.1 L) was filtered by leukocyte-removal filters and reinfused after cardiopulmonary bypass, whereas in the control group an identical amount of residual blood after cardiopulmonary bypass was reinfused without filtration ( n = 10). Leukocyte depletion removed more than 97% of leukocytes from the retransfused blood ( p < 0.01) and significantly reduced circulating leukocytes ( p < 0.05) and granulocytes ( p < 0.05) compared with the control group. Levels of the inflammatory mediator thromboxane B 2 determined at the end of operation ( p < 0.05) were significantly lower in the depletion group than in the control group, whereas no statistical differences in interleukin-6 levels were found between the two groups. After operation, pulmonary gas exchange function (arterial oxygen tension at a fraction of inspired oxygen of 0.4) was significantly higher in the leukocyte-depletion group 1 hour after arrival to the intensive care unit ( p < 0.05) and after extubation ( p < 0.05). There were no statistical differences between the two groups with respect to postoperative circulating platelet levels and blood loss, and no infections were observed during the whole period of hospitalization. These results suggest that leukocyte depletion of the residual heart-lung machine blood improves postoperative lung gas exchange function and is safe for patients who are expected to have a severe inflammatory response after heart operations. (J Thorac Cardiovasc Surg 1996;112:494-500

Intra-arterial Digital Subtraction Angiography (DSA) as an Outpatient Screening Method for the Follow-Up of Graft Patency in Coronary Surgery

In order to determine whether intra-arterial digital subtraction angiography (= DSA) is a suitable screening method to visualise graft patency and to determine whether DSA can be performed on an outpatient basis, we studied 73 patients shortly after coronary bypass surgery. In two patients DSA was precluded due to technical problems. The patency of the grafts was adequately visualised by means of DSA in 68 of the remaining 71 patients. During the DSA procedure complications occurred in two patients without serious consequences and bleeding at the puncture site was not observed in any patient whether mobilised at 24 or only 2 hours. We conclude that intra-arterial DSA is a suitable screening method to visualise patency in coronary bypass grafts and that it can be performed safely on an outpatient basi

In-hospital mortality and three-year survival after repaired acute type A aortic dissection

Background. The results of acute type A dissection (AAD) surgery in the Netherlands are largely unknown, as was recently stated in a report by the Health Council of the Netherlands. In order to gain more insight into the Dutch situation we investigated predictors of in-hospital mortality of surgically treated AAD patients and assessed threeyear survival

Comparison of late (four years) functional health status between percutaneous transluminal angioplasty intervention and off-pump left internal mammary artery bypass grafting for isolated high-grade narrowing of the proximal left anterior descending corona

In a 4-year follow-up study, we compared functional health status (FHS) in patients randomized to surgery (n = 51) or angioplasty (n = 51) for an isolated narrowing of the proximal left anterior descending coronary artery. FHS was assessed with the Short Form-36 and the Minnesota Living with Heart Failure questionnaires. Although the occurrence of angina (p = 0.036) and major adverse cardiac and cerebrovascular events (p = 0.02) was significantly higher 4 years after angioplasty, FHS did not differ between treatments and was comparable to a healthy reference population

Are the outcomes of clinical pathways evidence-based? A critical appraisal of clinical pathway evaluation research

Aim and objective To evaluate the validity of study outcomes of published papers that report the effects of clinical pathways (CP). Method Systematic review based on two search strategies, including searching Medline, CINAHL, Embase, Psychinfo and Picarta from 1995 till 2005 and ISI Web of Knowledge (SM). We included randomized controlled or quasi-experimental studies evaluating the efficacy of clinical pathway application. Assessment of the methodological quality of the studies included randomization, power analysis, selection bias, validity of outcome indicators, appropriateness of statistical tests, direct (matching) and indirect (statistical) control for confounders. Outcomes included length of stay, costs, readmission rate and complications. Two reviewers independently assessed the methodological quality of the selected papers and recorded the findings with an evaluation tool developed from a set of items for quality assessment derived from the Cochrane Library and other publications. Results The study sample comprised of 115 publications. A total of 91.3% of the studies comprised of retrospective studies and 8.7% were randomized controlled studies. Using a quality-scoring assessment tool, 33% of the papers were classified as of good quality, whereas 67% were classified as of low quality. Of the studies, 10.4% controlled for confounding by matching and 59.1% adopted parametric statistical tests without testing variables on normal distribution. Differences in outcomes were not always statistically tested. Conclusion Readers should be cautious when interpreting the results of clinical pathway evaluation studies because of the confounding factors and sources of contamination affecting the evidence-based validity of the outcomes

EuroSCORE predicts poor health-related physical functioning six month postcoronary artery bypass graft surgery

AIM: The objectives of this study are to test whether the European system of cardiac-operative risk evaluation score (EuroSCORE) is associated with preoperative health-related quality of life (HRQoL), and whether it is a predictor of mental and physical health-related quality of life six months after coronary artery bypass grafting (CABG). METHODS: A longitudinal observational study was carried out among 181 patients who underwent CABG. Physical and mental domains of quality of life were measured using SF-36 and risk stratification was estimated using the EuroSCORE. A post hoc test (with Bonferroni correction) was used to determine whether EuroSCORE was associated with preoperative HRQoL, LOS and postoperative rate of complications. Hierarchical regression analysis was performed to explore the associations between EuroSCORE, postoperative events and postoperative HRQoL. RESULTS: EuroSCORE is associated with physical functioning before and after CABG and a higher EuroSCORE is a predictor of poor physical functioning and not a predictor of the mental domains of quality of life, while smoking predicted bodily pain after CABG. Furthermore, readmission within six weeks after discharge was a predictor of poor physical functioning, physical role and general health. Moreover, post hoc tests showed statistically significant and clinically relevant differences in physical functioning between low-risk and high-risk EuroSCORE classes, and between medium and high classes at baseline and six months after CABG. High-risk patients had more perioperative complications and longer lengths of stay, as compared to low-risk patients. CONCLUSION: EuroSCORE is a predictor of poor self-reported physical functioning six months after CABG and is not a predictor of mental functioning

Impaired Right Ventricular Ejection Fraction after Cardiac Surgery is Associated with a Complicated ICU Stay

Raw data concerning a retrospective study titled: 'Impaired Right Ventricular Ejection Fraction after Cardiac Surgery is Associated with a Complicated ICU Stay' These data belong to a yet unpublished manuscript. Once the manuscript is published, the data will be available

Hybrid approach for complex coronary artery and valve disease: a clinical follow-up study

Background. For patients suffering from complex coronary artery disease (CAD) with or without concomitant valve disease, no evidence is available in the current guidelines to propose a predefined treatment regimen. We sought to assess the clinical impact of an unconventional or extended definition of the hybrid approach that combines percutaneous coronary intervention (PCI) and cardiac surgery in subjects suffering from severe solitary CAD or combined with valve disease. Methods and results. Between July 2002 and August 2004, 18 consecutive patients with complex CAD with or without significant valve disease who qualified for a hybrid approach were enrolled in a clinical follow-up study. Four patients eventually did not complete the proposed interventions. One patient refused treatment after inclusion, one patient died before treatment could be undertaken and two patients died after surgery but before PCI. In the other 14 cases combined treatment was technically successful. After a mean follow-up period of 15 +/- 5 months two patients had died, one due to sudden cardiac death and one of a noncardiac cause. No other major adverse clinical events were reported. A marked increase in quality of fife was reported in those alive. Conclusion. Hybrid approach had a favourable long-term outcome in patients with complex cardiovascular disease undergoing successful treatment; however, this was observed at the expense of significant periprocedural mortality in these high-risk subjects. Therefore we believe that hybrid approaches may provide an alternative for selected cases