Circulating endothelial cells demonstrate an attenuation of endothelial damage by minimizing the extracorporeal circulation

ObjectiveDetachment of endothelial cells may represent serious injury of the endothelium after cardiopulmonary bypass. We investigated whether the extent of endothelial injury is related to the type of cardiopulmonary bypass system used (conventional or minimized) and determined circulating endothelial cells as well as von Willebrand factor and soluble thrombomodulin.MethodsTwenty patients scheduled for elective coronary bypass grafting were randomly assigned to either the minimal extracorporeal circulation system or the standard cardiopulmonary bypass. Ten healthy volunteers served as controls. Circulating endothelial cells per milliliter of full blood were perioperatively determined by immunomagnetic cell separation technique. Endothelial plasma markers were measured by enzyme-linked immunosorbent assay.ResultsPreoperative circulating endothelial cell numbers did not differ between the experimental groups, but were significantly higher than in the healthy controls (18.6 ± 5.6 vs 7.2 ± 3.8, P < .001). At 6 hours, circulating endothelial cell numbers increased significantly compared with baseline in both experimental groups and peaked at 12 hours after cardiopulmonary bypass initiation, each time with significantly lower values in the minimal extracorporeal circulation group (6 hours: 44.0 ± 9.9 vs 29.6 ± 9.8, P = .007; 12 hours: 48.1 ± 6.8 vs 31.8 ± 7.1, P < .001). Likewise, von Willebrand factor and soluble thrombomodulin postoperatively increased in both groups with a tendency toward lower levels in the minimal extracorporeal circulation group. Although circulating endothelial cells gradually declined, continually with lower numbers in the minimal extracorporeal circulation group, the endothelial plasma markers remained elevated during observation time.ConclusionsCirculating endothelial cells represent a novel marker of the intrinsic endothelial damage caused by cardiopulmonary bypass. Its analysis facilitates the evaluation of cardiopulmonary bypass modifications as the minimal extracorporeal circulation system could be proven to be less injurious to endothelium and myocardium

Organ-specific regulation of pro-inflammatory molecules in heart, lung, and kidney following brain death

Nonspecific inflammatory events following brain death may increase the intensity of the immunological host response. The present study investigated the course of pro-inflammatory molecules in heart, lung, kidney, and plasma after brain death induction. Brain death was induced in five pigs by inflation of an intracranial Foley catheter and five pigs were sham-operated as controls. Each experiment was terminated 6 h after brain death/sham operation and the organs were harvested. We measured the mRNA and protein levels for TNF-α, IL-1β, and IL-6 in heart, lung, kidney, and plasma. Additionally, the mRNA expression for IL-6R, ICAM-1, MCP-1, and TGF-β was determined in each organ. After 6 h, the plasma cytokine levels were higher in the brain-dead animals than in the sham-operated. In heart, lung, and kidney there was an increase in IL-6 and IL-1β following brain death, while TNF-α was up-regulated in lung only ( P < 0.05). MCP-1 and TGF-β were significantly higher in heart and lung and IL-6R increased in heart after brain death ( P < 0.05). Brain death was associated with non-uniform cytokine expression patterns in the investigated organs. These expression patterns may cause variable pro-inflammatory priming resulting in different degrees of damage and explain the organ-specific variation in outcomes after transplantations

Placement of a left ventricular assist device in a patient with dextrocardia

Dextrocardia most commonly presents in the setting of situs inversus, but it may occur as an isolated anomaly with normal position of the abdominal organs. Herein we present a 54-year-old man with ischemic cardiomyopathy and dextrocardia with normal position of the abdominal organs who presented with an exacerbation of congestive heart failure requiring inotropic support as well as mechanical ventilation. An implantable, wearable left ventricular assist device was placed in this patient to allow for ambulation and eventual discharge home. The patient survived 4 months before he developed pneumonia and expired

LVAD coordinator effects on outcomes in patients undergoing LVAD implantation: The Methodist DeBakey Heart Center experience Betreuung von patienten an linksventrikulären unterstü tzungssystemen mittels koordinator: Erfahrungen des Methodist DeBakey Heart Centers

Linksventrikuläre mechanische Supportsysteme, left ventricular assist devices oder kurz LVAD, erlauben, Patientien mit terminalen Herzversagen bis zur Transplantation zu unterstützen. Dies hat positiven Einfluss zum einen auf die Überlebensrate als auch auf mögliche peri-operative Komplikationen. Wir berichten über unsere Erfahrungen mit einem LVAD-Koordinator, insbesondere hinsichtlich Patientengenesung und Inzidenz an Komplikationen.In der Zeit vom Juni 2000 und Januar 2002 erhielten 28 Patienten mit terminaler therapierefrakterer Herzinsuffizienz ein linksventrikuläres Assist Device, 14 Patienten in der Zeit vor Einsatz eines LVAD-Koordinators und weitere 14 Patienten unter der Betreuung eines LVAD-Koordinators. Die untersuchten Kriterien waren dabei Auftreten von Infektionen, lebensbedrohlichen Thromboembolien, Blutungsereignissen und Kostenaufwand, definiert als reine Krankenhauskosten ohne Personal- und Materialkosten.In der Prä-Koordinator-Gruppe wurden 2 Patienten mit Ihrem LVAD nach Hause entlassen, 7 Patienten (50%) entwickelten eine therapiepflichtige Infektion, 5 Patienten (35%) hatten lebensbedrohliche thrombembolische Komplikationen. 6 Patienten aus dieser Gruppe wurden transplantiert und 8 Patienten verstarben an dem Unterstützungssystem, woraus sich eine Überlebensrate von 42% errechnet. In der von einem LVAD-Koordinator betreuten Patientengruppe wurden 7 Patienten mit ihrem LVAD nach Hause entlassen, 4 Patienten entwickelten Infektionen und 1 Patient cerebrale Thrombembolien mit irreversiblen neurologischen Schäden. 10 Patienten wurden transplantiert, 3 Patienten verstarben am Assist Device und 1 Patient war bei Studienende noch am Assist Device. Die Überlebensrate in dieser Gruppe war 78%.Der Einsatz eines LVAD-Koordinators für die Betreuung von an linksventrikulären Assist Devices befindlichen Patienten trug in unserem Patienten-Kollektiv zu einer höheren Überlebensrate, niedrigeren Komplikationsrate und auch niedrigeren Krankenhauskosten bei.Use of left ventricular assist devices (LVAD) for support of endstage heart failure patients as a bridge to cardiac transplantation creates opportunities both for improved patient survival rate and for lower peri-operative complications. We investigated the effect on patient outcomes and incidence of complication of assigning an LVAD coordinator for heightened clinical monitoring and patient management in this population.Between June 2000 and January 2002, 28 patients with terminal heart failure underwent LVAD implantation, 14 patients prior to LVAD-coordinator employment and 14 patients under supervision of the LVAD coordinator. Patients’ records were retrospectively analyzed for incidence of infection, life-threatening thromboembolic and bleeding events, and hospital charges.In the pre-coordinator group, two patients were discharged home while on LVAD support. Seven patients (50%) developed infections requiring antibiotic treatment; five patients (35%) had severe life-threatening thromboembolic events. Six patients were transplanted and eight patients died while on LVAD support, giving an overall survival of 42% in this group. In the post-coordinator group, seven patients were discharged home while on LVAD support. Four patients developed infections, one patient had a severe life-threatening thromboembolic event. Ten patients were successfully transplanted, one patient is currently supported on the device, and 3 patients died, for an overall survival of 78% in this group.The use of a fulltime professional coordinator has had a beneficial impact on patient outcomes. Patient survival was improved, device-related complications were reduced and eligible patients could be discharged safely from the hospital