Bacchetta, Matthew D.

Girardi, Leonard N.

Gordon, Bruce R.

Isom, O.Wayne

Ko, Wilson

Krieger, Karl H.

Levine, Daniel M.

Moore, Matthew R.

Parker, Thomas S.

Saal, Stuart D.

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~5 
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422A ABSTRACTS - Valvular Heart Disease 
1060-132 Combination of Aspirin and Clopidogrel Exerts Superior 
Antithrombotic Potency Compared to Warfarin on 
Mechanical Heart Valves in a Rabbit Flow Chamber 
Axel Schiitt. Baerbel Hauroeder, Michael Buerke, Christoph Bickel, Dirk Peetz, Andy 
Campbell, Ferdinand Hundt, J0rgen Meyer, Hans J, Rupprecht, IL Medical Department, 
University Clinic Mainz, Mainz, Germany, Bundeswehrzentra/institut derBundeswehr 
Koblenz, Koblenz, Germany. 
Background: Lifelong oral anticoagulation (oac) is considered to be the gold standard for 
the prevention of thrombembolic events after implantation of artificial heart valves. In 
studies on the prevention of subacute coronary stent thrombosis the combination of aspi- 
rin with ADP-antagonists such as ticlopidine or clopidogrel was found to be more effec- 
tive than oac. The aim of our study is to investigate the efficiacy of the combination of 
aspirin and clopidogrel in the prevention of thrombus formation on artificial valves in an 
experimental animal model compared to an anticoagulation with cumadns. 
Methods: Antithrombotic potency was investigated in a rabbit-model using a perfusion 
chamber regarding the formation of thrombi on leaflets of Sulzer Carbomedics mechani- 
cal heart valves, 
Studies were performed after oral application of clopidogrel and aspirin in group I (n = 11) 
at best for 4 days, after minimal 5 days treatment of warfarin in group II (n = 11) and with- 
out medication in group nl (n = 5). Leaflets from mechanical heart valves were placed in 
a flow chamber. After tracheotomie and mechanical ventilation flow chamber was filled 
with blood in a circuit between art, carotis and v. jugulads. We compared the weight of 
the leaflets before and after the experiment. Further analysis were performed by electron 
microscopy. 
Results: In group III (controls) flow chamber was clotted after about 15 minutes of circula- 
tion. Comparison of weight analysis between group I and II before and after perfusion 
showed a superiority of clopidogrel/aspirin-treatment in preventing thrombus formation 
on leaflets. Mean weight difference in group I (clopidogrel/aspirin) was 11,2 mg com- 
pared to mean weight difference of 17,5 mg in group II (warfarin). 
Analysis by electron microscopy showed less fewer thrombus formation, i.e. deposition 
of platelets, fibrin and erythrocytas, on leaflets exposed to blood from rabbits in group I 
compared to group I1. 
Conclusion: Combination of clopidogrel and aspirin exerted in an experimental animal 
perfusion model compared to anticoagulation with warfarin superior potency in prevent- 
ing thrombus formation on artificial heart valve leaflets. 
1060-133 Role of Serial Troponin Testing for Diagnosis of 
Perioperative Myocardial Infarction After Cardiac 
Surgery 
Staohanie Lehrke, Evangelos Giannitsis, Margit M011er-Bardorff, Henning Steen, Arrnin 
Opitz, Hanno Peters, Uwe KH Wiegand, Hugo A Katus, Medizinische Universit~t zu 
LObeck, L9beck, Germany. 
Background.The value of serial troponin testing for diagnosis of perioperative myocardial 
infarction (MI) after major cardiac surgery is still unsettled. 
Methods, We studied 204 patients undergoing major cardiac surgery, including CABG 
(132/204) and valve surgery (36/204). Cardiac troponin T (cTnT) was measured before 
crossclamping and sedally at 4, 8, 24 hours and once daily thereafter for 7 days. Periop- 
erative MI was defined as new evolving Q-waves on serial ECGs, ROC analysis was per- 
formed to obtain the optimal cTnT discriminator for perioperative MI at different time 
points. 
Results. A total of 13/204 patients suffered a perioperative MI. In these patients, cTnT 
levels at all time-points beyond 8 hours and peak cTnT levels were higher compared to 
patients without pedoperative MI (figure). ROC analysis yielded an optimal discriminator 
above 1.26 pg/L at 24 hours (AUC 0.69,sens 54%, spec 87%). In addition, time to peak 
was higher in patients with perioperative MI (43.4 vs 26.4h, p=0.03). 
Conclusions. Serial cTnT testing may be useful in identifying patients with a pedoperative 
myocardial infarction following major cardiac surgery. 
cTnT_AMI 
4- 
2- t 
20 40 60 80 100 120 14(] 16(] 
sampling time [hours] 
180 
JACC March 6, 2002 
1060-134 The Utility of the ACCIAHA Guidelines for Screening 
Angiogrephy in Patients Undergoing Surgical Repair for 
Mitral Regurgitation 
Eric Lim, Zied AlL Clifford Barlow, A. R. Hosseinpour, James C. Halstaad, Christopher 
Wisbey, Susan C. Charman, John B. Badow, Francis C. Welts, Papworth Hospital, 
Cambridge, United Kingdom, University of Witwatersrand and Johannesburg Hospital, 
Johannesburg, South Africa. 
Background: As routine screening angiography is performed for the majority of patients 
undergoing mitral repair at our institution, we evaluated the utility of the 1998 ACC/AHA 
guidelines on a review of 400 patients who underwent surgery for mitral regurgitation 
from 1987 to 1999. 
Methods: Coronary angiography was performed and disease defined as lumen narrow- 
ing of >= 50%. Risk factors for coronary disease were: age (males > 35 or females >51 
years), family history, smoking, diabetes, and hypercholeetarolemia. Evaluated ACC/ 
AHA indications were: history of angina / MI and presence of >= 1 risk factor. Etiology 
was determined by histopathology of operative valve specimens. Sensitivity (Sn), speci- 
ficity (Sp) and likelihood ratio positive (LR+) for coronary disease on angiography were 
calculated for each risk. 
Results: Of 400 patients, angiographic details were unavailable in 12 (3%), and 29 
(7.5%) had no angiography due to emergent status (24 with and 5 without defined indica- 
tions). Angiography was performed in 359 (92.5%) patients with a mean age of 65 (± 10) 
years consisting of 234 (65.2%) males. The etiologies for mitral disease were degenera- 
tive (82.7%), rheumatic (7.0%), ischemic (5.6%) and endocarditis (4.7%). 
Prevalence of coronary disease and proportion of concomitant bypass surgery was 
28.1% and 22.3% respectively. 
Proportion of patients fulfilling either indication for angiography was 99.4%, Sn 1.00, Sp 
0.01, LR+ 1.01, with age criterion alone in 98.1%, Sn 1.00, Sp 0.03, LR+ 1.03, Angina 
was present in 30.9%, Sn 0.59, Sp 0.80, LR+ 3.01. 
Of 248 patients without angina or MI, indications were: hypertension in 24.6%, Sn 0.26, 
Sp 0.87, LR+ 1.98; hypercholesterolemia in 43.1%, Sn 0.20, Sp 0.89, LR+ 1.85; smoking 
in 26,6%, Sn 0.24, Sp 0.86, LR+ 1.77; diabetes in 5.6%, Sn 0.21, Sp 0.84, LR+ 1.30 and 
family history in 9.6%, Sn 0.17, Sp 0.83, LR+ 1.01. 
Conclusions: ACC / AHA guidelines have excellent Sn, but very low Sp. Similar result is 
achieved with age as the sole criterion for angiography. Angina was the best predictor of 
coronary disease. Almost all patients quality for angiography, but only a minority had con- 
comitant bypass surgery. More stringent criteria may improve the cost effectiveness of 
the guidelines. 
1060-135 Elevated Serum Interleukin-6 Has Prognostic 
Significance for Postoperative Outcome in Patients 
Undergoing Cardiothoracic Surgery 
Matthew D. Bacchetta. Matthew R. Moore, Daniel M. Levine, Thomas S. Parker, Bruce 
R, Gordon, O. Wayne Isom, Karl H. Kdeger, Leonard N. Girardi, Wilson Ko, Stuart D. 
Saal, New York Presbyterian Hospital-Weill Medical College of Comell University, New 
York, New York, Rogosin Institute at Rockefeller Universi~ New York, New York. 
Inflammatory cytokines become elevated during cardiothoracic surgery procedures. 
Many studies have sought to charactedze the differences in cytokine expression based 
on technical approaches, e.g. pump vs. off-pump CABG surgery. We undertook a pro- 
spective study to investigate the relationship between the inflammatory cytokines, IL-8, 
slL-2R, sTNF-R (p55), and sTNF-R (p75), and clinical outcomes as prognostic predictors 
of post-operative management and outcome in patients (n=65) who had cardiothoracic 
operations. Three sequential blood samples were collected: (1) prior to induction of anes- 
thesia, (2) completion of surgery, and (3) 24-hours after the induction of anesthesia. Pre- 
determined clinical outcome measures included ICU length of stay (ICULOS), total length 
of stay (TOTLOS), post-operative ventilation duration (VentTime), duration of vasopres- 
sor (PressorTime) and inotropic (InotropeTime) requirements, and complication rate. The 
pre-operative cytokine levels did not correlate with the outcome data, however IL-6 levels 
from time points 2 and 3 were found to have independently demonstrated statistically sig- 
nificant prognostic value in regard to the pre-determined outcome measures, ICULOS 
(p<0.01), TOTLOS (p<0.02), Vent'rime (p<0.01), PressorTime (p<0.01), and Inotrope- 
Time (p<0,01). slL-2R, sTNF-R (p55), and sTNF-R (p75) had less influential prognostic 
significance. Operative Bypass time independently showed prognostic value for ICULOS 
(p<0.01), TOTLOS (p<0.01), and PressorTime (p<.01). Elevated levels of cytokines 
cause Systemic Inflammatory Response Syndrome (SIRS) in patients undergoing car- 
diothoracic procedures, which manifest as increased ICULOS, TOTLOS, ventilatory sup- 
port, inotropic and vasopressor requirements. Of the operative variables, bypass time 
had the greatest prognostic value. IL-6 appears to play a major role in mediating post- 
operative outcome and may facilitate decision-making for critically ill cardiothoracic 
patients. 
1060-136 Use of Subeternal Echocardiogrephy in Patients on 
Ventricular Assist Devices: initial Experience 
John D. Blizzard. H. Storm Floten, Mathew Slater, Robert Lowe, David J. Sahn, Anthony 
J. Furnary, Oregon Health & Science University, Portlanc), Oregon. 
Background: Echocardiography is sometimes difficult in postop patients who may have 
dressings, poor windows and are difficult to reposition. Transesophageal echo carries the 
disadvantages of patient stress, respiratory compromise or the need to further sedate 
conscious patients. We have previously reported a dual lumen chest tube drain device 
with a sealed substernal echocardiography (SEE) lumen 36 Fr (SEE-IT® Medtronics 
Corporation) that allows insertion of a 10.2mm non-stedle minimultiplane TEE probe into 
a substernal position where it can be positioned and rotated for cardiac imaging intra- 
and postoperatively. Methods: At OHSU, 5 patients were studied serially for periods of 
up to 5 days with intermittent echo imaging performed by surgeons on their rounds used 


Elevated serum interleukin-6 has prognostic significance for postoperative outcome in patients undergoing cardiothoracic surgery 

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Elevated serum interleukin-6 has prognostic significance for postoperative outcome in patients undergoing cardiothoracic surgery

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