Background and Goal of Study: Following the publications of increased mor- tality with aprotinin in cardiac surgery patients, most cardiac surgery centers switched to tranexamic acid as antifibrinolytic. This retrospective study com- pares the effect of this switch on morbidity and mortality in our hospital. Materials and Methods: We compared patients undergoing cardiac surgery with cardiopulmonary bypass in 2006 (N=261), all of them received high-dose aprotinin, i.e. 2•10 6 KIU as a bolus, 2•10 6 KIU in the pump priming and a con- tinuous infusion of 0.5•10 6 KIU/h, with patients in 2008 (N=288) who received tranexamic acid, 30 mg/kg as bolus, 2 mg/kg in the pump priming and an infusion of 16 mg/kg/h. We compared overall mortality and morbidity, as well as transfusion requirements. Continuous variables were analyzed by t-test and categorical variables by Chi-square test. A p value < 0.05 was considered significant. Results and Discussion: The change from aprotinin to tranexamic acid was not associated with a higher use of blood products. Other studies concluded also to an equal effectiveness of aprotinin and tranexamic acid in reducing transfusion requirements. We did not observe a change in mortality/morbid-ity, except a higher rate of new onset of atrial fibrillation in the tranexamic acid group. This may be related to a sicker population as indicated by a higher NYHA class and higher ASA score. Background and Goal of Study: Extracorporeal circulation implies changes in coagulation mechanisms; hyperfibrinolysis is one of the causes of perioperative bleeding. Objective: to compare the use of low dosages of tranexamic acid (TA) and epsilon aminocaproic acid (EACA) in the prophylaxis of excessive bleeding in cardiovascular surgery. Materials and Methods: A prospective study was blindly carried out in 100 patients programmed for heart surgery. This group was divided randomly into two groups, with 50 patients in each of them: EACA (E) and TA (T). All patients were treated with the same anaesthetic, surgical and extracorporeal circulation proto- cols. Group E patients were given 100-125mg/kg of EACA once the i nduction and the ECC were done. Group T patients were given 10 mg/kg of TA at the same moments of surgery. The level of statistics significance was p < 0.05. Results and Discussion: The bleeding of the first day (p > 0.05) was higher than that of the second day in Group T (518 ± 249 vs.

comparing the different experimental stages. PPV and SVV, as well as CVP and PCWP showed a close correlation during changing loading conditions, whereas there was no correlation with the percentage change of SVI ( SVI) after volume loading. GEDV significantly correlated with SVI, GEDV and with SVI (r 0.66, r 0.80, r 0.45). Conclusion(s): In this experimental paediatric model, GEDV was the only variable to accurately reflect cardiac preload, suggesting that GEDV might be superior in guiding fluid therapy in children. References: 1 Kumar et al.; 2004, Crit Care Med 8:128–136. 2 Michard et al.; 2003, Chest 124:1900–1908.

BACKGROUNDDuring total intravenous anaesthesia, the target controlled infusion concentration of remifentanil can be achieved either in limiting maximum plasma concentration (Cp) to the effect site target concentration which corresponds to a plasma TCI technique (pTCI) or as fast as possible to achieve the effect-site target without limiting Cp (eTCI). The aim of this study was to compare the haemodynamic effects of remifentanil pTCI and eTCI during induction of anaesthesia in ASA III patients undergoing cardiac surgery.METHODS28 ASA III patients, scheduled for cardiac surgery, were randomized in two groups: Group pTCI received remifentanil to achieve an effect-site target of 15 ng ml(-1) by limiting Cp to 15 ng ml(-1) and group eTCI received remifentanil to achieve an effect-site target of 15 ng ml(-1) without limiting remifentanil Cp. Before induction, all patients received 30 microg kg(-1) of midazolam intravenously and 2 ml kg(-1) of a gelatin solution. Heart rate, invasive arterial pressure and bispectral index were continuously measured. Differences from baseline values were compared between the two groups using a Mann-Whitney U test. Baseline population characteristics were compared using an analysis of variance.RESULTSThere were no significant differences in haemodynamic parameters between the two groups. In the group pTCI final effect-site concentration was reached in 7.3 +/- 1.4 minutes and in the group eTCI in 2.2 +/- 0.2 minutes (p < 0.05).CONCLUSIONIn ASA III patients scheduled for elective cardiac surgery, remifentanil eTCI can be preferred to remifentanil pTCI for induction because of its shorter onset with the same haemodynamic stability.

Changes of lipoprotein composition have been mainly reported in conditions of sepsis. This study characterized compositional changes in LDL and HDL during the acute phase response following cardiac surgery with cardiopulmonary bypass. Twenty-one patients undergoing cardiac surgery were included in this study. Blood samples were drawn before operation and on day 2 post-surgery. In parallel to plasma lipids and antioxidant status, lipoproteins were analyzed for lipid, apolipoprotein (apo), hydroperoxide and alpha-tocopherol content. Beyond decreases in lipid concentrations and antioxidant defenses, cardiac surgery induced substantial modifications in plasma lipoproteins. ApoB decrease in LDL fraction (-46%; P < 0.0001) reflected a marked reduction in the circulating particle number. LDL cholesteryl ester content relative to apoB concentration remained unchanged post-surgery while triglyceride (+113%; P < 0.001), free cholesterol (+22%; P < 0.05) and phospholipid (+23%; P < 0.025) were raised relative to apoB indicating increased particle size. In HDL, an abrupt rise of apoSAA (P < 0.05) was observed together with a decrease of apoA1 (-22%; P < 0.005). Cholesteryl ester content in HDL fraction decreased in parallel to apoA1 concentration while triglycerides, free cholesterol and phospholipids increased relative to apoA1. In contrast to unchanged alpha-tocopherol content, hydroperoxide content was increased in LDL and HDL. By comparison to sepsis, cardiac surgery induces a comparable reduction in circulating LDL but a more limited decrease in HDL particles. Furthermore, in contrast, cardiac surgery induces an increase in polar and non-polar lipids, as well as of particle size in both LDL and HDL.

Schmitz, L.; Melot, C.; Hein, T.; Barvais, L.; Dejonckheere, M.; Schmartz, D.; Ducart, A. Author Information

Data on the effects of isovolemic hemodilution (IH) on oxygenation during one-lung ventilation (OLV) are lacking. We studied 47 patients with hemoglobin >14 g/dL who were scheduled for lung surgery (17 with normal lung function [group NL], 17 with chronic obstructive pulmonary disease [COPD] [group COPD], and 13 with COPD as control for time/anesthesia effects [group CTRL]). Anesthesia was standardized. The tracheas were intubated with a double-lumen tube. Ventilatory settings and fraction of inspired oxygen remained constant. The study was performed with patients in the supine position before surgery. OLV was initiated for 15 min. Two-lung ventilation was reinstituted, and IH was performed (500 mL); an identical volume of hydroxyethyl starch was administered. Subsequently, OLV was again performed for 15 min. In group CTRL, the same sequences of OLV were performed without IH. At the end of each period of OLV, pulmonary mechanics and blood gases were recorded. Data were analyzed by analysis of variance (mean +/- sd). In group NL and group CTRL, the arterial oxygen partial pressure remained constant, whereas it decreased in group COPD from 119 +/- 21 mm Hg before IH to 86 +/- 16 mm Hg after IH (P <0.01). Mild IH impairs gas exchange during OLV in COPD patients, but not in patients with normal lung function.

A bstract : Cardiac surgery was associated with a marked reduction in circulating LDL and HDL particles, which in turn largely affectd α‐toc transport. α‐toc was decreased in WBCs but not in PLTs and RBCs. An increased hydroperoxide content was observed in LDL and possibly in HDL after cardiac surgery.

The Department of Anesthesiology and Reanimation is organised in units with clinical activities, which include the pre-operative care of patients, anesthesiological care and immediate post-operative supervision. Two post-operative treatment rooms also form part of the department. The main fields of research of the various units result from collaborations with other departments of Hôpital Erasme, in particular with regard to the development of advanced techniques or fit within the confines of the speciality.

A 51-year-old man with a history of unstable angina was scheduled for CABG surgery. He had no history of a prior general anesthetic or allergies. He sustained a Q-wave inferior myocardial infarction 12 years ago, and his ejection fraction was 54%. Current medications were nisoldipine, 5 mg, a calcium channel blocker; celiprolol, 200 mg, a P-blocker; and md the peak inspiratory pressures were normal. Intravenous epinephrine was administered at a dose of 200 pg, repeated 1 minute later, and followed by a continuous infusion at a rate of 0.2 pg/kg/min. The propofol infdsion was then stopped. In addition, hemodynamic stabilization required volume loading with crystalloids and the percutaneous placement of an intraaortic balloon pump. Isoflurane was gradually introduced with midazolam and a continuous infusion of morphine to replace the anesthetic drugs used during the induction. As the hemodynamics improved, epinephrine was progressively reduced and discontinued over 90 minutes. The surgical procedure was uneventful. Weaning hrn cardiopulmonary bypass was possible without inotropes. Extubation was performed 8 hours

A case of patent foramen ovale opening was observed concomitantly to a defibrillation threshold determination in the setting of an internal cardioverter defibrillator implantation. The subsequent transient right-to-left shunt was confirmed by a peroperative transoesophageal echocontrast study. The underlying mechanism of this incident may be related to a transient reversal of the interatrial gradient, due to the pre-existence of pulmonary hypertension and tricuspid regurgitation, associated with ongoing mechanical ventilation and modifications of intracardiac pressures regimen secondary to the succeeding ventricular tachyarrhythmia and defibrillation. Paradoxical embolism can be an aetiology for neurologic injury during internal cardioverter defibrillator implantation.

Background: The estimation of left ventricular (LV) contractility is difficult in the presence of significant mitral regurgitation (MR). Prediction of LV performance after MR repair is even more problematic. The intraoperative Doppler-derived LV rate of pressure rise (LV Delta P/Delta t) analyzed before cardiopulmonary bypass (CPB) was presumed to be a useful predictive parameter for LV performance. Therefore, its relation to perioperative inotropic requirements (PIR) necessary for separation from CPB after surgical MR repair was investigated.Methods: Twenty-eight patients scheduled for surgical MR repair fulfilled the selection criteria. Pre-CPB LV Delta P/Delta t, pre-CPB echocardiographic LV fractional area change (LV FAG), and pre-CPB thermodilution-derived cardiac index (CI) were recorded. After MR repair, separation from CPB was performed with regard to standardized guidelines. PIR during the first 60 minutes following separation were recorded.Results:Pre-CPB LV Delta P/Delta t could be assessed in 22 patients. Pre-CPB LV Delta P/Delta t was 882 +/- 450 mmHg/sec, pre-CPB LV FAC was 49% +/- 9%, and pre-CPB CI was 2.0 +/- 0.2 L/kg/min. Pre-CPB LV Delta P/Delta t was significantly correlated with pre-CPB LV FAC (r=0.56), and with pre-CPB CI (r = 0.72). Inotropic support was necessary in 16 patients (73%), and was best predicted by the pre-CPB LV Delta P/Delta t, by means of logistic regression (p = 0.026).Conclusions: Doppler-derived LV Delta P/Delta t was assessable in most patients with severe chronic MR, and was the best intraoperative predictive parameter of post-CPB inotropic requirements after surgical MR repair. Copyright (C) 1998 by W.B. Saunders Company.

Introduction: Left ventricular (LV) rate of pressure rise (LV Delta P/Delta t) derived from the continuous Doppler profile of mitral regurgitant jet has been proven to be a reliable [1] and reproducible [2] index of peroperative LV performance in the presence of mild to moderate chronic mitral regurgitation (MR). This study was designed to precise the accuracy of the method in presence of unstable acute MR. Methods: The study conformed to the guiding principles of the AHA guidelines for animal research. Ten pigs (25-30 kg) were anesthetized, intubated and ventilated. Monitoring included left atrial pressure (LAP) line, LV micromanometer-tipped catheter and epicardial echocardiography. MR were created by repetitive echo-guided sections of mitral chordae tendinae by use of endoscopic scissors inserted through LV apex. Data were collected after induction of anesthesia (T0) and at three successive grades of MR (T1-3). MR were quantificated by the mitral to aortic velocity-time integral ratio (VTImit/VTIao) [3]. Doppler derived LV Delta P/Delta t (Dop LV Delta P/Delta t) was calculated according to Bargiggia et al. [4], and peak LV Delta P/Delta t was derived from LV catheterism data. All measurements were made blindly off-line and averaged from three successive cardiac cycles. In order to avoid interference with Dop LV Delta P/Delta t calculation caused by MR-related elevated LAP, data characterized by LAP > 20 mmHg were rejected. Values are expressed as mean +/- SD. Results: Data are summarized in Table 1.Table 1Discussion: These data seems to validate Dop LV Delta P/Delta t measurements in the setting of unstable acute MR. The accuracy of the method was not affected by acute increase of MR in a range of VTImit/VTIao values from 0.98 +/- 0.1 to 1.09 +/- 0.04 and in presence of LAP not exceeding 20 mmHg.

Two cases of casual discovery of persistent left superior vena cava during cardiac surgery are reported. Diagnoses were suspected at the time of peroperative transoesophageal echocardiography in the first case, and of preoperative fluoroscopy during a Swan-Ganz catheter insertion procedure in the second case. For both patients, a peroperative echo contrast study permitted to confirm the anomaly before initialization of cardiopulmonary bypass. Embryology, echocardiographic findings and surgical management, including cardioplegia delivering and left upper venous system drainage, are reviewed.