Background Pericardial effusion is common in pregnancy, with causes similar to the general population. Usually, it is found in the third trimester and disappears spontaneously after labour; however, there is a risk of progression to tamponade. Management is based on expert opinion, since few studies have been published.Case summary A woman with enlargement of a known, chronic, presumably idiopathic pericardial effusion, in the 17th gestation week, presented with mild dyspnoea, without specific echocardiographic signs of cardiac tamponade. She received double antithrombotic treatment with aspirin 100 mg, started before conception, and a prophylactic dose of tinzaparin 4500 IU, started at the beginning of the pregnancy due to obstetrical antiphospholipid syndrome. A multidisciplinary team consisting of the treating obstetrician-gynaecologist, haematologist, cardiothoracic surgeon, and cardiologist discussed the management, taking into account the large size of the effusion and the significant increase during pregnancy, the possibility of further increase during the third trimester, the antiplatelet and antithrombotic treatment, which increased the haemorrhagic risk, and the difficulty and risk to intervene later in pregnancy. A surgical pericardial window was proposed to the patient and family and was performed uneventfully.Discussion This case demonstrates the importance of a multidisciplinary team approach and shared decision-making in the management of these complex cardio-obstetric patients in order to achieve optimal therapeutic results.

Abstract Funding Acknowledgements Type of funding sources: None. Background The current guidelines about dyslipidemia classify coronary artery bypass grafting surgery (CABG) patients, as a very high-risk population. This is translated to a LDL-target ≤ 55mg/dL, based on observational studies that demonstrate better vein graft patency and deceleration of the native vessels’ atherosclerosis. Despite the well-defined benefit, the compliance of statin therapy at the secondary prevention is ailing. Purpose To capture and evaluate the trajectory of statin compliance during 4 years follow-up in patients after CABG, in a middle-income country. Methods This is a single-center, cohort, observational study, conducted in 365 consecutive post-CABG patients, from 2018-2021. We used data from the electronical files of the patients and the national electronical prescription platform, after consent. The follow-up period was divided: t1 = 6 months, t2 = 1 year, t3= 2 years, t4 = 3 years, and t5= 4 years. We defined as potent statin therapy the administration of ≥ 40mg of atorvastatin, ≥ 20mg of rosuvastatin or the concomitant use of ezetimibe. Results We included 365 patients, 52 females (14.4%). The median age was 69 years (ΙQR: 47-84). The indication for CABG was 65.7% an acute coronary syndrome and 34.3% stable coronary disease. At baseline, the mean LDL value was 108mg/dL, whereas one month post procedure was 71mg/dL, indicating reduction: Δ=34%. Alas, the achieved post-CABG LDL-level still is beyond the target of ≤ 55mg/dL. At t0 (discharge) the percentage of prescribed statins was 81%, but only in 68% of them, the statin was high potent. At t1 the rate of the compliance raised up to 92.5% and the potency rate to 74.6%. At t2 the compliance and the potency remained high, 94.3% and 74.8% respectively. At t3 the compliance is rather stable (92.3%) but the rate of potency declines (64%) and decline further at t4 (89% and 58% respectively). Finally, at t5 both indexes depleted (81% and 57.1%, respectively). The rate of escalation to a potent statin was: t1= 36.3%, t2= 13.9%, t3 = 12.4%, t4 = 3.8%, t5=2.1%. The de-escalation rate was: t1= 13.9%, t2= 2.4%, t3 = 7.3%, t4 = 0.8%, t5=0.1%. The prescribed statin remained the same at t1= 50.8%, t2= 83.6%, t3 = 76.6%, t4 = 79% and t5=75%. The rate of permanent discontinuation was null during the first year, 4.1% at 2 years, 18.2% at 3 years and 19.5% at 4 years. Conclusions The LDL level one-month post-CABG, remains out of target and a further 22% reduction is needed. We highlight the significant rate of prescribed statin at discharge and substantial compliance which is rather sustained during the follow-up period. Nota bene the rate of potency lessens over time, whereas the rate of permanent discontinuation raises, implying that as the patient enters a "stabilized period" at 2 years post-surgery, the eagerness to maintain high-potent statin therapy, declines. This real-world practice subtracts the pleiotropic benefits of potent statins, not only over the ongoing atherosclerosis.

IntroductionProtamine use for heparin reversal following cardiac surgery may be associated with adverse events, while protamine excess may have an additional anticoagulant effect.¹ There is no consensus on the appropriate protamine: heparin ratio despite the trend towards using a lower reversal ratio than 1:1.² The present pilot study aimed to compare the feasibility of using two low ratios (0.6:1 vs. 0.8:1) of total calculated heparin dose regarding the Activated Clotting Time (ACT), viscoelastic assays (Clot-Pro®), and clinical hemorrhage for the planned randomized controlled study.MethodsFollowing ethical approval, 27 patients undergoing elective cardiac surgery with cardiopulmonary bypass were randomized to receive an initial protamine dose in a ratio of 0.6:1 (11 patients) or 0.8:1 (16 patients) of the total calculated heparin dose used. ACT value and Clot Pro® tests were recorded before surgery and after administering the initial and subsequent reversal doses. Subsequent 25mg boluses of protamine were administrated in case of ongoing clinical hemorrhage or identified heparin excess measured with plasma heparin concentration. Cumulative 24-hour blood loss, packed red blood cells (PRBCs), platelets (PLT), fresh frozen plasma (FFP), prothrombin concentrate complex (PCC), and fibrinogen administrated, guided by the Clot Pro® results, were recorded.ResultsCompared with the 0.8:1 ratio, patients in the 0.6:1 ratio group received less protamine and less PLT units intraoperatively (Table 1). The two groups were similar regarding the need for additional protamine (0% vs. 38%, p=0.07), heparin excess without clinical bleeding detected with Clot Pro® (18% vs. 44%, p=0.33), intraoperative and 24 postoperative hours in the transfused PRBCs, FFP, fibrinogen, and PPC (Table 1), postoperative ACT. One patient of the 06:1 group required re-operation for postoperative bleeding.DiscussionHeparin reversal with a protamine: heparin ratio of 0.6:1 is feasible compared with a 0.8:1 ratio. Larger studies are needed to examine the efficacy and safety of the 0.6:1 ratio and the sensitivity and specificity of Clot Pro® ’s compared with ACT.

Introduction Cell salvaging is well established in the blood management of cardiac patients, but there remain some concerns about its effects on perioperative bleeding and transfusion variables. This randomized controlled study investigated the potential effects of the centrifuged end-product on bleeding, transfusion rates, and other transfusion-related variables in adult cardiac surgery patients submitted to extracorporeal circulation. Materials and Methods Patients were randomly chosen to receive (cell-salvage group, 99 patients) or not to receive (control group, 110 patients) the centrifuged product of a cell salvage apparatus. Bleeding and transfusion rates according to the universal definition of perioperative bleeding (UDPB) classification, postoperative hemoglobin, coagulation, and oxygenation indices were recorded and compared between the groups. Results Both groups had almost identical bleeding and transfusion rates (median value: 2 units of red blood cells (RBC) and no units of fresh frozen plasma (FFP) and platelets (PLT) for both groups, p > 0.05). Patients in the cell-salvage group presented slightly higher hemoglobin concentrations (10.6 ± 1.1 vs. 10.1 ± 1.7 g/dL, p < 0.05, respectively) and a tendency towards better oxygenation indices (PaO2/FiO2: 241 ± 94 vs. 207 ± 84, p=0.013) in the postoperative period albeit with a tendency for prolongation of prothrombin time (INR: 1.31 ± 0.18 vs. 1.26 ± 0.12, p=0.008). Conclusion Within the study's constraints, the perioperative use of the cell salvage concentrate does not seem to affect bleeding or transfusion variables, although it could probably ameliorate postoperative oxygenation in adult cardiac surgery patients. A tendency to promote coagulation disturbances was detected.

Abstract Background Over 6 decades since the first Coronary-Artery-Bypass-Grafting (CABG) and it is considered as the most common cardiac surgery with established benefits on mortality and morbidity. Purpose Following the well-recognized epidemiology of coronary disease, we attempted to capture the difference over time on parameters such as baseline clinical profile, comorbidities, operation characteristics, short-term complications and perioperative mortality. Methods In this retrospective study, all adults patients with isolated CABG were included. The study period was from January 1st, 1997 until December 31, 2019. The statistical analysis referred to the prespecified time-points (the first and the last enrolled patient). Results 14235 consecutively patients underwent isolated CABG during the study period. We reported the trajectory of their baseline clinical, operative and periprocedural outcome's phenotype for 23 years. In this way we captured the current holistic profile of the CABG-patient as a timelapse (Table 1). Amongst baseline comorbidities we highlight the 40% increase of hypertension. Regarding the surgery parameters the increase in total and cross clamping time likely attests to the increasing difficulty in performing grafting in more diffusely diseased coronary vessels plus the time-forfeit of the increased usage of non-saphenous vein grafts. Notwithstanding, the perioperative mortality did not significantly change over time. Cardiac and neurological complications also remained the same, whereas renal and pulmonary complications rose. A possible explanation is the worsen baseline profile of the patients and the prolongation of operative duration. Conclusion Over time, more complicated patients are entering the operation room with increased age, decreased ejection fraction (EF) and additive comorbidities. Nota bene the perioperative mortality did not change over time, despite the worsen clinical profile and the accretion of technical difficulties which are expressed via the increased cross clamp time and the establishment of arterial grafting. Arterial grafting could be the behoof parameter that attenuated the mortality trend. To our knowledge this is one of the largest series on isolated CABG and probably the lone with extended duration beyond two decades. Funding Acknowledgement Type of funding sources: None.

BACKGROUND:The administration of antegrade cardioplegia through vein grafts after the completion of each distal anastomosis is a common practice. However, the cardioplegic solution may disrupt the vein endothelium and contribute to late vein graft atherosclerotic disease. This study aimed at evaluating the possible impact of the cardioplegic solution on vein graft endothelium.METHODS:Total of 52 patients (16 women and 36 men) aged 68±8.5 years old that underwent on pump coronary revascularization with at least one vein graft were enrolled. Sections of grafts from the greater saphenous vein were obtained prior to and after delivery of potassium antegrade cardioplegic solution through them. These sections were then examined histologically with immunochemical stain and CD34 index. The endothelial damage and length of vein specimens of both graft sections were evaluated.RESULTS:The endothelial damage of vein specimens appeared to be increased significantly with exposure to antegrade cardioplegia in male and female patients (P from Wilcoxon tests <0.001, for both genders). The increase in the length of vein specimens was significant too (P from Wilcoxon test <0.001 for men and P=0.001 for women).CONCLUSIONS:Antegrade cardioplegia delivered through vein grafts causes substantial damage on vein endothelium. This may have an adverse effect on long-term graft patency.

Purpose: To estimate the incidence of postprocedural early cardiac complications among patients undergoing transcatheter aortic valve implantation, through transapical approach (TATAVI), and to identify factors independently associated with the occurrence of them. Patients and methods: A retrospective cohort study of 90 patients, who had undergone TATAVI in a tertiary hospital of Liverpool, UK, during a 5-year period (September 2008-October 2013), was conducted. Data on patient demographics, periprocedural characteristics and cardiac complications presented within 30-day post TA-TAVI were collected, retrospectively, using the hospital's electronic database. Results: The overall 30-day incidence of cardiac complications was estimated at 18.9% (n= 17/90). The rate of new onset of atrial fibrillation (AF), atrioventricular block requiring permanent pacemaker implantation, shockable cardiac arrest rhythm and cardiac tamponade was 11.1%, 3.3%, 2.2% and 2.2%, respectively. Bivariate analysis found that absence of preoperative AF (p= 0.01), receiving of oral inotropes preprocedurally (p= 0.01), intravenous inotropic support postprocedurally (p= 0.01) and requirement for postprocedural tracheal intubation (p= 0.001) were the main factors associated with increased probability for patient cardiac morbidity. Conclusion: It seems that patients with absence of AF and oral inotropic support preprocedurally and those with post TA-TAVI mechanical ventilatory and intravenous inotropic support have greater probability to develop cardiac complications. This knowledge allows the early identification of high-risk patients and supports clinicians to apply both preventive and therapeutic interventions for the optimum patient management and care. In addition, administrators could allocate the health care system resources effectively.

Background: While short-term outcomes for patients undergoing transcatheter aortic valve implantation (TAVI) have long been studied, there is very little data on their predictors. We aimed to identify the predictors of outcomes, such as intensive care unit (ICU) and in-hospital length of stay (LOS), duration of postoperative intubation and in-hospital mortality, after TAVI procedures.Methods: We conducted a retrospective cohort study of 162 consecutive patients with aortic valve disease, who were admitted to a tertiary hospital of Liverpool for TAVI, during a five-year period. The data was collected using of the hospital's structured database on November 2014.Results: By using a multivariate analysis we found that any postoperative bleeding [odds ratio (OR) 2.71; 95% confidence interval (CI): 1.41-5.24] was the independent predictor of prolonged ICU-LOS, while older age (OR 1.11; 95% CI: 1.05-1.17) and transapical TAVI (OR 4.11; 95% CI: 1.94-8.71) were the predictors of prolonged in-hospital LOS. Additionally, patients treated with oral inotropic agents, preoperatively (OR 5.77; 95% CI: 2.21-15.01), non-diabetics (OR 3.07; 95% CI: 1.12-8.42) and those with any postoperative bleeding (OR 3.53; 95% CI: 1.68-7.43) had a significantly greater probability in remaining intubated postoperatively. The multivariate analysis did not reveal any predictor of in-hospital mortality.Conclusions: The above predictors permit the early identification of TAVI patients at high risk for longer hospitalization and increased mechanical ventilation. This piece of information is crucial for clinicians and administrators contributing to more efficient patient care planning and better allocation of healthcare resources.

BACKGROUND:Severe or massive bleeding in cardiac surgery is an uncommon but important clinical scenario. Its existing definitions are diverse. Its characteristics constantly change during an active hemorrhage and, thus is difficult to define appropriately.METHODS:In this narrative, non-systematic review, we performed a literature search to retrieve data that could contribute to answering clinical questions on the definition and grading of severe hemorrhage and massive transfusion, identifying factors that predict and affect bleeding and transfusion-related mortality and describing the risks of re-exploration and the economic impact of severe bleeding in cardiac surgery.   Results: Massive perioperative bleeding is currently described by indices of its rate and extent and the magnitude of the consequent blood products transfusion. It has a significant impact on mortality, service logistics, and hospital financing. Proper and early identification of a massive bleeding is possible. Among other factors, patient's co-morbidities, bleeding severity and transfusion volume seem to predict the associated mortality. Consequent to severe bleeding, re-exploration, is also a potentially hazardous adverse event that also affects morbidity and mortality.CONCLUSIONS:Severe perioperative hemorrhage in cardiac surgery carries significant morbidity and mortality. Currently, prediction and identification of massive bleeding is a feasible but incomplete clinical task despite the availability of effective treatment regimens. A still missing, compact definition of massive perioperative bleeding in cardiac surgery that incorporates all phases of treatment could augment clinical preparedness, allow for the development of accurate prediction tools and permit the application of well-validated protocols of management. Hippokratia 2016, 20(3): 179-186.

The estrogen-mediated vasculoprotective effect has been widely reported in many animal studies, although the clinical trials are controversial and the detailed mechanisms remain unclear. In this study, we focused on the molecular mechanism and consequence of 17β-estradiol (E2)-induced ERRα (estrogen-related receptor alpha) expression in endothelium and its potential beneficial effects on vascular function. The human aorta endothelial cells were used to identify the detailed molecular mechanism and consequences for E2-induced ERRα expression through estrogen receptors (ER), where ERα responses E2-induced ERRα activation, and ERβ responses basal ERRα expression. E2-induced ERRα expression increases fatty acid uptake/oxidation with increased mitochondrial replication, ATP generation and attenuated reactive oxygen species (ROS) formation. We have obtained further in vivo proof from high-fat diet mice that the lentivirus-carried endothelium-specific delivery of ERRα expression on the vascular wall normalizes E2 deficiency-induced increased plasma lipids with ameliorated vascular damage. ERRα knockdown worsens the problem, and the E2 could only partly restore this effect. This is the first time we report the detailed mechanism with direct evidence that E2-induced ERRα expression modulates the fatty acid metabolism and reduces the circulating lipids through endothelium. We conclude that E2-induced ERRα expression in endothelium plays an important role for the E2-induced vasculoprotective effect.

Postoperative atrial fibrillation (POAF) after cardiac surgery represents a very common complication that seems to have a significant impact on both short- and long-term patient outcomes [ 1 Peretto G. Durante A. Limite L.R. Cianflone D. Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiol. Res. Pract. 2014; 2014: 615987 Crossref PubMed Scopus (106) Google Scholar , 2 LaPar D.J. Speir A.M. Crosby I.K. Fonner Jr., E. Brown M. Rich J.B. et al. Investigators for the Virginia Cardiac Surgery Quality Initiative. Postoperative atrial fibrillation significantly increases mortality, hospital readmission, and hospital costs. Ann. Thorac. Surg. 2014; 98: 527-533 Abstract Full Text Full Text PDF PubMed Scopus (159) Google Scholar ]. Several clinical and laboratory factors have been suggested to have predictive value in this setting [ [1] Peretto G. Durante A. Limite L.R. Cianflone D. Postoperative arrhythmias after cardiac surgery: incidence, risk factors, and therapeutic management. Cardiol. Res. Pract. 2014; 2014: 615987 Crossref PubMed Scopus (106) Google Scholar ]. On the other hand, red blood cell distribution width (RDW) has been independently associated with cardiovascular risk and mortality [ 3 Jung C. Fujita B. Lauten A. Kiehntopf M. Küthe F. Ferrari M. Figulla H.R. Red blood cell distribution width as useful tool to predict long-term mortality in patients with chronic heart failure. Int. J. Cardiol. 2011; 152: 417-418 Abstract Full Text Full Text PDF PubMed Scopus (49) Google Scholar , 4 Horne B.D. May H.T. Kfoury A.G. Renlund D.G. Muhlestein J.B. Lappé D.L. et al. The Intermountain Risk Score (including the red cell distribution width) predicts heart failure and other morbidity endpoints. Eur. J. Heart Fail. 2010; 12: 1203-1213 Crossref PubMed Scopus (59) Google Scholar ]. RDW is a marker of anisocytosis of erythrocytes and may be related to inflammation and oxidative stress. Apart from cardiac surgery-induced inflammatory and oxidative response, preoperative oxidative and inflammatory status may also play a role in the pathogenesis of POAF [ 5 Ramlawi B. Otu H. Mieno S. Boodhwani M. Sodha N.R. Clements R.T. et al. Oxidative stress and atrial fibrillation after cardiac surgery: a case–control study. Ann. Thorac. Surg. 2007; 84: 1166-1172 Abstract Full Text Full Text PDF PubMed Scopus (111) Google Scholar , 6 Kinoshita T. Asai T. Takashima N. Hosoba S. Suzuki T. Kambara A. Matsubayashi K. Preoperative C-reactive protein and atrial fibrillation after off-pump coronary bypass surgery. Eur. J. Cardiothorac. Surg. 2011; 40: 1298-1303 PubMed Google Scholar ]. Moreover, recent evidence suggests that RDW is associated with AF in non-surgical patients [ 7 Güngör B. Özcan K.S. Erdinler İ. Ekmekçi A. Alper A.T. Osmonov D. et al. Elevated levels of RDW is associated with non-valvular atrial fibrillation. J. Thromb. Thrombolysis. 2014; 37: 404-410 Crossref PubMed Scopus (44) Google Scholar , 8 Adamsson Eryd S. Borné Y. Melander O. Persson M. Smith J.G. Hedblad B. Engström G. Red blood cell distribution width is associated with incidence of atrial fibrillation. J. Intern. Med. 2014; 275: 84-92 Crossref PubMed Scopus (67) Google Scholar , 9 Liu T. Shao Q. Miao S. Liu E. Xu G. Yuan R. Li G. Red cell distribution width as a novel, inexpensive marker for paroxysmal atrial fibrillation. Int. J. Cardiol. 2014; 171: e52-e53 Abstract Full Text Full Text PDF PubMed Scopus (30) Google Scholar ]. Thus, the aim of the present pilot study was to prospectively evaluate the potential association of RDW with POAF as well as to examine its relative value compared to other conventional inflammatory indexes.

Asthma and chronic obstructive pulmonary disease (COPD) are chronic diseases, very common in general population. These obstructive airway illnesses are manifested with chronic inflammation affecting the whole respiratory tract. Obstruction is usually intermittent and reversible in asthma, but is progressive and irreversible in COPD. Asthma and COPD may overlap and converge, especially in older people [overlap syndrome-asthma-chronic obstructive pulmonary disease overlap syndrome (ACOS)]. Although ACOS accounts approximately 15-25% of the obstructive airway diseases, is not well recognised because of the structure of clinical trials. COPD studies exclude asthma patients and asthma studies exclude COPD patients, respectively. It is crucial to define asthma, COPD and overlap syndrome (ACOS), as notable clinical entities, which they share common pathologic and functional features, but they are characterized from differences in lung function, acute exacerbations, quality of life, hospital impact and mortality.

During the last decades lung cancer is the leading cause of death worldwide for both sexes. Even though cigarette smoking has been proved to be the main causative factor, many other agents (e.g., occupational exposure to asbestos or heavy metals, indoor exposure to radon gas radiation, particulate air pollution) have been associated with its development. Recently screening programs proved to reduce mortality among heavy-smokers although establishment of such strategies in everyday clinical practice is much more difficult and unknown if it is cost effective compared to other neoplasms (e.g., breast or prostate cancer). Adding severe comorbidities (coronary heart disease, COPD) to the above reasons as cigarette smoking is a common causative factor, we could explain the low surgical resection rates (approximately 20-30%) for lung cancer patients. Three clinical guidelines reports of different associations have been published (American College of Chest Physisians, British Thoracic Society and European Respiratory Society/European Society of Thoracic Surgery) providing detailed algorithms for preoperative assessment. In the current mini review, we will comment on the preoperative evaluation of lung cancer patients.

BACKGROUNDCardiac myxoma is a benign neoplasm that represents the most prevalent primary tumor of the heart. If not treated with the right surgical technique recurrence occurs. Aim of our study is to present our surgical approach and the histology of the tumors resected.METHODSAll patients, except for one, underwent extracorporeal circulation and mild hypothermia, right atrial or both atrial incision and excision of the fossa ovalis, followed by prosthetic patch suturing. All specimens were submitted for microscopic evaluation (haematoxylin-eosin). We contacted personally each patient and asked them to complete a standardized questionnaire, concerning their peri-operative characteristics.RESULTSSix cases were "active" myxomas, 3 were "mildly active" and 3 were "inactive". "Normal differentiation" was seen in 6, "medium" in 1 and "poor" in 5 cases. In our series there were no recurrences recorded during the follow-up period.CONCLUSIONSThe ideal approach, according to our experience is right atrial or both atrial incision as described by Shumacker and King, with excision of the fossa ovalis and the surrounding tissues and closure with a pericardial patch. Such a technique provides an excellent long-term survival in these patients.

The majority of patients survive after extracorporeal circulation without any clinically apparent deleterious effects. However, disturbances exist in various degrees sometimes, which indicate the harmful effects of cardiopulmonary bypass (CPB) in the body. Several factors during extracorporeal circulation either mechanical dependent (exposure of blood to non-biological area) or mechanical independent (surgical wounds, ischemia and reperfusion, alteration in body temperature, release of endotoxins) have been shown to trigger the inflammatory reaction of the body. The complement activation, the release of cytokines, the leukocyte activation and accumulation as well as the production of several "mediators" such as oxygen free radicals, metabolites of arachidonic acid, platelet activating factors (PAF), nitric acid, and endothelin. The investigation continues today on the three metabolites of lornoxicam (the hydroxylated metabolite and two other metabolites of unknown chemical composition) to search for potential new pharmacological properties and activities.

Superior sulcus tumors (SSTs), or as otherwise known Pancoast tumors, make up a clinically unique and challenging subset of non-small cell carcinoma of the lung (NSCLC). Although the outcome of patients with this disease has traditionally been poor, recent developments have contributed to a significant improvement in prognosis of SST patients. The combination of severe and unrelenting shoulder and arm pain along the distribution of the eighth cervical and first and second thoracic nerve trunks, Horner's syndrome (ptosis, miosis, and anhidrosis) and atrophy of the intrinsic hand muscles comprises a clinical entity named as "Pancoast-Tobias syndrome". Apart NSCLC, other lesions may, although less frequently, result in Pancoast syndrome. In the current review we will present the main characteristics of the disease and focus on the preoperative assessment.

Cerebral oximetry based on near-infrared spectroscopy (NIRS) is increasingly used during the perioperative period of cardiovascular operations. It is a noninvasive technology that can monitor the regional oxygen saturation of the frontal cortex. Current literature indicates that it can stratify patients preoperatively according their risk. Intraoperatively, it provides continuous information about brain oxygenation and allows the use of brain as sentinel organ indexing overall organ perfusion and injury. This review focuses on the clinical validity and applicability of this monitor for cardiac surgical patients.

BACKGROUND:The establishment of Extracorporeal Circulation (EC) significantly contributed to improvement of cardiac surgery, but this is accompanied by harmful side-effects. The most important of them is systemic inflammatory response syndrome. Many efforts have been undertaken to minimize this problem but unfortunately without satisfied solution to date.MATERIALS AND METHODS:Lornoxicam is a non steroid anti-inflammatory drug which temporally inhibits the cycloxygenase. In this clinical trial we study the effect of lornoxicam in lung inflammatory response after operations for cardiac surgery with cardiopulmonary bypass. In our study we conclude 14 volunteers patients with ischemic coronary disease undergoing coronary artery bypass grafting with EC. In seven of them 16 mg lornoxicam was administered iv before the anesthesia induction and before the connection in heart-lung machine. In control group (7 patients) we administered the same amount of normal saline.RESULTS:Both groups are equal regarding pro-operative and intra-operative parameters. The inflammatory markers were calculated by Elisa method. We measured the levels of cytokines (IL-6, IL-8, TNF-a), adhesion molecules (ICAM-1, e-Selectin, p-Selectin) and matrix metaloproteinase-3 (MMP-3) just after anesthesia induction, before and after cardiopulmonary bypass, just after the patients administration in ICU and after 8 and 24 hrs. In all patients we estimated the lung's inflammatory reaction with lung biopsy taken at the begging and at the end of the operation. We calculated hemodynamics parameters: Cardiac Index (CI), Systemic Vascular Resistance Index (SVRI), Pulmonary Vascular Resistance Index (PVRI), Left Ventricular Stroke Work Index (LVSWI), Right Ventricular Stroke Work Index (RVSWI), and the Pulmonary arterial pressure, and respiratory parameters too: alveolo-arterial oxygen difference D (A-a), intrapulmonary shunt (Qs/Qt) and pulmonary Compliance. IL-6 levels of lornoxicam group were statistical significant lower at 1st postoperative day compared to them of control group (113±49 and 177±20 respectively, P=0.008). ICAM-1 levels were statistical significant lower at the patient admission in ICU, compared to them of control group (177±29 and 217±22 respectively, P=0.014), and the 1st postoperative day compared to them in control group (281±134 and 489±206 respectively, P=0.045). P-selectin levels were statistical significant lower, compared to them in control group in four measurements (97±23 and 119±7 respectively, P=0.030, 77±19 and 101±20 respectively, P=0.044, 86±4 and 105±13 respectively, P=0.06, 116±13 and 158±17 respectively, P=0.000).CONCLUSIONS:Hemodynamics and respiratory parameters were improved compared to control group, but these differences was not statistical significant. Eosinofil adhesion and sequestration in intermediate tissue of lung parenchyma were significantly lower compared to control group. Also, alveolar edema was not noted in lornoxicam's group. Lornoxicam reduce the inflammatory response in patients undergone coronary artery bypass grafting with extracorporeal circulation. This calculated from levels reduction of IL-6, ICAM-1 και p-Selectin, and from lung pathologoanatomic examination (absence of alveolar edema, reduce in eosinofil adhesion and sequestration in intermediate tissues). Despite the favorable effect of lornoxicam on the hemodinamics and respiratory parameters these improvement did not seem to be statistical significant.