Anesthesia for a hemodialysis patient with HIT undergoing CABG using argatroban

Anesthetic Management of CABG in a Hemodialysis patient complicated by heparin-induced thrombocytopenia (HIT) type II is one of the different procedures in hemodialysis patients using heparin. An 81-year-old man receiving hemodialysis complicated by HIT type II was scheduled for coronary artery bypass grafting (CABG). Anesthesia was induced and maintained with propofol, remifentanil and rocuronium. During artificial cardiopulmonary bypass, activated clotting time (ACT) was maintained above 300 sec by in initial 0.1 mg x kg(-1) and subsequent 2.0-7.0 microg x kg(-1) x min(-1) doses of argatroban; a direct thrombin inhibitor. Immediately after the completion of the external cardiopulmonary circulation, continuous infusion of argatroban was discontinued. Seven hours later ACT was restored to the preoperative level. Both intra and postoperative courses were uneventful.     

Effects of exercise training after open heart surgery on quality of life and exercise tolerance in patients with mitral regurgitation or aortic regurgitation

We conducted a questionnaire survey regarding quality of life (QOL) to evaluate the effects of exercise training on the QOL in patients with valvular heart disease after surgery. This study included 64 consecutive patients who underwent heart surgery. They were divided into two groups: exercise training could (EX(+) group, n = 31) and could not be performed (EX(-) group, n = 33) until 6 months after surgery. To evaluate the QOL and exercise tolerance, we employed "a questionnaire regarding disease and quality of life" developed for Japanese people and cardiopulmonary exercise testing. In our questionnaire survey, the improvement rating (Delta subjective/social index), which was calculated from the difference between the pre-and postoperative values, was greater in the EX(+) group than that in the EX(-) group (4.9 +/- 3.1 versus 1.1 +/- 4.0, P < 0.05). In the changes in exercise tolerance, Delta anaerobic threshold was greater in the EX(+) group (0.79 +/- 0.17 versus -0.02 +/- 0.28, P < 0.01). Moreover, there was a positive correlation between Delta subjective/social index and Delta peak VO(2) (r = 0.62, P < 0.05). We concluded that exercise training for patients after cardiac surgery improves the QOL and exercise tolerance. It is suggested that changes in subjective and social parameters contribute to an exercise training-related improvement in the QOL.     

Autocrine growth inhibition of IL-1β-treated cultured human aortic smooth muscle cells: Possible role of nitric oxide

Summary This study was designed to investigate whether interleukin (IL)-1 would stimulate nitric oxide (NO) production in cultured human aortic vascular smooth muscle cells (VSMCs), and to determine the basic effect of the liberated NO on VSMC proliferation. NO production was estimated from nitrite concentration of culture medium in multi-well plates, determined by the Griess method. VSMCs were IL-1-pretreated in insert cups, and co-cultured with untreated VSMC in the wells.³H-thymidine (³H-Tdr) incorporation into the VSMC in wells was evaluated for VSMC proliferative activity. IL-1 stimulated NO production in VSMCs in a concentration-dependent manner. This effect was further enhanced by the addition of a membrane-permeable cyclic adenosine monophosphate derivative, dibutyryl cyclic AMP (db-cAMP), and was significantly reduced by concomitant use of an NO synthase inhibitor, N^G-nitro-l-arginine methyl ester (l-NAME). IL-1-pretreated VSMCs significantly inhibited³H-Tdr incorporation of the co-cultured VSMC. This inhibitory effect was significantly enhanced by the addition of db-cAMP, while this inhibition was significantly decreased by preincubation withl-NAME, and was abolished in thel-arginine-free medium. These results suggest that, in human VSMC, IL-1 stimulates NO production that is enhanced by intracellular cAMP accumulation, and that the liberated NO inhibits further VSMC proliferation in an autocrine fashion.     

Blunted peripheral vasodilatory response is a hallmark of progressive deterioration in mild to moderate congestive heart failure

BACKGROUND: Several reports have shown that dilatory response to acetylcholine (ACh) and nitroprusside (SNP) is blunted in the limb vasculature in patients with congestive heart failure (CHF). However, it is not yet known whether this vascular dysfunction is related to clinical outcome. We have examined the relationship between peripheral vasodilatory response and prognosis of CHF. METHODS AND RESULTS: A total of 46 patients with mild to moderate CHF were enrolled (mean age 56 years). Changes in forearm blood flow (FBF) during intra-arterial infusion of ACh and SNP were determined by plethysmography. FBF changes above baseline for each dose were cumulated and used as an index of endothelium-dependent (ACh) response and endothelium-independent (SNP) response, respectively. During the follow-up period (mean 32 months), 9 patients were admitted to the hospital for treatment of worsening refractory CHF, and 6 patients died suddenly or developed life-threatening arrhythmia. By Kaplan-Meier analysis, when all cardiac events were included, no significant differences were observed between any levels of vascular response in terms of prognosis. However, when deterioration events were analyzed separately, patients with SNP responses below the median (7.4 mL/min/dL) had significantly higher rates of hospital admission caused by worsening CHF than those with above the median responses (P <.05). This relationship was not found between ACh response and clinical outcome. By Cox multivariate analysis, blunted vasodilatory response to SNP was a significant predictor of worsening CHF (chi(2) = 3.95; P <.05). CONCLUSION: This study has shown that patients with mild to moderate CHF showing a blunted vascular response to SNP rather than ACh were admitted to the hospital more frequently because of deterioration of CHF. This finding suggests that changes in vascular smooth muscle and/or vascular structure in the peripheral vasculature may be a critical element in the worsening of CHF.     

Rapid,sensitive detection of myoglobinemia by improved counterimmunoelectrophoresis in cases of acute myocardial infarction

A counterimmunoelectrophoresis technique for detection of serum myoglobin (Mb) was improved using non-ionic polymer dextran. Precipitin lines were graded according to their strength, which was ascertained by radioimmunoassay data. By this method, serum Mb in concentrations of 500 ng./ml. before stain and of 200 ng./ml. after stain were detected. Electrophoretic time was 60 minutes. Among 32 cases of acute myocardial infarction (AMI) whose blood samples were collected within 24 hours after disease onset, precipitin lines were detected in 25 cases (78 per cent) before stain and 31 cases (97 per cent) after stain. Considering the early peak concentration time (approximately 10 hours) of serum Mb after AMI onset, diagnosis becomes more rapid and exact with this method, especially in severe cases.     

Hyperkinesis without the Frank-Starling mechanism in a nonischemic region of acutely ischemic excised canine heart

To determine the essential mechanism of increased systolic wall motion, i.e., hyperkinesis, in a nonischemic region (NIR) during acute ischemia, we simultaneously evaluated global and regional function of the excised, cross-circulated canine left ventricle connected to a volume servo pump before and after coronary occlusion. Regional areas were determined with pairs of orthogonal subendocardial sonomicrometers in the ischemic region (IR) and NIR. After coronary occlusion with left ventricular end-diastolic and stroke volumes kept constant, the amount of systolic area shrinkage (delta A) in NIR increased by 33 +/- 41% (p less than .05), despite a decrease in end-diastolic regional area by 3 +/- 4% (p less than .05). Regional work obtained from the wall tension-regional area (T-A) loop in NIR decreased by 50 +/- 24% due to a similar decrease in afterload despite the presence of hyperkinesis, indicating regional systolic unloading. When left ventricular end-diastolic volume was subsequently increased with a constant stroke volume, delta A in NIR increased at the expense of a further decrease in delta A in IR. The end-systolic T-A relationship in NIR remained unchanged, whereas that in IR markedly shifted rightward, suggesting that the contractile state of NIR was constant. These results indicate that hyperkinesis in NIR during acute ischemia can occur without a utilization of the Frank-Starling mechanism or an enhancement of regional contractile state, and that the essential mechanism of this phenomenon is regional afterload reduction due to an intraventricular mechanical interaction between IR and NIR.     

Risk factors of thrombotic recurrence and major bleeding in patients with intermediate-risk for recurrence of venous thromboembolism

Journal of Thrombosis and Thrombolysis - Prolonged anticoagulation therapy is recommended for patients with intermediate-risk for recurrence of venous thromboembolism (VTE). The current study aimed...