Clinical advantages of using mini-bypass systems in terms of blood product use, postoperative bleeding and air entrainment: an in vivo clinical perspective

Objective: In an effort to minimize the effect of extracorporeal circulation (ECC), mini-bypass is gaining clinical acceptance in routine coronary artery bypass grafting (CABG). These small circuits target combine the clinical advantages of reduced prime, 100% bio-coating and suction blood separation. We demonstrate that the use of mini-bypass in routine CABG reduces homologous blood product use and postoperative bleeding. Our goal was to also demonstrate that these small systems are effective in gaseous microemboli (GME) management as compared to a conventional extracorporeal system. Methods: Prospective, randomized study comparing 30 mini-bypass (Dideco ECC.O™) to 30 conventional systems (n = 30, Dideco 903 Avant™). Study included CABG cases only, independent of preoperative coagulative status; clinic ethical committee approval and informed patient consent was obtained before initiating study. Results: There were no statistical differences in terms of patient demographics. Statistically significant differences were seen in transfusion frequency (27% of the study group vs 43% in the control group, p = 0.05), transfused volume (133.3 ± 244.5 ml vs 325 ± 483.1 ml, p < 0.05), fresh frozen plasma (0 unit vs 3 units, p < 0.001), postoperative bleeding (301.8 ± 531.9 ml vs 785.5 ± 1000.4 ml, p < 0.05) and GME activity post-arterial filter (0.14 μl vs 5.32 μl, p < 0.05). Conclusions: The adoption of mini-bypass significantly potentially reduces hemodilution, donor blood usage, postoperative bleeding and exposure to GME in routine CABG patients as compared to the use of conventional extracorporeal circulation circuits.     

Does radial use as a second arterial conduit for coronary artery bypass grafting improve long-term outcomes in diabetics?

Objectives: The evidence supporting the survival benefit of multiple arterial grafts in the general coronary bypass surgery (CABG) population is compelling. Alternatively, results of studies comparing 2 versus 1 internal thoracic artery (ITA) grafts in diabetics have reported conflicting survival data. The use of radial versus ITA as the second arterial conduit has not been studied. Methods: We obtained complete death follow-up in 1516 consecutive diabetic [64 ± 10 years (mean ± SD). Insulin/no insulin: There were 540 (36%)/976 (64%)] primary isolated CABG patients all with ≥1 ITA grafts. The series included 626 ITA/radial (41%) and 890 ITA/vein (59%) patients. Using separate radial-use propensity models, we matched one-to-one 475 (76%) ITA/radial to 475 (53%) unique ITA/vein patients; each including 166 insulin and 309 no insulin patients. Results: Unadjusted survival was markedly better for (1) ITA/radial (94.3%, 86.7% and 70.4% at 1, 5 and 10 years, respectively) versus ITA/vein (91.8%, 74.5% and 53.8%; p < 0.0001) and (2) for no insulin (94.2%, 82.8% and 65.5%) versus insulin (90.4%, 73.1% and 49.2%; p < 0.0001). In matched patients, 11-year Kaplan–Meier analysis showed essentially identical ITA/radial and ITA/vein survival for all diabetics combined (p = 0.53; log rank) and for the no insulin (p = 0.76) cohort. Lastly, a trend for better ITA/radial survival in insulin dependent diabetics after the second postoperative year did not reach significance (p = 0.13). Conclusions: Using radial as a second arterial conduit as opposed to vein grafting did not confer a survival benefit in diabetics. This unexpected result is perhaps related to relatively diminished radial graft patency and/or the augmented radial vasoreactivity characteristic of diabetics. These findings indicate that the radial survival advantage demonstrated in the general CABG population lies primarily in non-diabetics in whom this advantage may be underestimated.     

Preoperative C-reactive protein is predictive of long-term outcome after coronary artery bypass surgery

Background: Increased levels of C-reactive protein (CRP) are associated with the presence and severity of atherosclerosis, and with increased risk of coronary events as well as of cardiac events after coronary percutaneous intervention. Methods: We have investigated whether preoperative CRP had an impact on the long-term outcome of 843 patients who underwent on-pump coronary artery bypass surgery (CABG). Results: Among operative survivors, patients with preoperative CRP <1.0 mg/dL had significantly better 12-year overall survival rate (74.1% vs 63.0%, p = 0.004) and survival freedom from fatal cardiac event (86.7% vs 78.1%). Multivariate analysis including patients’ age, extracardiac arteriopathy, urgent/emergent operation, recent myocardial infarction, congestive heart failure, left ventricular ejection fraction, atrial fibrillation, transient ischemic attack/stroke, number of distal anastomoses, diabetes, and preoperative CRP ≥1.0 mg/dL or <1.0 mg/dL, showed that the latter was an independent predictor of late all-cause mortality (p = 0.017, RR 1.60, 95% CI 1.09–2.35). Its impact on overall survival was particularly evident in patients with left ventricular ejection fraction <50% (CRP < 1.0 mg/dL: 58.7% vs CRP ≥ 1.0 mg/dL: 43.7%, p < 0.00001). Conclusions: Increased preoperative levels of CRP are associated with significantly decreased overall survival after primary on-pump CABG.     

Factors affecting early and long-term outcomes after completion pneumonectomy

Objective: To identify factors that affect operative mortality and morbidity and long-term survival after completion pneumonectomy. Methods: We retrospectively reviewed the charts of consecutive patients who underwent completion pneumonectomy at our cardiothoracic surgery department from January 1996 to December 2005. Results: We identified 69 patients, who accounted for 17.8% of all pneumonectomies during the study period; 22 had benign disease and 47 malignant disease (second primary lung cancer, n = 19; local recurrence, n = 17; or metastasis, n = 11). There were 50 males and 19 females with a mean age of 60 years (range, 29–80 years). Postoperative mortality was 12% and postoperative morbidity 41%. Factors associated with postoperative mortality included obesity (p = 0.005), coronary artery disease (p = 0.03), removal of the right lung (p = 0.02), advanced age (p = 0.02), and renal failure (p < 0.0001). Preoperative renal failure was the only significant risk factor for mortality by multivariate analysis (p = 0.036). Bronchopleural fistula developed in seven patients (10%), with risk factors being removal of the right lung (p = 0.04) and mechanical stump closure (p = 0.03). Overall survival was 65% after 3 years and 46% after 5 years. Long-term survival was not affected by the reason for completion pneumonectomy. Conclusion: Although long-term survival was acceptable, postoperative mortality and morbidity rates remained high, confirming the reputation of completion pneumonectomy as a challenging procedure. Significant comorbidities and removal of the right lung were the main risk factors for postoperative mortality. Improved patient selection and better management of preoperative renal failure may improve the postoperative outcomes of this procedure, which offers a chance for prolonged survival.     

Retransfusion of pericardial blood does not trigger systemic coagulation during cardiopulmonary bypass

Objective: During cardiopulmonary bypass (CPB), systemic coagulation is believed to become activated by blood contact with the extracorporeal circuit and by retransfusion of pericardial blood. To which extent retransfusion activates systemic coagulation, however, is unknown. We investigated to which extent retransfusion of pericardial blood triggers systemic coagulation during CPB. Methods: Thirteen patients undergoing elective coronary artery bypass grafting surgery were included. Pericardial blood was retransfused into nine patients and retained in four patients. Systemic samples were collected before, during and after CPB, and pericardial samples before retransfusion. Levels of prothrombin fragment F₁₊₂ (ELISA), microparticles (flow cytometry) and non-cell bound (soluble) tissue factor (sTF; ELISA) were determined. Results: Compared to systemic blood, pericardial blood contained elevated levels of F₁₊₂, microparticles and sTF. During CPB, systemic levels of F₁₊₂ increased from 0.28 (0.25–0.37; median, interquartile range) to 1.10 (0.49–1.55) nmol/l (p = 0.001). This observed increase was similar to the estimated (calculated) increase (p = 0.424), and differed significantly between retransfused and non-retransfused patients (1.12 nmol/l vs 0.02 nmol/l, p = 0.001). Also, the observed systemic increases of platelet- and erythrocyte-derived microparticles and sTF were in line with predicted increases (p = 0.868, p = 0.778 and p = 0.205, respectively). Before neutralization of heparin, microparticles and other coagulant phospholipids decreased from 464 μg/ml (287–701) to 163 μg/ml (121–389) in retransfused patients (p = 0.001), indicating rapid clearance after retransfusion. Conclusion: Retransfusion of pericardial blood does not activate systemic coagulation under heparinization. The observed increases in systemic levels of F₁₊₂, microparticles and sTF during CPB are explained by dilution of retransfused pericardial blood.     

Prognostic value of FDG uptake in early stage non-small cell lung cancer

Background: Non-small cell lung cancer (NSCLC) has a poor prognosis even for early stages of the disease (stage I and II). We studied the prognostic value of PET FDG in patients with completely resected stage I and II NSCLC. Methods: Retrospective study of 96 patients with NSCLC whose staging included ¹⁸F-FDG PET (fluoro deoxy glucose positron emission tomography). Histopathological stage was either stage I (75) or stage II (n = 21). FDG uptake was measured as maximal standardized uptake value for body weight (SUVmax). Mean follow-up was 45 ± 30 months (1–142 months). Overall and cancer-free survival rates were recorded. Results: SUVmax were higher for stage II than for stage I (10.5 ± 4.5 vs 8.5 ± 5, p = 0.04). Mean tumor volumes were equivalent for both stages (33 cm³, p = 0.18), excluding a partial volume effect. The median SUVmax in the whole study population was 7.8. The median survival was significantly longer in patients with a lower (SUVmax ≤ 7.8) FDG uptake (127 months vs 69 months, p = 0.001). For stage I tumors (n = 75), high FDG uptake was significantly associated with reduced median survival: 127 months if SUVmax ≤ 7.8 and 69 months if SUVmax > 7.8 (p = 0.001). For stage II tumors (n = 21), no statistical difference was observed: 72 months vs 40 months for SUVmax ≤ 7.8 and for SUVmax > 7.8, respectively (p = 0.11), although there was a clear trend towards reduced survival for highly metabolic tumors. Disease-free survival was also significantly better for lower metabolic tumors: 96.1 months vs 87.7 months (p = 0.01). Conclusion: High FDG uptake is associated with reduced overall survival and disease-free survival of patients with completely resected stage I–II NSCLC. Whether patients with highly metabolic tumors should undergo a closer postoperative surveillance or adjuvant chemotherapy has to be addressed in a properly designed prospective trial.     

Impact of HIV Infection on Total Body Composition in Treatment—Naive Men Evaluated by Dual-Energy X-ray Absorptiometry Comparison of 90 Untreated HIV-Infected Men to 241 Controls

The aim of this study was to establish the contribution of human immunodeficiency virus (HIV) itself on body composition changes evaluated by dual-energy X-ray absorptiometry (DXA). Body composition evaluated by DXA in 90 HIV never treated men, without comorbidity, or current or past opportunistic infections were compared with 241 healthy volunteers. The mean duration of seropositivity from HIV diagnosis was 41 ± 62 mo, mean CD4 and viral load at the time of DXA were 402/mm³ ± 263 (control values 500–1200/mm³) and 4.2 log copies/mL ± 1.3. Mean age (41 vs 39 yr, respectively, for HIV never treated patients and controls) and mean height (174.5 vs 176 cm) were not different, but mean weight was lower among HIV never treated patients (69.8 vs 78.7 kg). Mean total body bone mineral density (BMD) of naive HIV-infected patients was lower than that of controls (1.20 vs 1.23 g/cm², p = 0.01) but not after adjustment on age, height, lean mass (LM), and fat mass ratio (FMR = % trunk fat mass/% lower limb fat mass). Fat mass (13.2 vs 16.5 kg, p < 0.0001) and LM (53.5 vs 59 kg, p < 0.0001) of naive HIV-infected patients were lower whatever the adjustment variables. The FMR was lower in naive HIV-infected men (1.0 vs 1.3, p < 0.0001) because of a decreased trunk fat mass. After adjustment on age, height, LM, and fat mass, the lower limbs fat mass percentage was higher in HIV-infected men. The profile of naïve HIV-infected patients displayed low lean and fat masses, and a fat mass repartition characterized by a predominant loss in the trunk. Those alterations may result from the catabolic effect of the chronic HIV infection.     

Relationship of Circulating Total Homocysteine and C-Reactive Protein to Trabecular Bone in Postmenopausal Women

Homocysteine (Hcy) and C-reactive protein (CRP) are novel risk factors for osteoporosis. The purpose of this analysis was to determine the relationship of Hcy and CRP to volumetric trabecular bone, but also to assess their relationship to areal composite bone in healthy postmenopausal women (N = 184). We used peripheral quantitative computed tomography to assess volumetric bone at the distal tibia and dual-energy X-ray absorptiometry to assess areal composite bone at the proximal femur and lumbar spine. Multiple regression revealed that 22% of the variability in trabecular bone mineral content (F = 9.59, p ≤ 0.0001) was accounted for by weight (12.4%; p ≤ 0.0001), hemoglobin (5.5%; p = 0.0006), uric acid (4.2%; p = 0.003), and blood glucose (1.5%; p = 0.07). Multiple regression revealed that 5.4% of the variability in trabecular bone mineral density (F = 3.36; p = 0.020) was accounted for by hemoglobin (4.2%; p = 0.006) and Hcy (1.5%; not significant, p = 0.10). Total Hcy and CRP were not significantly related to trabecular bone, perhaps because these were nonosteoporotic women. However, our results suggested a weak but negative relationship between Hcy and trabecular bone. Further investigation is needed to examine the relationship of Hcy as an endogenous bioactive molecule to trabecular bone loss in early postmenopausal women and the response of trabecular bone to dietary intervention.     

Post-transplant diabetes mellitus in lung transplant recipients: incidence and risk factors

Objective: Post-transplant diabetes mellitus (PTDM) is a common and potentially serious complication after solid organ transplantation. There are only a few data, however, about the incidence of DM in patients undergoing lung transplantation. Patients and methods: The medical records of 119 consecutive patients who underwent lung transplantation from 1998 to September 2004 were reviewed. Patients were divided in three groups according to their diabetes status, including pre-transplant DM, the PTDM group and those without DM. Patient records and all laboratory data were reviewed and the clinical course of diabetes was monitored. All recipients were treated with tacrolimus based regimen. Results: Mean follow-up for all patients was 25 ± 10. Twenty-three patients had DM in the pre-lung transplantation (LTX) DM group. PTDM developed in 34 of the remaining 96 patients (35.4%) with an incidence of 20%, 23% after 6 months and 12 months post-transplant. No significant difference was noted between 12 and 24 months post-LTX. The patients who developed DM were older (57 ± 15 vs 53 ± 13 years, p = 0.009), had increased BMI (26 ± 5 vs 24 ± 4, p = 0.0001), shorter time from diagnosis to LTX (21 ± 13 vs 28 ± 18 months, p = 0.007) more cytomegalovirus infection and more acute rejection and hyperglycemia in the first month after LTX. Four patients died in the PTDM group compared to nine patients in the no-DM group (12% vs 14%; p = 0.72). Conclusions: Post-transplant diabetes is a common complication in lung transplant patients receiving tacrolimus-based immunosuppression. The risk for developing PTDM is greatest among older recipients, those obese, and among recipients with more rejections episodes.     

A three decade analysis of factors affecting burn mortality in the elderly

This study's objective was to identify variables that affect the mortality of elderly burn patients and to assess their changes over time. A retrospective review was conducted on all patients 75 or older (n = 201) admitted to a university-based burn center between 1972 and 2000. Variables examined were age, sex, TBSA, ABSI, inhalation injury, timing from burn to operative intervention, the number of surgical procedures, the number of pre-morbid conditions, and mortality. There were 95 fatalities. TBSA strongly correlated with mortality (p < 0.0001). Adjusting for TBSA and inhalation injury, mortality significantly decreased (p = 0.04, odds ratio = 0.58). Mortality significantly increased with inhalation injury (p < 0.01). Fatality risk increased by 400% with inhalation injury. Absence of inhalation injury was not significant with respect to mortality in the 1970s, however there was a significant decrease (p = 0.02) in mortality without an inhalation injury in the 1980s and 1990s. ABSI was strongly predictive of mortality (p < 0.0001). On average there was a 200% increase in mortality per unit increase of ABSI. The elderly are 58% less likely to die from burns now as compared to the 1970s. Although mortality rose with increasing TBSA equally in each decade, the absolute risk of mortality decreased over time. This data suggests major strides have been made in burn care, however similar success has not been achieved with inhalation injuries.     

Paclitaxel treatment reduces neointimal hyperplasia in cultured human saphenous veins

Background: Paclitaxel exerts antiproliferative properties by stabilizing microtubuli of the cell. The substance is in clinical use for drug-eluting coronary stents. We aimed to test the hypothesis that paclitaxel treatment can reduce neointimal hyperplasia in cultured human saphenous veins and thus might be useful for local pharmacologic treatment of vein grafts prior to coronary artery bypass grafting (CABG). Methods: The remnants of saphenous veins from 13 patients undergoing CABG were collected. The development of neointimal hyperplasia was induced using an established organ culture model (incubation time 2 weeks). In the treatment group, paclitaxel was added to the culture medium at different concentrations. Results: Veins treated with 1 μmol/l paclitaxel showed a median increase of intimal thickness of 2 μm (range −76 to 46) above baseline levels, whereas untreated control veins increased by 15 μm (range −3 to 142) (p = 0.022). Treatment with 10 μmol/l paclitaxel resulted in a lower intimal thickness growth of 1 μm (range −82 to 212) above baseline levels (p = 0.035 vs controls). Treatment with 25 or 50 μmol/l paclitaxel did not further inhibit intimal hyperplasia. The neointimal amount of the contractile protein smooth muscle actin (SMA) in paclitaxel 1 μmol/l treated veins was significantly higher than baseline values (p = 0.037). The cytoskeletal protein desmin was predominant in the media, whereas it was less frequently found in the intima, and we observed no difference between controls and paclitaxel treated veins. The proliferation marker ki-67 was occasionally present in the circumferential media, whereas it was almost absent in both the (inner) longitudinal media and the intima. Elastic fibers were present in the media and intima before and after organ culture without significant differences between the groups. Collagen fibers (Masson's trichrome) were found abundantly (80%) in the inner longitudinal media, less commonly (20%) in the outer circumferential media, and they were absent in the intima without difference between the groups. Conclusion: Local paclitaxel treatment reduces neointimal hyperplasia in cultured human saphenous veins, without changing the amount of elastic or collagen fibers. Paclitaxel treatment leads to an increased amount of the contractile protein SMA and thus might have a therapeutic potential for the prevention of vein graft disease.     

Intestinal ischaemia following cardiac surgery: a multivariate risk model

Objective: Intestinal ischaemia following cardiac surgery is a serious complication, which carries a high mortality rate. Several studies have examined pre-operative and intra-operative risk factors. We aimed to develop a multivariate risk model to identify those patients at highest risk of intestinal ischaemia. Methods: Data was prospectively collected for 10,976 consecutive cardiac surgery patients from our institution between April 1997 and March 2004. Fifty (0.5%) patients developed post-operative intestinal ischaemia. A forward stepwise multivariate logistic regression analysis was undertaken to identify predictors of developing intestinal ischaemia. Intra-operative and post-operative variables were censored at the time of onset of intestinal ischaemia. Results: The predictors of post-operative intestinal ischaemia were: post-op inotrope and dialysis support (OR 6.7; p < 0.001), post-op ventilation >48 h (OR 5.1; p < 0.001), age at operation (OR 1.06 [for each additional year]; p < 0.001), post-op atrial fibrillation (OR 2.3; p = 0.014) and blood loss in intensive care unit (ICU) >700 ml (OR 2.0; p = 0.037). The predictive ability of this model was very good with an area under the receiver operating characteristic curve of 0.93. In-hospital mortality for the patients who developed intestinal ischaemia was 94% (47/50) compared to 3.6% (390/10,926) for the other patients (p < 0.001). Conclusions: Although the incidence of intestinal ischaemia following cardiac surgery is low, the prognosis for these patients is very poor. We have identified several risk factors, and developed a multivariate prediction tool, which may be useful in identifying patients at high-risk of developing intestinal ischaemia.     

Immunohistochemistry-detected microscopic tumor spread affects outcome in en-bloc resection for T3-chest wall lung cancer

Objective: This study is aimed at analyzing the effect of immunohistochemistry-detected microscopic tumor spread on long-term survival after en-bloc lung and chest wall resection for T3-chest wall non-small cell lung cancer (NSCLC). Methods: We retrospectively reviewed 47 patients (mean age 64.4 ± 7.1 years, range 48–77) who underwent radical en-bloc lung and chest wall resection for NSCLC between 1987 and 2000. Resection margins, invasion depth, and lymph nodes were re-assessed by immunohistochemistry with AE1/AE3 anti-cytokeratin and anti-CEA monoclonal antibodies. Results: Operative mortality and morbidity were 2.1% and 34%, respectively. At immunohistochemistry analysis, five patients (10.6%) revealed microinfiltration of the resection margins that was significantly correlated with the development of local recurrence (p < 0.005). Nodal micrometastases were found in 4 out of 33 N0 patients (12.1%), and correlated with distant relapse (p < 0.001). Overall and disease-free survivals were significantly influenced by N-status (p < 0.001), especially after re-evaluation of micrometastases (p < 0.0001), and resection margins microinfiltration (p < 0.0001) being these last two the only significant prognostic factors at Cox regression analysis. Five-year overall survival in radically resected patients was 73%. Conclusions: In this study immunohistochemical analysis allowed to identify patients at higher risk of recurrence following en-bloc resection for T3-chest wall NSCLC.     

A prospective analysis of the inter-relationship between lung volume reduction surgery and body mass index

Objectives: LVRS is thought to result in significant improvements in BMI. Patients with a higher BMI at the time of diagnosis of COPD are known to have better survival, and those with a low BMI prior to LVRS have significantly worse perioperative morbidity. We aimed to assess the influence of BMI on the outcome of LVRS in our own experience. Methods: Complete preoperative BMI data was available in 114 of 131 consecutive patients who have undergone LVRS since 1995. These patients were arbitrarily classified into three categories: underweight (BMI ≤ 19 kg/m²), normal (BMI 20–25 kg/m²) and overweight (BMI > 26 kg/m²). The in-hospital course and perioperative change in BMI at 3, 6, 12, 24 and 36 months were prospectively recorded for each category and compared. Results: There were no significant differences in preoperative variables except BMI. There were significantly more postoperative ITU admissions among the lowest two BMI groups (12/29, 18/58 and 3/27 patients, respectively, p = 0.02), and significantly shorter hospital stay in overweight patients [16 days (5–79) vs 18 days (6–111) vs 13 days (6–25), respectively, p = 0.005, expressed as median (range)]. However, there was no difference in survival between the three groups (p = 0.21). Postoperative physiological improvements in the first year were related to preoperative BMI for both FEV₁ (r = 0.29, p = 0.02) and DLCO (r = 0.33, p = 0.02). Postoperative BMI significantly increased in the underweight yet significantly decreased in the overweight at all time points. Conclusions: The perioperative course of LVRS and its physiological benefits are influenced by preoperative BMI. Whilst the treatment of the underweight is more complicated, LVRS may be the only way of increasing their BMI. Future work is needed to explore the roles of changing energy requirements and body composition following LVRS.     

Intra-tumoral vascular or perineural invasion as prognostic factors for long-term survival in early stage non-small cell lung carcinoma

Objective: In recent studies focusing on the prognostic significance of histologic features of NSCLC tumors, vessel invasion was correlated to survival across all surgical stages. We similarly analyzed whether intra-tumoral permeation could affect survival in subgroups of stage I and II NSCLC. Methods: A retrospective single institution analysis of a prospectively computed database. Specimens were analyzed for intra-tumoral vascular, lymphatic and nervous permeation. Overall mortality was determined and for each stage, a Cox regression analysis of selected variables was performed. Detailed histologic information was available in all patients. Follow-up was 100% complete (median = 69 months). Results: From 1989 to 2004, out of 346 patients with stage I and II NSCLC, 253 patients with p stage I (75.7%) and 81 patients with p stage II (24.3%) underwent surgery with complete resection, for a completeness resection rate of 97% (334/346). We performed 70 pneumonectomies, 255 lobectomies and 9 lesser resections (respectively, 21%, 76.3% and 2.7%). In-hospital mortality was 2.1%. The incidence of intra-tumoral permeation was 14.4% (48/334). Permeation correlated both with T status (p = 0.04), grade of differentiation (p = 0.03) and stage (p = 0.02). Median survival and overall 5-year survival for patients with and without permeation were 42.3 months (95% CI [20–64.6]) and 72.1 months (95% CI [56.9–87.2]), respectively; and 44% and 54%, respectively (p = NS). However, intra-tumoral permeation was not a significant predictor for overall death (HR = 1.1 [95% CI = 0.74–1.66). Conclusion: In this large institutional study of early stage NSCLC, the presence of intra-tumoral permeation was correlated both to T, grade of differentiation, as well as to stage. However, in contrast to recent reports, we did not find that intra-tumoral permeation adversely affects long-term survival.     

糖尿病病人行OPCAB与CCABG的早期结果对比

目的 比较糖尿病病人非体外循环和经典体外循环冠状动脉旁路移植(OPCAB和CCABG)的术后早期临床结果.方法 1999年4月至2008年1月,318例糖尿病病人行冠状动脉旁路移植术(CABG).OPCAB 210例,CCABG 108例.两组术前总体情况差异无统计学意义.OPCAB在非体外循环、心脏跳动下完成,CCABG在体外循环、心脏停跳下完成.正中开胸,胸膜外游离带蒂左乳内动脉(LIMA),与左前降支(LAD)吻合,大隐静脉(GSV)与其他靶血管吻合,吻合口超过2个采用序贯吻合.术前口服降糖药或皮下注射胰岛素将血糖控制在6 mmol/L以下,术后早期在ICU时持续泵入胰岛素,将血糖控制在6～8mmol/L.结果 两组共5例(1.57%)死亡,7例(2.20%)发生并发症.两组均达到完全再血管化,平均移植旁路血管OPCAB组(2.6±1.1)支,低于CCABG组的(3.1±1.3)支,P＜0.05.OWCAB组死亡1例(0.48%),明显低于CCABG组4例(3.70%),P＜0.05.OPCAB组发生并发症5例(2.30%),CCABG组2例(1.85%),组间差异无统计学意义,P＞0.05.结论 糖尿病者冠状动脉旁路移植手术围术期严格控制血糖至接近正常水平,住院病死率和并发症率低.OWAB术后早期病死率明显低于CCABG.     

Genetic background influences fluoride's effects on osteoclastogenesis

Excessive fluoride (F) can lead to abnormal bone biology. Numerous studies have focused on the anabolic action of F yet little is known regarding any action on osteoclastogenesis. Little is known regarding the influence of an individual's genetic background on the responses of bone cells to F. Four-week old C57BL/6J (B6) and C3H/HeJ (C3H) female mice were treated with NaF in the drinking water (0 ppm, 50 ppm and 100 ppm F ion) for 3 weeks. Bone marrow cells were harvested for osteoclastogenesis and hematopoietic colony-forming cell assays. Sera were analyzed for biochemical and bone markers. Femurs, tibiae, and lumbar vertebrae were subjected to microCT analysis. Tibiae and femurs were subjected to histology and biomechanical testing, respectively. The results demonstrated new actions of F on osteoclastogenesis and hematopoietic cell differentiation. Strain-specific responses were observed. The anabolic action of F was favored in B6 mice exhibiting dose-dependent increases in serum ALP activity (p < 0.001); in proximal tibia trabecular and vertebral BMD (tibia at 50&100 ppm, p = 0.001; vertebrae at 50 and 100 ppm, p = 0.023&0.019, respectively); and decrease in intact PTH and sRANKL (p = 0.045 and p < 0.001, respectively). F treatment in B6 mice also resulted in increased numbers of CFU-GEMM colonies (p = 0.025). Strain-specific accumulations in bone [F] were observed. For C3H mice, dose-dependent increases were observed in osteoclast potential (p < 0.001), in situ trabecular osteoclast number (p = 0.007), hematopoietic colony forming units (CFU-GEMM: p < 0.001, CFU-GM: p = 0.006, CFU-M: p < 0.001), and serum markers for osteoclastogenesis (intact PTH: p = 0.004, RANKL: p = 0.022, TRAP5b: p < 0.001). A concordant decrease in serum OPG (p = 0.005) was also observed. Fluoride treatment had no significant effects on bone morphology, BMD, and serum PYD cross-links in C3H suggesting a lack of significant bone resorption. Mechanical properties were also unaltered in C3H. In conclusion, short term F treatment at physiological levels has strain-specific effects in mice. The expected anabolic effects were observed in B6 and novel actions hallmarked by enhanced osteoclastogenesis shifts in hematopoietic cell differentiation in the C3H strain.     

Human gastroepiploic artery has greater chymase activity than the internal thoracic artery

Objective: Recent reports have demonstrated that long-term patency of the gastroepiploic artery (GEA) in coronary artery bypass grafting (CABG) is less satisfactory compared with the internal thoracic artery (ITA). However, the reason has not been fully elucidated. Angiotensin II is known to play an important role in the development of intimal hyperplasia, we hypothesized that the GEA is different from the ITA with respect to angiotensin II-forming ability. Accordingly, we measured activities of angiotensin II-forming enzymes, angiotensin-converting enzyme (ACE) and chymase, in human GEA and ITA. Methods: Remnant of the GEAs and ITAs were obtained from 24 patients who underwent CABG in which both conduits were used simultaneously. Activities of ACE and chymase were measured by using the extract form the GEA or ITA. Sections of the GEA or ITA were immunohistochemically stained with anti-human chymase antibody. Results: The ACE activity of the GEA (0.28 ± 0.16 mU/mg protein) was greater than that of the ITA (0.18 ± 0.11, p < 0.001). The chymase activity of the GEA (11.11 ± 7.15 mU/mg protein) was also greater than that in the ITA (7.13 ± 4.89, p < 0.001). The density of chymase-positive cells in the GEA (3.8 ± 4.2 cells/mm²) was greater than that in the ITA (1.1 ± 1.2, p < 0.01). Conclusion: Activities of both ACE and chymase were significantly greater in the GEA compared with the ITA. The GEA may be different from the ITA with respect to potential ability of angiotensin II-formation.     

Risk factors for reoperation after relief of congenital subaortic stenosis

Background: Congenital subaortic stenosis entails a lesion spectrum, ranging from an isolated obstructive membrane, to complex tunnel narrowing of the left outflow associated with other cardiac defects. We review our experience with this anomaly, and analyze risk factors leading to restenosis requiring reoperation. Methods: From 1994 to 2006, 58 children (median age 4.3 years, range 7 days–13.7 years) underwent primary relief of subaortic stenosis. Patients were divided into simple lesions (n = 43) or complex stenosis (n = 15) associated with other major cardiac defects. Age, pre- and postoperative gradient over the left outflow, associated aortic or mitral valve insufficiency, chromosomal anomalies, arteria lusoria, and operative technique (membrane resection (22) vs associated myectomy (34) vs Konno (2)) were analyzed as risk factors for reoperation (Kaplan–Meier, Cox regression). Results: There was no operative mortality. Median follow-up spanned 2.7 years (range 0.1–10), with one late death at 4 months. Reoperation was required for recurrent stenosis in 11 patients (19%) at 2.6 years (range 0.3–7.5) after initial surgery. Risk factors for reoperation included complex subaortic stenosis (p = 0.003), younger age (p = 0.012), postoperative residual gradient (p = 0.019), and the presence of an arteria lusoria (p = 0.014). For simple lesions, no variable achieved significance for stenosis recurrence. Conclusions: Surgical relief of congenital subaortic stenosis, even with complex defects, yields excellent results. Reoperation is not infrequent, and should be anticipated with younger age at operation, complex defects, residual postoperative gradient, and an arteria lusoria. Myectomy concomitant to membrane resection, even in simple lesions, does not provide enhanced freedom from reoperation, and should be tailored to anatomic findings.     

Long-term experiences on cardiac retransplantation in adults

Background: It remains disputed whether cardiac retransplantation should be performed. This study aimed to evaluate our long-term experiences on cardiac retransplantation in adults. Patients and methods: Between March 1989 and December 2004, 2% (28/1290) of cardiac retransplantations were performed. Results: The reasons for cardiac retransplantation were cardiac allograft vasculopathy (n = 13; 47%), primary graft failure (n = 11; 39%), and refractory acute rejection (n = 4; 14%). The 30-day mortality risk was 29% (acute rejection: 50%; primary graft failure: 36%; cardiac allograft vasculopathy: 15%, p = 0.324), compared to 8.5% for primary cardiac transplantation (p < 0.001). The causes of early death were acute rejection (n = 3; 37%), multiorgan failure (n = 3; 37%), primary graft failure (n = 1; 13%), and right ventricular failure (n = 1; 13%). The late mortality rate was 96/1000 patient-years. The causes of late death were acute rejection (n = 4; 50%), cardiac allograft vasculopathy (n = 2; 25%), multiorgan failure (n = 1; 13%), and infection (n = 1; 13%). The 1-, 5-, 10-, and 15-year survival was respectively 78, 68, 54, and 38% (primary cardiac transplantation), and 46, 41, 32, and 32% (cardiac retransplantation) (p = 0.003). The short-term survival for cardiac retransplantation due to cardiac allograft vasculopathy was likely better than primary graft failure and refractory acute rejection (p = 0.09). Conclusion: The overall outcomes of cardiac retransplantation are significantly inferior to primary cardiac transplantation. Cardiac retransplantation should be only performed for selected patients.