Effects of autologous platelet concentrate reinfusion after open heart surgery in patients with congenital heart disease

BACKGROUND: Plasma pheresis and reinfusion of platelet-rich plasma has not been shown to reduce blood loss in cardiac patients. Recently, freshly prepared autologous platelet concentrates (PC) can be made from patient's blood and has a higher concentration than conventional platelet rich plasma. In this study, the effects of autologous PC reinfusion were examined after open heart surgery in patients with congenital heart disease. METHODS: Eight patients with noncyanotic congenital heart disease, who underwent open heart surgery and reinfusion of autologous PC, were classified as the PC group. Eight other patients with noncyanotic congenital heart disease, who underwent only open heart surgery, were defined as the control group. Ages ranged from 2 to 24 years and were not significantly different between the two groups (9.3 +/- 5.1 years in the PC group and 12.6 +/- 7.9 years in the control group, p = 0.33). In the PC group, blood was collected from the femoral vein through a 6F catheter introducer; 9 to 20 U (13.0 +/- 5.4 U, 0.42 +/- 0.22 U/kg) of autologous PC were prepared and were reinfused after protamine administration. The time course of platelet counts was examined until postoperative day 7. Aggregation responses to adenosine diphosphate; (4 micromol/L and 8 micromol/L), collagen (1 micromol/L and 5 micromol/L), and epinephrine (5 micromol/L and 10 micromol/L) were evaluated after induction of anesthesia (individual references), after protamine administration, at the end of the operation; these responses were shown as recovery ratios. RESULTS: Blood loss during surgery in the PC group was significantly less than in the control group (4.8 +/- 3.0 mL/kg versus 7.8 +/- 1.7 mL/kg, p = 0.044). Similarly blood loss on postoperative day 1 in the PC group was significantly less than in the control group (3.6 +/- 1.2 mL/kg versus 7.2 +/- 3.1 mL/kg, p = 0.013). The platelet counts in the PC group were larger than those in the control group until postoperative day 5, after reinfusion of prepared autologous PC. The recovery ratios of the aggregation responses to adenosine diphosphate, collagen, and epinephrine after protamine administration were not significantly different between the two groups. However, recovery in the PC group after reinfusion of the prepared autologous PC was greater than in the control group. CONCLUSIONS: Reinfusion of the freshly prepared autologous PC was followed by good aggregation responses and low blood loss in patients with noncyanotic congenital heart disease after open heart surgery. This procedure may be useful in pediatric open heart surgery without blood transfusion or with little administration of homologous blood products.     

Plasma arginine vasopressin levels and arterial pressure during open heart surgery

A study of plasma arginine vasopressin (AVP) levels and their relation to changes in arterial pressure was undertaken in 13 patients undergoing open heart surgery. Seven of the patients received high doses of intravenous morphine (1 or 2 mg/kg) as part of their anaesthetic, whereas the other six did not. Increases in the AVP levels during cardiopulmonary bypass (CPB) were significant in both groups, but were significantly greater in the patients not receiving morphine (median 86.1 fmol/ml) than in those who did (47.5 fmol/ml). In both groups there was a linear correlation between the natural logarithm of the plasma AVP level and the percentage fall in the mean arterial pressure, although the slope of the relationship was significantly less in the group receiving morphine than in the group not receiving morphine. These results indicate that in patients undergoing cardiac surgery the neuroendocrine reflex control of plasma AVP levels in relation to changes in arterial pressure is intact, but that the sensitivity of the reflex (i.e. the increase in plasma AVP level for a given fall in arterial pressure) is reduced by the administration of high doses of intravenous morphine.     

Plasma hepatocyte growth factor levels are increased in systemic inflammatory response syndrome

Interleukin-1 (IL-1), a cytokine released from macrophages by endotoxin stimulation, has been shown to upregulate the genetic expression of the hepatocyte growth factor (HGF). The present study was conducted to determine whether plasma HGF is increased in patients with systemic inflammatory response syndrome (SIRS). The plasma levels of HGF, endotoxin, and beta-glucan were measured in 41 surgical patients without hepatic diseases, 18 of whom had been diagnosed with sepsis, and 33, with nonseptic SIRS. The plasma HGF was found to be significantly increased in the 18 patients with sepsis, at 0.69±0.47 ng/ml (mean ± SD), and in the 23 patients with nonseptic SIRS, at 0.49±0.37 ng/ml, compared to values in 40 normal controls, at 0.10±0.03 ng/ml (P<0.001). No significant correlations were observed between the plasma levels of HGF and endotoxin (r=0.02) or beta-glucan (r=–0.05) in any of the patients; however, plasma HGF was significantly correlated with the WBC count (r=0.34, P<0.05) and with total bilirubin (r=0.45, P<0.01). Plasma HGF was also strongly correlated with alanine transaminase (ALT) in 8 patients with ALT levels higher than 50 U/I (r=0.70), but there was no such correlation in 33 patients with ALT levels of 50 U/I or less (r=0.30). Thus, although the clinicopathologic significance of HGF is not well understood, the present findings indicate that plasma HGF increases in response to infection or inflammation.     

Comparative study on cerebral injury after open heart surgery in patients with congenital and rheumatic heart disease

Alongwiththedevelopmentofscienceandtechnology,intracardiacoperationsbecomemuchsaferthanever.Althoughthemortalityrateofthepatientsreceivingintracardiacoperationwith helpofcardiopulmonarybypass(CPB)hasdecreased butneurologicalcomplicationsoccurfrequently.Neurologicalcomplicationshavebeenidentifiedsince theearlydayswhenemployingcardiacsurgery.1And neurologicalcomplicationsaftertheemploymentofCPB areimportantfatalcomplicationsofnon cardiovascular originatpresent.2Theincidenceofneuropsychologica…     

Recombinant factor VIIa (NovoSeven) as a hemostatic agent after surgery for congenital heart disease

BACKGROUND: Postoperative bleeding and blood product requirements can be substantial in children undergoing open-heart surgery, and reexploration is required in 1% of cases. Recombinant activated factor VII (rFVIIa, NovoSeven, NovoNordisk, Denmark) is a hemostatic agent approved for the treatment of hemophilic patients with inhibitors to factor VIII or factor IX. It has also been used with success in other conditions. We present our experience with rFVIIa treatment for uncontrolled bleeding after open-heart surgery in five pediatric patients. METHODS: The study group consisted of five patients after open-heart surgery with excessive blood loss. The patients were treated with rFVIIa after failure of conventional treatment to control the bleeding. Blood loss, blood product consumption, and coagulation test results were recorded before and after rFVIIa administration. RESULTS: In all cases, blood loss decreased considerably after rFVIIa administration (mean 7.8 ml x kg(-1) x h(-1)), almost eliminating the need for additional blood products, and the prolonged prothrombin time normalized. In two patients with thrombocytopathy, rFVIIa helped to discriminate surgical bleeding from bleeding caused by a defect in hemostasis. No side effects of rFVIIa treatment were noted. CONCLUSIONS: These cases support the impression that RFVIIa is efficient and safe in correcting hemostasis in children after cardiopulmonary bypass when other means fail. However, the data are still limited, and more extensive research is needed.     

Palliative surgery for cyanotic congenital heart disease

Recently, there has been an increasing emphasis on definitive correction of congenital heart defects at an early age. Nevertheless, in the presence of severe cyanotic congenital heart disease, survival may depend on palliative techniques designed either (1) to promote increased pulmonary blood flow by means of a systemic-pulmonary artery shunt or (2) to promote mixing of blood by means of a left-to-right shunt. For some patients with other cases, palliative techniques serve to "buy time" until the patient attains a more desirable age and body size. Whether subsequent definitive repair is performed, the above-described procedures allow the salvage of numerous patients whose cyanotic anomalies would otherwise be incompatible with life.     

Vascular endothelial growth factor in children with congenital heart disease

BACKGROUND: Children with cyanotic congenital heart disease may experience the development of abnormal vessels that become a source of significant morbidity. Abnormal vessel proliferation in these children may take several forms, including systemic-to-pulmonary collateral arteries, systemic-to-pulmonary venous collaterals, systemic venous collateral channels after bidirectional cavopulmonary anastomosis, and pulmonary arteriovenous malformations. However, no entity responsible for these abnormalities has been identified yet. This study determined whether children with cyanotic congenital heart disease have elevated serum levels of vascular endothelial growth factor (VEGF) and whether elevated VEGF correlated with these abnormal vessels. METHODS: Mean systemic room air oxygen saturation (SpO2), blood cell counts (RBC), and serum VEGF levels were measured preoperatively. Samples were obtained from 61 children with acyanotic heart disease (group N) and 102 children with cyanotic heart disease (group C) before cardiac surgery. Postoperative catheterization was performed 1-month after the operation to evaluate the abnormal vessels in group C. RESULTS: The VEGF level was significantly elevated in group C (355.0 +/- 287.1 pg/mL) compared with group N (203.0 +/- 221.6 pg/mL; p < 0.001). VEGF levels in patients with a single ventricle associated with asplenia syndrome (n = 7) in group C were significantly elevated (711.9 +/- 443.5 pg/mL) compared with other patients. There was no significant correlation between VEGF level and SpO2 or RBC. Abnormal vessels were diagnosed in 19.6% (20/102) patients in group C. There was no difference in VEGF levels between the patients with abnormal vessels (336.8 +/- 182.5 pg/mL) and the patients without abnormal vessels (359.1 +/- 306.8 pg/mL). CONCLUSIONS: Children with cyanotic heart disease have elevated systemic levels of VEGF, especially in those patients with a single ventricle associated with asplenia syndrome. There was no significant relationship in VEGF levels between the patients with abnormal vessels and without these vessels.     

Anesthetic complications in surgery for congenital heart disease

Anesthetic complications in 500 consecutive operations for congenital heart disease were studied and their contribution to mortality and morbidity were assessed. The great majority of the cases were young and sick children in ASA Class III, IV, or V with complex congenital heart disease. Anesthetic mortality was zero and hospital mortality was 6.3%. Anesthetic complications occurred in 2% of the cases. Four major complications were seen, including two tension pneumothoraces, one episode of severe hypotension on induction, and a breathing circuit malfunction on induction leading to bradycardia and hypotension. Six minor complications included two cases of premature extubation that required reintubation postoperatively, one case of subglottic edema, airway obstruction from inadvertent tracheal insertion of an esophageal temperature probe, one corneal abrasion, and one case of erosion of the nasal ala secondary to a nasotracheal tube. Half of the complications were probably preventable, but the other half of the complications occurred despite specific attempts at their prevention.     

Antifibrinolytic therapy in surgery for congenital heart disease

The efficacy of the serine protease inhibitor, aprotinin, and the lysine analogs, epsilon-aminocaproic acid and tranexamic acid, in reducing bleeding and transfusion in adults undergoing cardiac surgery is well established. Although children undergoing cardiac surgery are clearly at high risk for bleeding and transfusion, the risks and benefits of this therapy for the pediatric population are less well understood. There is a reasonable body of literature examining antifibrinolytic therapy in congenital heart surgery, but the large variability in patients studied, procedures, methods, and dosing schemes makes a quantitative analysis of this literature impractical. A qualitative review of this literature reveals significant support for the efficacy of all three drugs for decreasing bleeding and transfusion in congenital heart surgery, likely with more benefit in certain populations. Limited data suggest that there is no difference in efficacy among the three drugs, although aprotinin may have unique antiinflammatory effects that are of benefit in pediatric patients. There is not enough evidence to draw any conclusions about the safety of these drugs in children, although it appears that the risk of anaphylaxis with aprotinin in children may be less than in adults. Dosing schemes used for these drugs have been variable and not always based on sound pharmacologic principles, despite available pharmacokinetic and pharmacodynamic data. Further research should be directed toward establishing safety, evaluating the relative efficacy of the two classes of drugs, proving benefit in specific patient groups, and better defining effective dosing schemes.     

Mediastinal infection after open heart surgery

Mediastinal infection occurred in 29 of 2031 patients (1.4%) who underwent median sternotomy for cardiac operation at the National Heart, Lung and Blood Institute between 1956 and 1981. Factors associated with the development of mediastinitis included postoperative complications such as low cardiac output, respiratory insufficiency, reoperation for bleeding, repeat median sternotomy, and triple valve replacement. Factors that were not significantly associated with the development of mediastinitis included preoperative functional class, preoperative cardiac index, age, sex, weight, or presence of diabetes mellitus. The mortality rate in patients who developed mediastinitis was 52%. Factors associated with death included preoperative functional class III or IV, type of operation, type of organism involved, and the development of pneumonia. The mortality rate was significantly lower (35% versus 73%) in the patients who underwent mediastinal exploration for treatment. There was no difference in survival whether the wound was closed over drainage tubes or packed open. Hospital stay, however, was significantly prolonged in the patients whose wounds were packed open.