S100β correlates with neurologic complications after aortic operation using circulatory arrest

Background. Astrocyte protein S100β is a potential serum marker for neurologic injury. The goals of this study were to determine whether elevated serum S100β correlates with neurologic complications in patients requiring hypothermic circulatory arrest (HCA) during thoracic aortic repair, and to determine the impact of retrograde cerebral perfusion (RCP) on S100β release in this setting.

Methods. Thirty-nine consecutive patients underwent thoracic aortic repairs during HCA; RCP was used in 25 patients. Serum S100β was measured preoperatively, after cardiopulmonary bypass, and 24 hours postoperatively.

Results. Neurologic complications occurred in 3 patients (8%). These patients had higher postbypass S100β levels (7.17 ± 1.01 μg/L) than those without neurologic complications (3.63 ± 2.31 μg/L, p = 0.013). Patients with S100β levels of 6.0 μg/L or more had a higher incidence of neurologic complications (3 of 7, 43%) compared with those who had levels less than 6.0 μg/L (0 of 30, p = 0.005). Retrograde cerebral perfusion did not affect S100β release.

Conclusions. Serum S100β levels of 6.0 μg/L or higher after HCA correlates with postoperative neurologic complications. Using serum S100β as a marker for brain injury, RCP does not provide improved cerebral protection over HCA alone.     

Blade and balloon atrial septostomy for left heart decompression in patients with severe ventricular dysfunction on extracorporeal membrane oxygenation

Extracorporeal membrane oxygenation (ECMO) is used as circulatory support or bridge to transplantation in patients with severe left ventricular (LV) dysfunction. Left heart decompression is needed to reduce pulmonary edema, prevent pulmonary hemorrhage, and reduce ventricular distention that may aid in recovery of function. We reviewed our experience from November 1993 to December 1997 with 10 patients having severe LV dysfunction (7 myocarditis, 3 dilated cardiomyopathy) who required circulatory support with ECMO and who underwent left heart decompression with blade and balloon atrial septostomy (BBAS). Patients ranged in age from 1 to 24 years (median, 3 years). Indications for BBAS included left atrial/left ventricular distension (10), pulmonary edema/hemorrhage (9), or severe mitral regurgitation (2). BBAS was performed electively in eight patients and urgently in two patients. BBAS was performed while on ECMO in seven patients and pre-ECMO in three. A femoral venous approach was used in all patients. ECMO patients were fully heparinized. Transseptal puncture was required in nine patients while one patient had a patent foramen ovale. Blade septostomy was performed in all patients. Enlargement of the defect was then performed by stationary balloon dilation in nine and Rashkind balloon atrial septostomy in one. Balloon diameters ranged from 10 to 20 mm. Sequential balloon inflations were performed in some patients. Adequacy of the atrial septal defect (ASD) was confirmed by pressure measurement and echocardiography. Adequate left heart decompression was achieved in all patients. Pulmonary edema improved in nine of nine patients. Left atrial mean pressure fell from a mean of 30.5 mm Hg, (range, 12–50 mm Hg) to 16 mm Hg (range, 9–24 mm Hg). Left atrial to right atrial pressure gradient fell from a mean of 20 mm Hg pre-BBAS to 3 mm Hg post-BBAS. ASDs ranged in size from 2.5 to 8 mm (mean, 5.9 mm). Complications included needle perforation of the left atrium without hemodynamic compromise (one), ventricular fibrillation requiring defibrillation (one), and hypotension following BBAS which responded to volume infusion (two). Duration of ECMO ranged from 41 hr to 704 hr (mean, 294 hr). Seven patients survived and four patients had recovery of normal LV function. Of those who recovered, two had no ASD at follow-up while two ASDs are patent 14 days and 3 months post-BBAS. Three patients underwent successful cardiac transplantation. Three patients died, all of whom had multisystem organ failure with or without sepsis. A patent ASD was noted at transplant (three) or autopsy (two). No patient required a second BBAS. BBAS alleviates severe left atrial hypertension and pulmonary edema. In addition, BBAS avoids the potential bleeding complications of surgical left heart decompression. Stationary balloon dilation of the atrial septum is an effective alternative to Rashkind balloon septostomy in older patients. BBAS achieves left heart decompression that may permit recovery of LV function or allow extended ECMO support as a bridge to transplant. Cathet. Cardiovasc. Intervent. 46:179–186, 1999. © 1999 Wiley-Liss, Inc.     

Totally peripheral approach for ICD lead vegetation removal in a GUCH patient

AngioVac system (AngioDynamics) has already proved to be a useful tool in the treatment of thrombotic and endocarditic formations concerning the venous district. Herein, the AngioVac aspiration system combined with the bidirectional rotational Evolution mechanical sheath lead extraction was used for an effective and safety cardiac-device-related-infective-endocarditis removal in a grown-up congenital heart disease patient through a totally peripheral approach.     

Loss of Paramedic Availability in an Urban Emergency Medical Services System during a Severe Acute Respiratory Syndrome Outbreak

OBJECTIVES: To describe the loss of paramedic availability to Toronto Emergency Medical Services during a biphasic (SARS-1 and SARS-2) outbreak of severe acute respiratory syndrome (SARS). METHODS: During the SARS outbreak, a dedicated paramedic surveillance and quarantine program was developed. The authors determined the number of paramedics on quarantine each day, the type of quarantine (either home quarantine [HQ] or work quarantine [WQ]), and the development of SARS-like symptoms. RESULTS: During the SARS outbreak, there were five cases of probable SARS and three cases of suspect SARS. SARS-1 lasted 30 days, during which 234 paramedics were placed on HQ. The total number of HQ days was 1,615. During the five peak days of SARS-1, the total number of HQ days was 664. SARS-2 lasted 18 days, during which 292 paramedics were placed on either HQ or WQ, for a combined number of quarantine days of 1,637. During the five peak days of SARS-2, the combined number of quarantine days was 910. Of these, paramedics were available for duty on 708 days (78%) due to the WQ program. The primary reason for quarantine was unprotected exposure to a health care institution experiencing a SARS outbreak. Under quarantine, SARS-like symptoms developed in 68 paramedics, including cough (53 [78%]), myalgia (33 [48%]), fatigue (30 [44%]), headache (29 [43%]), fever (11 [16%]), and shortness of breath (7 [10%]). CONCLUSIONS: Paramedics were among the health care workers who developed SARS. During SARS-2, WQ optimized the number of days on which paramedics were available for duty. Many paramedics developed SARS-like symptoms without being diagnosed as having SARS. A dedicated paramedic surveillance and quarantine program provided a useful means to manage the paramedic resource during the SARS outbreak.