Standardized diaper care regimen: a prospective, randomized pilot study on skin barrier function and epidermal IL-1α in newborns

Adaptation of skin barrier function and interleukin-1α (IL-1α) content in diapered and nondiapered skin are poorly characterized in newborns receiving standard skin care. In a monocentric, prospective pilot study 44 healthy, full-term neonates were randomly assigned to skin care with baby wipes (n = 21) or water-moistened washcloth (n = 23) at each diaper change. Transepidermal water loss (TEWL), skin hydration, skin-pH, IL-1α, and epidermal desquamation were measured on days 2, 14, and 28 postpartum. Microbiological colonization was evaluated at baseline and on day 28. Significantly lower TEWL was found on the buttock in the group using baby wipes compared to water. IL-1α and skin hydration significantly increased and pH decreased independent of skin care regimen. IL-1α was significantly higher in diapered skin compared to nondiapered skin. Although skin care with wipes seems to stabilize TEWL better than using water, the skin condition and microbiological colonization were comparable using both cleansing procedures. Increase of epidermal IL-1α may reflect postnatal skin barrier maturation. These data suggest that neither of the two cleansing procedures harms skin barrier maturation within the first four weeks postpartum. Longer observations on larger populations could provide more insight into postnatal skin barrier maturation.     

Intraoperative flow measurement of native coronary artery can help decision making before CABG

We report the case of a patient with three-vessel coronary artery disease whose right coronary artery had been stented at the time of the diagnostic procedure. He had recurrent angina 12 days later and was transferred for urgent coronary artery bypass grafting. No repeat coronary angiography was performed. In the operating room, the flow on the native right coronary artery was determined with an ultrasonic flow probe.     

Giant transit thrombus—From right to left

Pulmonary embolism can be associated with paradox embolism requiring immediate surgical therapy regardless of hemodynamic status. Here we present images illustrating a giant transit thrombus as a concomitant finding in a patient with pulmonary artery embolism.     

Evaluation of brain injury after coronary artery bypass grafting. A prospective study using neuropsychological assessment and diffusion-weighted magnetic resonance imaging.

OBJECTIVE: Neurocognitive dysfunction is a common complication after cardiac surgery with cardiopulmonary bypass (CPB). Studies using magnetic resonance imaging (MRI) have demonstrated that new focal brain lesions can occur after coronary artery bypass grafting (CABG), even in patients without apparent neurological deficits. Diffusion-weighted MRI is superior to conventional MRI and allows for sensitive and early detection of ischemic brain lesions. We prospectively investigated cerebral injury early and 3 months after CABG using diffusion-weighted MRI and related the findings to clinical data and neurocognitive functions. METHODS: Twenty-nine patients [67.6+/-8.6 (52-85) years, 5 females] undergoing elective CABG with CPB were examined before surgery, at discharge and 3 months after surgery. A battery of standardized neuropsychological tests and questionnaires on depression and mood were administered. Conventional and diffusion-weighted MRI of the brain was performed and new lesions were analyzed. Clinical characteristics, neuropsychological test performance and radiographic data were collected and compared. RESULTS: There was no major neurological complication after CABG. Thirteen patients (45%) exhibited 32 new ischemic lesions on postoperative diffusion-weighted MRI. The lesions were small, rounded and equally dispersed in both hemispheres. Eight patients had at least two lesions. At discharge, significant deterioration of neuropsychological performance was observed in 6 of the 13 tests compared to baseline assessment. By 3 months postoperatively, 5 of the 6 tests returned to preoperative levels. Verbal learning ability, however, remained impaired. The presence of new focal brain lesions was not associated with impaired neuropsychological performance. There was also no correlation between clinical variables, intraoperative parameters and postoperative complications and MRI findings. CONCLUSIONS: Although neurocognitive decline after CABG is mostly transient, memory impairment can persist for months. New ischemic brain lesions on postoperative diffusion-weighted MRI do not appear to account for the persistent neurocognitive decline.     

Role of troponin I, myoglobin, and creatine kinase for the detection of early graft failure following coronary artery bypass grafting.

OBJECTIVE: The detection of early graft failure following coronary artery bypass grafting (CABG) enables immediate reintervention and may significantly limit myocardial damage, thus potentially improving outcome. To date, non-invasive indicators of early graft failure following coronary surgery are still of uncertain diagnostic value. METHODS: In a prospective study, patients following isolated CABG with a postoperative serum cardiac troponin I (cTnI) above 20 ng/ml or significant ECG-changes underwent acute repeat angiography. cTnI, myoglobin (Myo), and creatine kinase (CK) were measured preoperatively and at 1, 6, 12, and 24 h after aortic unclamping. Peak values of cTnI, Myo, CK and isoenzyme CK-MB were determined postoperatively. Receiver operating curves (ROC) for cTnI, Myo and CK/CK-MB were constructed at 6, 12, and 24 h after aortic unclamping to differentiate between patients with and without early graft failure. Based on these curves, the area under curve+/-standard deviation (AUC+/-SD), the sensitivity and specificity were calculated. RESULTS: Out of 2078 consecutive patients having undergone isolated CABG from January 2001 to April 2003, 55 fulfilled the inclusion criteria and underwent acute repeat angiography. Early graft failure was found in 35 patients (group 1), whereas 20 patients did not show graft failure (group 2). CTnI and Myo, but not CK and CK-MB levels were significantly increased in group 1 compared to group 2 at 12 and 24 h after aortic unclamping. ROC analysis of cTnI, Myo and CK/CK-MB indicated cTnI as the best discriminator between the groups with 21.5 ng/ml at 12 h (AUC, 0.82+/-0.06; sensitivity, 82%; specificity, 66%) and 33.4 ng/ml at 24 h (AUC, 0.95+/-0.03; sensitivity, 98%; specificity, 82%) and Myo with 887 microg/ml at 12 h (AUC, 0.72+/-0.07; sensitivity, 73%; specificity, 57%) after aortic unclamping. In contrast, CK/CK-MB as well as the appearance of ECG-changes could not separate between the groups. CONCLUSIONS: cTnI, but not Myo and CK served as a reliable marker for the identification of patients with early graft failure following CABG.     

Magnetic resonance imaging in coronary artery bypass surgery--improvement of global and segmental function in patients with severely compromized left ventricular function

Objectives

In the present study, patients with severely compromized left ventricular function underwent magnetic resonance imaging (MRI) before and after coronary artery bypass grafting (CABG). Although improvement of global myocardial contractile function has been shown before, we sought to evaluate whether a functional contractile improvement may be determinable on a myocardial segmental basis after CABG surgery.

Methods

Thirty-three CABG patients with left ventricular ejection fraction (LVEF) ≤30% prospectively underwent MRI to compare pre- and postoperative functional data. At follow-up, all survivors underwent clinical assessment. In 16 patients (three patients died perioperatively, 13 could were lost to MRI follow-up because of cardiac resynchronization therapy and other reasons) postoperative MRI scanning was performed.

Results

In-hospital mortality was 9%. At 20 ± 2 months after surgery, New York Heart Association class improved from 3.0 ± 0.1 to 2.2 ± 0.2 (p < 0.01). Left ventricular end-diastolic volumes decreased significantly from 229 ± 14 mL to 189 ± 19 mL (p < 0.05). LV end-systolic volumes decreased significantly from 163 ± 13 mL to 126 ± 17 mL (p < 0.05). LVEF improved from 30 ± 2% to 36 ± 3% (p < 0.05). On a segmental basis, 42 out of 875 segments (4.8%) had normal function before surgery, at follow-up, 177 segments (20.4%) had normal regional function (p < 0.05).

Conclusions

Patients who undergo CABG surgery with severely compromized left ventricular function, postoperative MRI shows improved global and segmental cardiac function at mid-term follow-up. At the same time there is considerable clinical improvement.     

Repetitive monomorphic ventricular tachycardia originating from the aortic sinus cusp: electrocardiographic characterization for guiding catheter ablation

OBJECTIVES: We sought to investigate the electrocardiographic (ECG) characteristics for guiding catheter ablation in patients with repetitive monomorphic ventricular tachycardia (RMVT) originating from the aortic sinus cusp (ASC). BACKGROUND: Repetitive monomorphic ventricular tachycardia can originate from the right ventricular outflow tract (RVOT) and ASC in patients with a left bundle branch block (LBBB) morphology and an inferior axis. METHODS: Activation mapping and ECG analysis was performed in 15 patients with RMVT or ventricular premature contractions. The left main coronary artery (LMCA) was cannulated as a marker and for protection during radiofrequency delivery if RMVT originated from the left coronary ASC. RESULTS: During arrhythmia, the earliest ventricular activation was recorded from the superior septal RVOT in eight patients (group 1) and from the ASC in the remaining seven patients (group 2). The indexes of R-wave duration and R/S-wave amplitude were significantly lower in group 1 than in group 2 (31.8+/-13.5% vs. 58.3+/-12.1% and 14.9+/-9.9% vs. 56.7+/-29.5%, respectively; p < 0.01), despite similar QRS morphology. In five patients from group 2, RMVT originated from the left ASC, with a mean distance of 12.2+/-3.2 mm (range 7.3 to 16.1) below the ostium of the LMCA. In the remaining two patients, the RMVT origin was in the right ASC. All arrhythmias were successfully abolished. None of the patients had recurrence or complications during 9+/-3 months of follow-up. CONCLUSIONS: On the surface ECG, RMVT from the ASC has a QRS morphology similar to that of RVOT arrhythmias. The indexes of R-wave duration and R/S-wave amplitude can be used to differentiate between the two origins. Radiofrequency ablation can be safely performed within the left ASC with a catheter cannulating the LMCA.     

Surgical treatment of atrial fibrillation using cryothermy in patients undergoing mitral valve surgery

Surgical treatment of atrial fibrillation (AF) using a variety of energy sources and a mixture of lesion sets has become an important adjunct in patients undergoing cardiac surgery. We retrospectively analyzed prospectively collected data of 141 patients with a history of AF (mean duration of AF 35+/-39 months; intermittent AF: n=72; 51%; permanent AF: 69 (49%)) who underwent a left-sided Cryomaze procedure in conjunction with mitral valve (MV) surgery between January 2003 and September 2006. Freedom from AF was 77% at discharge and 87% at a mean follow-up of 305+/-195 days with a decreasing rate of AF during the first 3-9 months from 13% to 9% and an increase beyond the first year (29% at 2 years). Predictors of failed Cryomaze in multivariate analysis were left atrial size >50 mm (OR=5.7), AF at surgery (OR=5.0) and cardiac reoperation (OR=3.4), whereas preoperative beta-blocker treatment was a predictor of success (OR=0.2). Our data suggest that a left-sided Cryomaze procedure effectively restores sinus rhythm in patients with AF undergoing MV surgery. The success rate should not be evaluated immediately postoperatively because there is a steady increase in the rate of patients with freedom from AF in the first year. It appears, however, that there is a higher rate of recurrence during later follow-up.