Interest of thoracic ultrasound after cardiac surgery or interventional cardiology

Thoracic ultrasound has attracted much interest in detecting pleural effusion or pulmonary consolidation after cardiac surgery.In 2016,Trovato reported,in the World Journal of Cardiology,the interest of using,in addition to echocardiography,thoracic ultrasound.In this editorial,we highlight the value of assessing diaphragm function after cardiac surgery and interventional cardiology pro-cedures.Various factors are able to impair diaphragm function after such interventions.Diaphragm motion may be decreased by chest pain secondary to sternotomy,pleural effusion or impaired muscle function.Hemidiaphragmatic paralysis may be secondary to phrenic nerve damage complicating cardiac surgery or atrial fibrillation ablation.Diagnosis may be delayed.Indeed,respi-ratory troubles induced by diaphragm dysfunction are frequently attributed to pre-existing heart disease or pulmonary complications secondary to surgery.In addition,elevated hemidiaphragm secondary to diaphragm dysfunction is sometimes not observed on chest X-ray performed in supine position in the intensive care unit.Analysis of diaphragm function by ultrasound during the recovery period appears essential.Both hemidiaphragms can be studied by two complementary ultrasound methods.The mobility of each hemidiaphragms is measured by M-mode ultrasonography.In addition,recording the percentage of inspiratory thickening provides important information about the quality of muscle function.These two approaches make it possible to detect hemidiaphragm paralysis or dysfunction.Such a diagnosis is important because persistent diaphragm dysfunction after cardiac surgery has been shown to be associated with adverse respiratory outcome.Early respiratory physio-therapy is able to improve respiratory function through strengthening of the inspiratory muscles i.e.diaphragm and accessory inspiratory muscles.

Incidence and peri-operative risk factors for development of acute kidney injury in patients after cardiac surgery:A prospective observational study

BACKGROUND Patients admitted to intensive care unit(ICU) after cardiac surgery develop acute kidney injury(AKI) immediately post-operation. We hypothesized that AKI occurs mainly due to perioperative risk factors and may affect outcome.AIM To assess peri-operative risk factors for AKI post cardiac surgery and its relationship with clinical outcome.METHODS This was an observational single center, tertiary care setting study, which enrolled 206 consecutive patients, admitted to ICU after cardiac surgery. Patients were followed-up until ICU discharge or death, in order to determine the incidence of AKI, perioperative risk factors for AKI and its association with outcome.Univariate and multivariate logistic regression analysis was performed to assess predictor variables for AKI development.RESULTS After ICU admission, 55 patients(26.7%) developed AKI within 48 h. From the logistic regression analysis performed, high EuroScore Ⅱ(OR: 1.18;95%CI: 1.06-1.31, P = 0.003), white blood cells(WBC) pre-operatively(OR: 1.0;95%CI: 1.0-1.0, P = 0.002) and history of chronic kidney disease(OR: 2.82;95%CI: 1.195-6.65, P = 0.018) emerged as independent predictors of AKI among univariate predictors. AKI that developed AKI had longer duration of mechanical ventilation [1113(777–2195) vs 714(511–1020) min, P = 0.0001] and ICU length of stay [70(28–129) vs 26(21–51) h, P = 0.0001], higher rate of ICU-acquired weakness(16.4% vs 5.3%, P =0.015), reintubation(10.9% vs 1.3%, P = 0.005), dialysis(7% vs 0%, P = 0.005), delirium(36.4% vs 23.8%, P = 0.001) and mortality(3.6% vs 0.7%, P = 0.046).CONCLUSION Patients present frequently with AKI after cardiac surgery. EuroScore Ⅱ, WBC count and chronic kidney disease are independent predictors of AKI development. The occurrence of AKI is associated with poor outcome.

Application progress of nursing intervention in cardiac surgery

As a stressor,cardiac surgery affects the physiology and psychology of patients,as well as their postoperative recovery.Patients tend to worry about cognitive deficiency,pain,discomfort,the risk of death,sleep,complications,and other factors,resulting in stress and anxiety.Moreover,serious adverse events,such as circulatory and respiratory dysfunction and infection,tend to occur after cardiac surgery and increase the economic burden on patients.Therefore,appropriate nursing interventions should be selected to strengthen patients’cognitive levels,compliance,and postoperative practices to accelerate their recovery,reduce complications,and shorten hospital stays so as to contribute to patients’lives and health.

Short- and Long-Term Outcomes of Cardiac Surgery in Kidney Transplant Recipients: A Review—Kidney Transplant and Cardiac Surgery

Background: Cardiovascular diseases remain the leading cause of death in kidney transplant patients and increasing proportion of these patients are referred to cardiac surgery. Data on short- and long-term outcomes of these patients are limited to single center reports with no randomized trials and no prospective studies published previously. The aim of this review was to report both short- and long-term outcomes of these patients. Methods: Literature review was conducted using three databases from inception to June 2022. Multiple search terms were used and limited to English language. Thirty-one relevant articles were included. Outcomes of interest were short-term mortality, long-term survival, renal allograft failure and infection in kidney transplant patients undergoing cardiac surgery. Results: Cardiac risk factors (diabetes mellitus, hypertension, hyperlipidemia) were prevalent in kidney transplant patients. 30-days mortality ranged across the studies from zero to 18.8%. The 1-year survival ranged from 71% - 97% and 5-years survival ranged from 31% - 95.7%. Commonest causes of death were cardiac and sepsis. Multiple predictors of mortality were reported. Postoperative acute kidney injury ranged from 0 - 74% with most of them being transient. Kidney graft failure ranged from 0 - 45% with 5-year kidney graft survival rates ranged between 37% - 80%. Post-operative infection rates ranged from 1% - 25% and the most common sites were pneumonia followed by septicemia and surgical site infections. Conclusion: Cardiac surgery can be performed in kidney transplant patients with good short- and long-term results.

Isogeometric Analysis of Hyperelastic Material Characteristics for Calcified Aortic Valve

This study explores the implementation of computed tomography(CT)reconstruction and simulation techniques for patient-specific valves,aiming to dissect the mechanical attributes of calcified valves within transcatheter heart valve replacement(TAVR)procedures.In order to facilitate this exploration,it derives pertinent formulas for 3D multi-material isogeometric hyperelastic analysis based on Hounsfield unit(HU)values,thereby unlocking foundational capabilities for isogeometric analysis in calcified aortic valves.A series of uniaxial and biaxial tensile tests is executed to obtain an accurate constitutive model for calcified active valves.To mitigate discretization errors,methodologies for reconstructing volumetric parametric models,integrating both geometric and material attributes,are introduced.Applying these analytical formulas,constitutive models,and precise analytical models to isogeometric analyses of calcified valves,the research ascertains their close alignment with experimental results through the close fit in displacement-stress curves,compellingly validating the accuracy and reliability of the method.This study presents a step-by-step approach to analyzing themechanical characteristics of patient-specific valves obtained fromCT images,holding significant clinical implications and assisting in the selection of treatment strategies and surgical intervention approaches in TAVR procedures.

Thoracoscopic resection of giant left atrial appendage aneurysm: A case report

Left atrial appendage aneurysm(LAAA)was first reported in the 1960s.1 LAAA is a rare condition,with just over 100 congenital or acquired cases reported to date.2 LAAA is frequently diagnosed incidentally during echocardiography or computed tomography(CT)scans.Most patients with LAAA are asymptomatic,while a few exhibit nonspecific symptoms,such as dyspnea,palpitation,and chest tightness.Patients with LAAA frequently present with atrial arrhythmias and systemic thromboembolism,such as stroke or multiorgan infarctions,due to the formation of a left atrial appendage thrombus.3 The lesion may be cured using aneurysm resection.Considering it as the potential cause of atrial arrhythmias and thromboembolism,the lesion must be identified on time and cured using a suitable treatment approach.

Acute Coronary Syndrome of Young Subjects at the Luxembourg Mother-Child University Hospital in Bamako

Introduction: Acute coronary syndrome is often the first event of coronary disease of young subjects. Objective: To study sociodemographic, clinical, paraclinical, therapeutic and evolutionary aspects of acute coronary syndrome of young subjects. Patients and Methods: Descriptive cross-sectional study with prospective recruitment from October 01, 2020 to March 31, 2022. Were included all patients admitted for acute coronary syndrome whose age was less or equal to 45 years and who had undergone coronary angiography at the Mother-Child University Hospital on Luxembourg from Bamako. Results: During the study period, we collected 60 patient files out of 198. These 60 patient files met our inclusion criteria. Hospital frequency was 30.30%. Average age of patients was 40.43 ± 3.9 years. Sex ratio M/F was 5.3. Main cardiovascular risk factor was smoking tobacco (23.42%), followed by dyslipidemia (13.92%). Functional signs were dominated by angina 62% followed by dyspnea 25.3%. Persistent ST-segment elevation on electrocardiogram was present in 76.4%. Left ventricular systolic dysfunction was present in 26.5%. Time to first medical contact was more than 12 hours in 62.7% of cases. Radial approach was adopted in 94% of cases. Coronary angiography was pathological in 85% (n = 51) of cases. Lesions were single-vessel disease in 47.1% and culprit artery was anterior interventricular in 51% of cases. Dual anti-platelet aggregation was aspirin and ticagrelor in 91.8% of cases. Angioplasty was performed in all patients who had significant abnormalities at coronary angiography. In-hospital mortality was 3.9%. Conclusion: Acute coronary syndromes exist in young Africans with a male predominance. Main cardiovascular risk factor is smoking tobacco. Coronary lesions are single vessel disease in the majority of case. Most of patients meet medical team after 12 hours. Time to first medical contact is a main challenge in our country.

Implications of Elevated Serum Cortisol in the Onset of Postoperative Delirium Following Off-Pump Coronary Artery Bypass Grafting: Insights from a Bangladesh-Based Single Center Experience

Background: Following coronary artery bypass grafting (CABG), delirium emerges as a prevalent complication. This study aimed to assess the correlation between elevated serum cortisol levels and the occurrence of postoperative delirium subsequent to off-pump CABG. Methods: Conducted in the Department of Cardiac Surgery at BSMMU from October 2020 to September 2022, this comparative cross-sectional study included a total of 44 participants. Subjects, meeting specific criteria, were purposefully assigned to two groups based on off-pump CABG. Group A (n = 22) consisted of patients with normal serum cortisol levels, while Group B (n = 22) comprised individuals with high serum cortisol levels on the first postoperative day. Delirium onset was assessed at the bedside in the ICU on the 1st, 2nd, 3rd, 4th, and 5th postoperative days using standard tools, namely the Richmond Agitation Sedation score (RASS) and The Confusion Assessment Method (CAM-ICU). Data were collected based on the presence or absence of delirium. Statistical analysis utilized SPSS version 26.0, employing an independent Student’s t-test for continuous data and chi-square and Fischer’s exact test for categorical data. A p-value ≤ 0.05 was considered statistically significant. Results: Group-A had a mean age of 54.50 ± 17.97, and Group-B had a mean age of 55.22 ± 15.45, both with a male predominance (81.81% and 86.36% respectively). The mean serum cortisol level was significantly higher in Group B (829.71 ± vs. 389.98 ± 68.77). Postoperative delirium occurred in 27.3% of Group B patients, statistically significant compared to the 4.5% in Group A. However, patients in Group B who developed delirium experienced significantly longer postoperative ICU and hospital stays (79.29 ± 12.27 vs. 11.44 ± 2.85, p ≤ 0.05). There was one mortality in Group B, which was statistically not significant. Conclusion: This study observed a significant association between elevated serum cortisol levels in the postoperative period and the occurrence of postoperative delirium after off-pump coronary artery bypass grafting.

Construction of A Prediction Model for Atrial Fibrillation in Patients with Dilated Cardiomyopathy and Heart Failure

Dilated cardiomyopathy(DCM)is a common myocardial disease characterized by enlargement of the heart cavity and decreased systolic function,often leading to heart failure(HF)and arrhythmia.The occurrence of atrial fibrillation(AF)is closely related to the progression and prognosis of the disease.In recent years,with the advancement of medical imaging and biomarkers,models for predicting the occurrence of AF in DCM patients have gradually become a research hotspot.This article aims to review the current situation of AF in DCM patients and explore the importance and possible methods of constructing predictive models to provide reference for clinical prevention and treatment.We comprehensively analyzed the risk factors for AF in DCM patients from epidemiological data,pathophysiological mechanisms,clinical and laboratory indicators,electrocardiogram and imaging parameters,and biomarkers,and evaluated the effectiveness of existing predictive models.Through analysis of existing literature and research,this article proposes a predictive model that integrates multiple parameters to improve the accuracy of predicting AF in DCM patients and provide a scientific basis for personalized treatment.

Correlation of Electric Cardiometry and Continuous Thermodilution Cardiac Output Monitoring Systems

Purpose: Impedance Cardiography (ICG) with its drawbacks to reliably estimate cardiac output (CO) when compared to reference methods has led to the development of a novel technique called Electrical Cardiometry (EC). The purpose of this study was to compare EC-CO with the Continuous CO (CCO) derived from Pulmonary Artery Catheter (PAC). Methods: 60 patients scheduled to undergo coronary artery surgery necessitating the placement of PAC were studied in the operating room. Standard ECG electrodes were used for EC-CO measurements. Simultaneous CO measurement from EC and PAC was done at three predefined time points and were correlated. Results: A significant high correlation was found between the EC-CO and CCO at the three time points. Bland and Altman analysis revealed a bias of 0.08 L/min, a precision of 0.15 L/min, with a narrow limit of agreement (-0.13 to 0.28 L/min). The percentage error between the methods was 3.59%. Conclusion: The agreement between EC-CO and CCO is clinically acceptable and these two techniques can be used interchangeably. Mediastinal opening has no effect on the correlation between these two modalities.

Activation of Aryl Hydrocarbon Receptor Prolongs Survival of Fully Mismatched Cardiac Allograft

Recent data suggest that activation of aryl hydrocarbon receptor （AhR） by its high-affinity ligand 2,3,7,8-tetrachlorodihenzo-p-dioxin （TCDD） results in expansion of regulatory T （Treg） cells and suppresses the development of autoimmune and allergic diseases in several models. Treg cells have been increasingly documented to suppress allograft rejection and even to establish stable long-term graft acceptance. However, the involvement of TCDD in the regulation of solid organ transplantation rejec- tion is largely unknown. Here, we examined whether activation of AhR with TCDD altered cardiac al- lograft rejection in an allogeneic heart transplant model. Recipient C57BL/6 （H-2b） mice were adminis- trated with a single intraperitoneal injection of TCDD, and the murine cardiac transplant models from BALB/c （H-2d） to C57BL/6 （H-2b） were built 24 h later. The complete cessation of cardiac contractility was defined as the observation endpoint. The effect of TCDD on T-cell proliferation was assessed by mixed lymphocyte reaction （MLR）. Histological and immunohistochemical analyses were performed to estimate the severity of rejection. The phenotype and cytokine profile of lymphocytes were analyzed by flow cytometry and enzyme-linked immunosorbent assay （ELISA）. Activation of AhR remarkably pro- longed the survival of cardiac allografts to more than 20 days. In vitro, TCDD ugregulated the fre- quency of CD4＋CD25＋Foxp3＋ Treg cells and suppressed the proliferation of T lymphocytes. In vivo, the prolonged survival time was associated with increased number of Treg cells in allografls and spleens Furthermore, the secretion of interferon-3, （IFN-3,） and interleukin-17 （IL-17） was reduced to less than 50% of that of the PBS treatment control group by TCDD treatment, whereas IL-10 was elevated to 10-fold of that of the PBS treatment control group. Collectively, our data indicate that activation of AhR with a single dose of TCDD significantly prolonged the survival of fully allogeneic cardiac grafts, and the mechanism underlying this effect might be involved in the induction of Treg cells.

Effect of L-carnitine on Cardiomyocyte Apoptosis and Cardiac Function in Patients Undergoing Heart Valve Replacement Operation

Summary： The effects of L-carnitine, as an ingredient of cardioplegia solution, on cardiac function and cardiomyocyte apoptosis in patients undergoing heart valve replacement operation were investigated. Twenty-three cases undergoing heart valve replacement with cardiopulmonary bypass （CPB） were randomly allocated into two groups： L-carnitine group （n=12, 12 g/L L-carnitine was put in the ST. Thomas cardioplegia） and control group （n=11, identical to the L-carnitine group except that normal saline was administered instead of L-carnitine）. Serum cardial troponin I （cTnI） levels, the left ventricular ejection fraction （LVEF）, and cardiac index （CI） were measured perioperatively. A bit of myocardial tissue obtained from right atria was taken before CPB and by the end of intracardiac procedure to undergo electron microscopy examination and estimate apoptosis by terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling （TUNEL）. From the end of CPB to 3 days after operation, the serum levels of cTnI in the L-carnitine group was significantly lower than that in the control group （P〈0.05）. Heart color ultrasonogram showed that the CI index and LVEF at 7th day postoperatively in the L-carnitine group were significantly higher than in the control group （P〈0.05）. Compared to the control group, L-carnitine significantly alleviated the morphologic changes of cardiac muscle cells （electron microscopy examination） and decreased the amounts of apoptotic cardiac muscle cells （TUNEL）. Furthermore, the dosage of vasoactive drugs used after operation was significantly less in the L-carnitine group （P〈0.01）. It was concluded that L-carnitine cardioplegia solution could improve cardiac function in patients undergoing heart valve replacement operation and alleviate CPB-mediated apoptosis of cardiac muscle cells.

The value of serum metabolomics analysis in predicting the response to cardiac resynchronization therapy

Objective To construct a prediction model based on metabolic profiling for predicting the response to cardiac resynchronization therapy(CRT).Methods Peripheral venous(PV)and coronary sinus(CS)blood samples were collected from 25 patients with heart failure(HF)at the time of CRT implantation,and PV blood samples were obtained from ten healthy controls.The serum samples were analyzed by liquid chromatography-mass spectrometry(LC-MS).As per the clinical and echocardiographic assessment at the 6-month follow-up,the HF patients were categorized as CRT responders and non-responders.Results HF patients had altered serum metabolomic profiles that were significantly different from those of the healthy controls.Differential metabolites were also observed between CRT responders and non-responders.A prediction model for CRT response(CRT-Re)was constructed using the concentration levels of the differential metabolites,L-arginine and taurine.The optimal cutoff value of the CRT-Re model was found to be 0.343 by ROC analysis(sensitivity,88.2%;specificity,87.5%;Area under curve(AUC)=0.897,P=0.002).The concentration levels of the differential metabolites,L-arginine and lysyl-gamma-glutamate,in PV serum were significantly correlated with that in CS serum(r=0.945 and 0.680,respectively,all P<0.001).Conclusions Our results suggest that serum-based metabolic profiling may be a potential complementary screening tool for predicting the outcome of CRT.

Randomized controlled trial of remote ischemic preconditioning and atrial fibrillation in patients undergoing cardiac surgery

AIM To study whether remote ischemic preconditioning(RIPC) has an impact on clinical outcomes, such as post-operative atrial fibrillation(POAF).METHODS This was a prospective, single-center, single-blinded,randomized controlled study. One hundred and two patients were randomized to receive RIPC(3 cycles of 5 min ischemia and 5 min reperfusion in the upper arm after induction of anesthesia) or no RIPC(control). Primary outcome was POAF lasting for five minutes or longer during the first seven days after surgery. Secondary outcomes included length of hospital stay, incidence of inpatient mortality, myocardial infarction, and stroke. RESULTS POAF occurred at a rate of 54% in the RIPC group and 41.2% in the control group(P = 0.23). No statistically significant differences were noted in secondary outcomes between the two groups. CONCLUSION This is the first study in the United States to suggest that RIPC does not reduce POAF in patients with elective or urgent cardiac surgery. There were no differences in adverse effects in either group. Further studies are required to assess the relationship between RIPC and POAF.

Comparison of the Hemodynamic Effects of the Induction Agents Ketamine, Etomidate and Sevoflurane Using the Model of Electrical Velocimetry Based Cardiac Output Monitoring in Pediatric Cardiac Surgical Patients

Objective: To compare the haemodynamic effects of the induction agents ketamine, etomidate and sevoflurane using the model of electrical velocimetry based cardiac output monitoring in paediatric cardiac surgical patients. Design: Prospective randomized study. Setting: Tertiary care hospital. Participants: 60 children < 2 years age undergoing cardiac surgery. Interventions: The patients were randomized into 3 equal groups to receive 1.5-2.5 mg/kg iv ketamine (group K), 0.2-0.3 mg/kg iv etomidate (group E) or upto 8% sevoflurane (group S) as the induction agent. Hemodynamic parameters were noted before and after induction of anaesthesia utilizing a noninvasive cardiac monitor based on the model of electrical velocimetry. Measurements and Main Results: The demographic characteristics of the patients were similar in the three groups. The HR decreased in all groups, least in group E (P ≤ 0.01) but the MAP decreased only in group S (P ≤ 0.001). In group S, the stroke volume improved from 9 ± 3.2 ml to 10 ± 3.2 ml (P ≤ 0.05) and the stroke volume variation decreased from 25% ± 6.4% to 13% ± 6.2% (P ≤ 0.001). The stroke index and systemic arterial saturation improved in all groups (P ≤ 0.01). The cardiac index and index of contractility were unchanged. The transthoracic fluid content reduced in groups E and S, but did not change in group K (P ≤ 0.05). Conclusions: Etomidate appeared to provide the most stable conditions for induction of anesthesia in children undergoing cardiac surgery, followed by ketamine and sevoflurane.

Improved methodology for efficient establishment of the myocardial ischemia-reperfusion model in pigs through the median thoracic incision

To investigate the feasibility and effectiveness of establishing porcine ischemia-reperfusion models by ligating the left anterior descending(LAD)coronary artery,we first randomly divided 16 male Bama pigs into a sham group and a model group.After anesthesia,we separated the arteries and veins.Subsequently,we rapidly located the LAD coronary artery at the beginning of its first diagonal branch through a mid-chest incision.Then,we loosened and released the ligation line after five minutes of pre-occlusion.Finally,we ligated the LAD coronary artery in situ two minutes later and loosened the ligature 60 min after ischemia.Compared with the sham group,electrocardiogram showed multiple continuous lead ST-segment elevations,and ultrasound cardiogram showed significantly lower ejection fraction and left ventricular fractional shortening at one hour and seven days post-operation in the model group.Twenty-four hours after the operation,cardiac troponin T and creatine kinase-MB isoenzyme levels significantly increased in the model group,compared with the sham group.Hematoxylin and eosin staining showed the presence of many inflammatory cells infiltrating the interstitium of the myocardium in the model group but not in the sham group.Masson staining revealed a significant increase in infarct size in the ischemia/reperfusion group.All eight pigs in the model group recovered with normal sinus heart rates,and the survival rate was 100%.In conclusion,the method can provide an accurate and stable large animal model for preclinical research on ischemia/reperfusion with a high success rate and homogeneity of the myocardial infarction area.

Effect of Cardioplegia for Myocardial Protection in Pediatric Cardiac Surgery:A Network Meta-Analysis

Cardioplegia has been widely used to reduce myocardial injury during pediatric cardiac surgery;however,which cardioplegia solution has the best protective effect has not been established.Thus,we compared the myocardial protective effects of different cardioplegia solutions used in pediatric cardiac surgery.Seven databases were searched to identify the relevant randomized controlled trials.A network meta-analysis with a Bayesian framework was conducted.The outcomes included the following biochemical and clinical outcomes:serum concentrations of the creatine kinase-myocardial band at 6 h postoperatively;cardiac troponin I(cTnI)at 4,12,and 24 h postoperatively;spontaneous beating after declamping;postoperative arrhythmias;inotropic support percentage and duration;mechanical ventilation hours;intensive care unit stay in days;hospital stay in days;and mortality.The group treated with cold crystalloid cardioplegia(cCCP)was chosen as the control group.The 22 studies involved 1529 patients.Six types of cardioplegia solutions were described in these studies,including cold blood cardioplegia,cCCP,del Nido,histidine-tryptophan-ketoglutarate(HTK),terminal warm blood cardioplegia,and warm blood cardioplegia(wBCP).The serum concentrations of the 24-h cTnI with wBCP(MD=−2.52,95%CI:−4.74 to−0.27)was significantly lower than cCCP.The serum concentrations of the 24-h cTnI with HTK(MD=4.91,95%CI:2.84–7.24)was significantly higher than cCCP.There was no significant difference in other biochemical and clinical outcomes when compared to cCCP.In conclusion,wBCP may have a superior myocardial protective effect with lower 24-h cTnI levels postoperatively and similar clinical outcomes after pediatric cardiac surgery.

Preoperative application of combination of portal venous injection of donor spleen cells and intraperitoneal injection of rapamycin prolongs the survival of cardiac allografts in mice

Objective:To investigate the effects of preoperative portal venous injection of donor spleen cells(PVIDSC) and intraperitoneal injection of rapamycin in the acute rejection of cardiac allograft in mice and the underlying mechanisms. Methods:Homogenous female B6 mice and BALB/c mice were used as recipients and donors of heart transplantation. These mice were randomly divided into different groups and received PVIDSC alone,rapamycin alone,or PVIDSC and rapamycin combined therapy. In addition,the underlying mechanism was studied by measuring a number of cytokines. Results:Preoperative combination of PVIDSC and intraperitoneal injection of rapamycin significantly prolonged the survival of heterotopic cardiac allograft in mice,but had no effects on the survival time of cardiac allografts in mice pre-sensitized by skin grafting. Preoperative combination of PVIDSC and intraperitoneal injection of rapamycin increased the expression of IL-10 and Foxp3 and reduced the expression of INF-γ. Short-term preoperative administration of rapamycin promotes the expression of CD4^+CD25^+Foxp3^+ regulator T cells. However,preoperative using alone of rapamycin,or combination of PVIDSC and rapamycin had no effects on the inhibition of proliferation of memory T cells. Conclusions:Preoperative application of combination of PVIDSC and rapamycin significantly prolonged the survival time of cardiac allografts in mice but not in mice pre-sensitized by skin grafting. This may be explained by the fact that combination of PVIDSC and rapamycin inhibited the cellular immune response and induced the expression of IL-10 from Tr1 cells and CD4^+CD25^+FoxP3^+ regulatory T cells.

SUCCESSFUL RESECTION OF CARDIAC ANGIOSARCOMA COMBINED WITH RIGHT CORONARY ARTERY BYPASS GRAFTING

ANGIOSARCOMA is the most common primary malignant cardiac tumor. Until recently, the diagnosis is often not established until the tumor is advanced with vital cardiac structure involved or distal metastasis, mainly because the symptoms are initially nonspecific. The natural history of cardiac angiosarcoma is characterized by a short clinical course and a fatal outcome. Surgical resection remains the preferential therapy for palliation or cure, where as irradiation and chemotherapy have only limited use. We herein reported a successful radical resection of cardiac angiosarcoma with concomitant reconstruction of right coronary artery, tricuspid leaflet, and atrial wall. The literature on cardiac angiosarcomas is reviewed extensively, with emphasis on presentation and surgical

The Variation in Plasma Cortisol Levels in Response to Anesthetic Induction with Etomidate or Ketamine in Children Undergoing Intracardiac Repair of Tetralogy of Fallot on Cardiopulmonary Bypass

Objective: To compare the effect of a single induction dose of etomidate or ketamine on plasma cortisol levels in children with Tetralogy of Fallot (TOF) undergoing intra-cardiac repair on cardiopulmonary bypass (CPB). Design: A prospective randomized trial. Setting: Cardiac center of a tertiary care hospital. Participants: Thirty children with TOF undergoing intra-cardiac repair on CPB. Interventions: After random allocation of the children into two groups, the children either received etomidate 0.2 mg/kg or ketamine 2 mg/kg intravenously for anesthetic induction along with fentanyl 2 mcg/kg and midazolam 100 mcg/kg. Endotracheal intubation was accomplished with rocuronium bromide in the dose of 1 mg/kg. Anesthesia was maintained with sevoflurane in air-oxygen, titrated to response and supplemental vecuronium bromide for muscle relaxation, fentanyl chloride for pain relief. Serum cortisol was measured on three occasions, at preinduction, at the end of surgery and at 24 hours postoperatively. Measurements and Main Results: Baseline plasma cortisol (Normal 5 - 25 mcg/dl) in the etomidate group (19.91 ± 3.51 mcg/dl) decreased significantly at the end of surgery (5.78 ± 2.0 mcg/dl) and rose to significantly higher than baseline values at 24 hours (27.31 ± 8.30 mcg/dl). The baseline cortisol levels in the ketamine group (20.91 ± 3.19 mcg/dl) increased significantly at the end of surgery (44.02 ± 5.49 mcg/dl) and remained significantly higher than baseline at 24hours (45.93 ± 3.05 mcg/dl). Plasma cortisol levels in the etomidate group at end of surgery, and at 24 hours post-operatively, were significantly lower than the ketamine group. Conclusions: This study shows that etomidate is a suitable and safe agent for suppression of the increase in serum cortisol associated with the use of CPB in children with TOF undergoing intra-cardiac repair.