Prevalence of and risk factors for perioperative arrhythmias in neonates and children after cardiopulmonary bypass: continuous holter monitoring before and for three days after surgery.
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in Journal of cardiothoracic surgery (2010), 5
BACKGROUND: A comprehensive evaluation of postoperative arrhythmias following surgery for congenital heart disease by continuous Holter monitoring has not been carried out. We aimed, firstly, to establish ... [more ▼]
BACKGROUND: A comprehensive evaluation of postoperative arrhythmias following surgery for congenital heart disease by continuous Holter monitoring has not been carried out. We aimed, firstly, to establish the time course of pre- and early postoperative arrhythmias by beat-to-beat analysis following cardiopulmonary bypass and, secondly, to examine which surgical procedures present risk factors for specific arrhythmias. METHODS: 494 consecutive patients, including 96 neonates, were studied with serial 24-hour Holter electrocardiograms before as well as uninterruptedly during the first 72 hours after surgery and prior to discharge. RESULTS: Within 24 hours of surgery 59% of the neonates and 79% of the older children developed arrhythmias. Junctional ectopic tachycardia occurred in 9% of neonates and 5% of non-neonates and ventricular tachycardia in 3% and 15%, respectively.For neonates, male sex and longer cross-clamping time independently increased the risk for arrhythmias (odds ratios 2.83 and 1.96/minute, respectively). Ventricular septal defect repair was a strong risk factor for junctional ectopic tachycardia in neonates and in older children (odds ratios 18.8 and 3.69, respectively). For infants and children, older age (odds ratio 1.01/month) and closure of atrial septal defects (odds ratio 2.68) predisposed to arrhythmias of any type. CONCLUSIONS: We present the largest cohort of neonates, infants and children that has been prospectively studied for the occurrence of arrhythmias after cardiac surgery. Postoperative arrhythmias are a frequent and transient phenomenon after cardiopulmonary bypass, provoked both by mechanical irritation of the conduction system and by humoral factors. [less ▲]Detailed reference viewed: 27 (0 ULg)
The use of moderate hypothermia during cardiac surgery is associated with repression of tumour necrosis factor-alpha via inhibition of activating protein-1: an experimental study.
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in Critical Care: the Official Journal of the Critical Care Forum (2006), 10(2), 57
INTRODUCTION: The use of moderate hypothermia during experimental cardiac surgery is associated with decreased expression of tumour necrosis factor (TNF)-alpha in myocardium and with myocardial protection ... [more ▼]
INTRODUCTION: The use of moderate hypothermia during experimental cardiac surgery is associated with decreased expression of tumour necrosis factor (TNF)-alpha in myocardium and with myocardial protection. In order to identify the cellular mechanisms that lead to that repression, we investigated the effect of hypothermia during cardiac surgery on both main signalling pathways involved in systemic inflammation, namely the nuclear factor-kappaB (NF-kappaB) and activating protein-1 pathways. METHOD: Twelve female pigs were randomly subjected to standardized cardiopulmonary bypass with moderate hypothermia or normothermia (temperature 28 degrees C and 37 degrees C, respectively; six pigs in each group). Myocardial probes were sampled from the right ventricle before, during and 6 hours after bypass. We detected mRNA encoding TNF-alpha by competitive RT-PCR and measured protein levels of TNF-alpha, inducible nitric oxide synthase and cyclo-oxygenase-2 by Western blotting. Finally, we assessed the activation of NF-kappaB and activating protein-1, as well as phosphorylation of p38 mitogen-activated protein kinase by electrophoretic mobility shift assay with super shift and/or Western blot. RESULTS: During and after cardiac surgery, animals subjected to hypothermia exhibited lower expression of TNF-alpha and cyclo-oxygenase-2 but not of inducible nitric oxide synthase. This was associated with lower activation of p38 mitogen-activated protein kinase and of its downstream effector activating protein-1 in hypothermic animals. In contrast, NF-kappaB activity was no different between groups. CONCLUSION: These findings indicate that the repression of TNF-alpha associated with moderate hypothermia during cardiac surgery is associated with inhibition of the mitogen-activated protein kinase p38/activating protein-1 pathway and not with inhibition of NF-kappaB. The use of moderate hypothermia during cardiac surgery may mitigate the perioperative systemic inflammatory response and its complications. [less ▲]Detailed reference viewed: 20 (1 ULg)
Does cardiac surgery in newborn infants compromise blood cell reactivity to endotoxin?
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in Critical Care: the Official Journal of the Critical Care Forum (2005), 9(5), 549-55
INTRODUCTION: Neonatal cardiac surgery is associated with a systemic inflammatory reaction that might compromise the reactivity of blood cells against an inflammatory stimulus. Our prospective study was ... [more ▼]
INTRODUCTION: Neonatal cardiac surgery is associated with a systemic inflammatory reaction that might compromise the reactivity of blood cells against an inflammatory stimulus. Our prospective study was aimed at testing this hypothesis. METHODS: We investigated 17 newborn infants with transposition of the great arteries undergoing arterial switch operation. Ex vivo production of the pro-inflammatory cytokine tumor necrosis factor-alpha (TNF-alpha), of the regulator of the acute-phase response IL-6, and of the natural anti-inflammatory cytokine IL-10 were measured by enzyme-linked immunosorbent assay in the cell culture supernatant after whole blood stimulation by the endotoxin lipopolysaccharide before, 5 and 10 days after the operation. Results were analyzed with respect to postoperative morbidity. RESULTS: The ex vivo production of TNF-alpha and IL-6 was significantly decreased (P < 0.001 and P < 0.002, respectively), whereas ex vivo production of IL-10 tended to be lower 5 days after the operation in comparison with preoperative values (P < 0.1). Ex vivo production of all cytokines reached preoperative values 10 days after cardiac surgery. Preoperative ex vivo production of IL-6 was inversely correlated with the postoperative oxygenation index 4 hours and 24 hours after the operation (P < 0.02). In contrast, postoperative ex vivo production of cytokines did not correlate with postoperative morbidity. CONCLUSION: Our results show that cardiac surgery in newborn infants is associated with a transient but significant decrease in the ex vivo production of the pro-inflammatory cytokines TNF-alpha and IL-6 together with a less pronounced decrease in IL-10 production. This might indicate a transient postoperative anti-inflammatory shift of the cytokine balance in this age group. Our results suggest that higher preoperative ex vivo production of IL-6 is associated with a higher risk for postoperative pulmonary dysfunction. [less ▲]Detailed reference viewed: 16 (0 ULg)
Intrahepatic synthesis of tumor necrosis factor-alpha related to cardiac surgery is inhibited by interleukin-10 via the Janus kinase (Jak)/signal transducers and activator of transcription (STAT) pathway.
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in Critical Care Medicine (2003), 31(12), 2769-75
SUMMARY: OBJECTIVES To identify the signaling pathways involved in the anti-inflammatory shift of the cytokine balance due to hypothermia during cardiopulmonary bypass. DESIGN Experimental animal study ... [more ▼]
SUMMARY: OBJECTIVES To identify the signaling pathways involved in the anti-inflammatory shift of the cytokine balance due to hypothermia during cardiopulmonary bypass. DESIGN Experimental animal study. SETTING Department of experimental surgery of a university hospital. SUBJECTS Young pigs. INTERVENTIONS Animals underwent normothermic (37 degrees C) or hypothermic (28 degrees C) cardiopulmonary bypass (n = 6 each). Samples of liver tissue were taken before and 6 hrs after cardiopulmonary bypass. MEASUREMENTS AND MAIN RESULTS Intrahepatic expression of tumor necrosis factor-alpha, interleukin-10, inducible nitric oxide synthase, and suppressor of cytokine signaling-3 was detected by reverse transcriptase polymerase chain reaction and/or Western blotting. Concentrations of the inhibitory protein of nuclear factor-kappaB, IkappaB, and of the signal transducer and activator of transcription (STAT)-3 were measured by Western blotting. The DNA-binding activity of nuclear factor-kappaB and STAT-3 was assessed by electrophoretic mobility shift and supershift assays. Liver cell necrosis and apoptosis were assessed by histology and terminal deoxynucleotidyl transferase-mediated dUTP nick end-labeling assay, respectively. Pigs operated on in hypothermia showed significantly higher intrahepatic concentrations of interleukin-10 and lower concentrations of tumor necrosis factor-alpha than the others. They also showed a lower percentage of hepatic cell necrosis but not of apoptosis. This anti-inflammatory reaction observed in the hypothermic group was associated with a higher expression of suppressor of cytokine signaling-3 and with increased activation of STAT-3. Activation of nuclear factor-kappaB and expression of inducible nitric oxide synthase, however, were not significantly different between both groups. CONCLUSION Our results show that hypothermia during cardiopulmonary bypass up-regulates interleukin-10 via STAT-3 activation, which in turn leads to the attenuation of tumor necrosis factor-alpha expression and to hepatic protection. [less ▲]Detailed reference viewed: 3 (1 ULg)
Intramyocardial synthesis of pro- and anti-inflammatory cytokines in infants with congenital cardiac defects.
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in Journal of the American College of Cardiology (2003), 41(12), 2266-74
OBJECTIVES: We sought to test the hypothesis that cytokines would be expressed in the myocardium of infants with congenital cardiac defects and to identify the signaling pathways involved. BACKGROUND ... [more ▼]
OBJECTIVES: We sought to test the hypothesis that cytokines would be expressed in the myocardium of infants with congenital cardiac defects and to identify the signaling pathways involved. BACKGROUND: Mechanical stress upregulates pro-inflammatory cytokines in the myocardium. METHODS: Fifteen infants with tetralogy of Fallot (TOF) (n = 7) or with ventricular septal defects (VSDs) (n = 8) were investigated. Concentrations of pro- and anti-inflammatory cytokines and of the inducible nitric oxide synthase (iNOS) were measured by enzyme-linked immunosorbent assay and/or Western blotting in the right ventricular myocardium taken during cardiac surgery. Activation of the nuclear factor-kappa-B (NF-kappa-B) and p38 mitogen-activated protein kinase (MAPK) pathways was assessed by electrophoretic mobility shift assay with supershift and/or Western blotting, respectively. RESULTS: The pro-inflammatory cytokines tumor necrosis factor (TNF)-alpha, interleukin (IL)-1-beta, and IL-6 and the anti-inflammatory cytokine IL-10 were detected in the myocardium of all patients. Concentrations of the pro-inflammatory cytokines and also of phosphorylated p38 MAPK were higher in patients with TOF than in those with VSD and correlated with the degree of pressure overload of the right ventricle. Levels of phosphorylated I-kappa-B-alpha, iNOS, and IL-10 were similar in patients with TOF and in those with VSD. CONCLUSIONS: Our results show intramyocardial synthesis of pro-inflammatory cytokines in infants with congenital cardiac defects. This is associated with activation of both the NF-kappa-B and p38 MAPK pathways. The latter could be particularly important for the transduction of mechanical signals in the infant's myocardium. Synthesis of IL-10 indicates an intramyocardial anti-inflammatory potential in this age group. [less ▲]Detailed reference viewed: 1 (0 ULg)
Production of proinflammatory cytokines and myocardial dysfunction after arterial switch operation in neonates with transposition of the great arteries.
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in Journal of Thoracic and Cardiovascular Surgery (The) (2002), 124(4), 811-20
OBJECTIVE: Neonates undergoing cardiac surgery have a systemic inflammatory reaction with release of proinflammatory cytokines, which could be responsible for myocardial dysfunction as a result of ... [more ▼]
OBJECTIVE: Neonates undergoing cardiac surgery have a systemic inflammatory reaction with release of proinflammatory cytokines, which could be responsible for myocardial dysfunction as a result of myocardial cell damage. The purpose of this study was to test the hypothesis that the production of proinflammatory cytokines during cardiac surgery would be associated with myocardial dysfunction after the arterial switch operation in neonates. METHODS: A total of 63 neonates with transposition of the great arteries were operated on with combined deep hypothermic circulatory arrest and low-flow cardiopulmonary bypass at a median age of 7 days. Perioperative plasma concentrations of interleukins 6 and 8 were correlated with myocardial dysfunction, as assessed clinically and by echocardiography within 24 hours after the operation, and with perioperative cardiac troponin T blood levels as a marker of myocardial cell damage. RESULTS: Myocardial dysfunction was observed in 11 patients (17.5%), and 2 of them died. Durations of cardiopulmonary bypass and aortic crossclamping, but not of circulatory arrest, were correlated with myocardial dysfunction. Patients with myocardial dysfunction had significantly higher cardiac troponin T blood levels at the end of cardiopulmonary bypass and 4 and 24 hours after the operation than did patients without myocardial dysfunction. Patients with myocardial dysfunction also had higher interleukin 6 plasma concentrations after cardiopulmonary bypass and 4 hours after the operation, as well as higher interleukin 8 plasma concentrations 4 and 24 hours after the operation, than did those without myocardial dysfunction. Postoperative interleukin 6 and 8 plasma concentrations were significantly correlated with postoperative cardiac troponin T blood levels. Multivariable analysis of independent risk factors for myocardial dysfunction comprising cytokine and troponin levels and bypass duration revealed interleukin 6 levels 4 hours after the operation as significant (P =.047). CONCLUSIONS: Cardiac operations in neonates stimulate the production of proinflammatory cytokines, which may contribute to myocardial cell damage and myocardial dysfunction. [less ▲]Detailed reference viewed: 1 (0 ULg)
Moderate hypothermia during cardiopulmonary bypass increases intramyocardial synthesis of heat shock protein 72.
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in Journal of Thoracic and Cardiovascular Surgery (The) (2002), 124(4), 724-31
OBJECTIVES: This study was undertaken to test the hypothesis that the myocardial protective effect of moderate hypothermia during cardiopulmonary bypass involves upward regulation of heat shock protein 72 ... [more ▼]
OBJECTIVES: This study was undertaken to test the hypothesis that the myocardial protective effect of moderate hypothermia during cardiopulmonary bypass involves upward regulation of heat shock protein 72. METHODS: Sixteen young pigs were randomly assigned to a temperature regimen during standardized cardiopulmonary bypass of normothermia or moderate hypothermia (temperatures 37 degrees C and 28 degrees C, respectively, n = 8 per group). Myocardial probes were sequentially sampled from the right ventricle before and during bypass and 6 hours after bypass. Messenger RNA encoding for heat shock protein 72 was assessed by competitive reverse transcriptase-polymerase chain reaction, and heat shock protein 72 synthesis was assessed by Western blot and immunohistochemical methods. Induction of apoptosis was assessed by gene expression of apoptosis-regulating proteins (Bcl-xL, Bak, and Fas) according to competitive reverse transcriptase polymerase chain reaction. Apoptotic cells were identified with an in situ apoptosis-detection kit (terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling) in combination with morphologic criteria. Necrotic cells were detected by standard histologic methods. RESULTS: Moderate hypothermia rather than normothermia was associated with earlier and higher gene expression and synthesis of heat shock protein 72 in the myocardium during and after cardiac surgery. In the hypothermia group both heat shock protein 72 and the messenger RNA encoding it were detected as soon as 30 minutes after initiation of bypass and before aortic clamping, whereas in the normothermia group they were not detected before aortic clamping. Immunohistochemical methods showed localization of heat shock protein 72 in the cardiomyocytes, endothelial cells, and macrophages. Although the percentage of necrotic cells in the myocardium was lower in the hypothermic group, the induction of apoptosis regulatory proteins and the percentage of apoptotic cells did not differ between the groups. CONCLUSIONS: These results suggest that the myocardial protective effect of moderate hypothermia during cardiopulmonary bypass involves upward regulation of heat shock protein 72 and inhibition of necrosis but not of apoptosis. [less ▲]Detailed reference viewed: 2 (0 ULg)
Antegrade palliation for diminutive pulmonary arteries in Tetralogy of Fallot.
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in European Journal of Cardio - Thoracic Surgery (2002), 21(4), 721-4724
OBJECTIVES: The purpose of this study was to evaluate the outcome following palliative reconstruction of right ventricular outflow tract in Tetralogy of Fallot (TOF) with diminutive pulmonary arteries ... [more ▼]
OBJECTIVES: The purpose of this study was to evaluate the outcome following palliative reconstruction of right ventricular outflow tract in Tetralogy of Fallot (TOF) with diminutive pulmonary arteries with central and peripheral stenosis. METHODS: Between 1986 and 1999 in 15 children with the diagnosis of TOF palliative reconstruction of the right ventricular outflow tract without closure of the ventricular septal defect (VSD) was performed. All patients were not suitable for an AP-Shunt because of a diminutive pulmonary vascular bed. Six patients were younger than 1 year at operation. RESULTS: There was one hospital death (6.7%) in a child with additional aortic valve insufficiency in multi-organ failure. Although the postoperative course was prolonged (median duration on ICU: 8 days) and complicated by congestive heart failure, clinically the 14 patients discharged improved significantly. The arterial oxygen saturation increased from 67 to 93% (P<0.001), the hemoglobin decreased from 16.1 to 13.3g/l (P=0.02) and hematocrit from 0.52 to 0.40 (P=0.06). In control angiography, the McGoon Index increased in the average from 1.01 to 1.95 (P<0.001). VSD closure was performed in 12 patients (median: 2.5 years after initial operation) with one perioperative death. A homograft had to be implanted in seven patients and a mechanical prosthesis in the right ventricular outflow tract in one. One late death occurred due to ventricular arrhythmia 12 years after antegrade palliation (11 years after corrective operation). CONCLUSIONS: The antegrade palliation seems to be an adequate strategy for the treatment of selected children with diminutive pulmonary arteries in TOF, who were not candidates for primary correction or an AP-Shunt. [less ▲]Detailed reference viewed: 2 (0 ULg)
Cytokine balance in infants undergoing cardiac operation.
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in Annals of Thoracic Surgery (2002), 73(2), 601-8608-9
BACKGROUND: The control of the systemic inflammatory response taking place during cardiac operations depends on adequate antiinflammatory reaction. In this prospective study we tested the hypothesis that ... [more ▼]
BACKGROUND: The control of the systemic inflammatory response taking place during cardiac operations depends on adequate antiinflammatory reaction. In this prospective study we tested the hypothesis that cytokine balance during pediatric cardiac surgical procedures would be influenced by the patients' preoperative clinical condition, defined as hypoxemia or heart failure. METHODS: Twenty infants (median age, 8 months) with hypoxemia owing to intracardiac right-to-left shunt (group 1, n = 10) or with heart failure because of intracardiac left-to-right shunt (group 2, n = 10), scheduled for elective primary corrective operation, were enrolled. Plasma levels of the proinflammatory cytokine interleukin (IL) 6, the natural antiinflammatory cytokine IL-10, and the markers of the acute-phase response, C-reactive protein and procalcitonin, were sequentially measured before, during, and after cardiac operation up to the 10th postoperative day. The ratio of IL-10 to IL-6 levels served as a marker for the individual's antiinflammatory cytokine balance. RESULTS: Group 1 showed higher preoperative IL-6 (p < 0.001), lower IL-10 levels (p < 0.02), and lower ratio of IL-10 to IL-6 levels (p < 0.001) than group 2. Preoperative C-reactive protein and procalcitonin were not detectable. In group 1, preoperative IL-6 levels inversely correlated with preoperative oxygen saturation (Spearman correlation coefficient, -0.74, p < 0.02). During cardiopulmonary bypass, IL-6 levels were higher, whereas IL-10 and ratio of IL-10 to IL-6 levels were lower in group 1 than in group 2. In all patients, postoperative IL-6 levels were positively correlated with duration of inotropic support and serum creatinine value and inversely correlated with oxygenation index and diuresis. CONCLUSIONS: Infants with hypoxemia show a preoperative inflammatory state with low antiinflammatory cytokine balance in contrast to those with heart failure. This in turn is associated with lower perioperative antiinflammatory cytokine balance and might contribute to postoperative morbidity. [less ▲]Detailed reference viewed: 3 (0 ULg)