Biomedical subjects

Carol A Bodian

Publications and source records attributed to Carol A Bodian.

At least 19 recordsLinked to original sources

PubMed2005

Marked Differences in acute cellular rejection rates between living-donor and deceased-donor liver transplant recipients.

BACKGROUND: : Due to ongoing organ donor shortage, an increasing number of adult live-donor liver transplants (LDLT) are being performed. The aims of this study were to compare the incidence of ACR between recipients of live- and deceased-donor liver transplants, and to note any differences in ACR among related and unrelated living-donor recipients. METHODS: : Sixty-four adults undergoing LDLT between 1998-2001 were closely matched with a deceased recipient. Statistical comparisons in ACR between the live- and deceased-donor groups were based on the differences between the ACR rates of each LDLT patient and the corresponding matched deceased recipient. Analyses were performed separately for pairs in which the living donor was not related to the recipient, was a nonsibling relative, or was a sibling. RESULTS: : Live- and deceased-donor recipients underwent a similar number of liver biopsies. In all, 16/50 (32%) of the biopsied LDLT patients had ACR compared to 36/49 (73%) of the deceased-donor recipients. ACR rates of living donors and their deceased-donor matches did not differ significantly for the unrelated living donors, but did differ for the nonsibling related (P=0.03) and the sibling LDLT (P=0.03). The results were similar when comparing rates of high-degree ACR for unrelated, nonsibling related, and sibling pairs. High-degree ACR differences in the sibling LDLT group were significantly greater than in the nonsibling group (P=0.05). CONCLUSIONS: : Rates of ACR and high-degree ACR are decreased in living-related liver transplant recipients. This difference is likely genetically related as ACR rates are lower in recipient-donor pairs of increasing genetic similarity.

Acute Disease↗

PubMed2005

Pathology of Berkeley sickle cell mice: similarities and differences with human sickle cell disease.

Because Berkeley sickle cell mice are used as an animal model for human sickle cell disease, we investigated the progression of the histopathology in these animals over 6 months and compared these findings to those published in humans with sickle cell disease. The murine study groups were composed of wild-type mixed C57Bl/6-SV129 (control) mice and sickle cell (SS) mice (alpha-/-, beta-/-, transgene +) of both sexes and between 1 and 6 months of age. SS mice were similar to humans with sickle cell disease in having erythrocytic sickling, vascular ectasia, intravascular hemolysis, exuberant hematopoiesis, cardiomegaly, glomerulosclerosis, visceral congestion, hemorrhages, multiorgan infarcts, pyknotic neurons, and progressive siderosis. Cerebral perfusion studies demonstrated increased blood-brain barrier permeability in SS mice. SS mice differed from humans with sickle cell disease in having splenomegaly, splenic hematopoiesis, more severe hepatic infarcts, less severe pulmonary manifestations, no significant vascular intimal hyperplasia, and only a trend toward vascular medial hypertrophy. Early retinal degeneration caused by a homozygous mutation (rd1) independent from that causing sickle hemoglobin was an incidental finding in some Berkeley mice. While our study reinforces the fundamental strength of this model, the notable differences warrant careful consideration when drawing parallels to human sickle cell disease.

Anemia, Sickle Cell↗

PubMed2005

Use of a maze to detect cognitive dysfunction in a porcine model of hypothermic circulatory arrest.

BACKGROUND: Hypothermic circulatory arrest (HCA) can result in cognitive impairment not reflected by histopathology or gross neurologic observation. We tested the sensitivity of two multi-room maze tasks in detecting cerebral dysfunction after HCA in pigs. METHODS: Twenty-seven pigs were studied, divided between two tasks. 13 underwent 90 minutes HCA at 20 degrees C and were trained from postoperative day (POD) 7; 14 were unoperated controls. The maze includes a holding area, 8 rooms, and a center hallway. One piece of apple is placed in each baited room on each of 10 days of learning evaluation. After a pig enters a room, doors to all other rooms close, and the pig must return to the holding area. In task 1, 6 of 8 rooms were baited, and each day's session ended when each baited room had been entered, or after 20 trials. In task 2, initially only the right- or left-sided rooms were baited. Pigs were evaluated each day until they entered 4 baited rooms, or for 15 trials; the process was then repeated, baiting the other side. RESULTS: Intraoperative physiology and postoperative recovery showed no differences between task 1 or 2 pigs. Task 1 did not distinguish between control and HCA groups (p = 0.5), but task 2 revealed significantly (p = 0.04) better learning in controls. CONCLUSIONS: The significantly poorer performance of pigs after HCA suggests that the reversal of baited rooms in task 2 provides the sensitivity to detect cognitive dysfunction. The maze is a promising tool to investigate in pigs the mild cerebral damage often seen after HCA.

Animals↗

PubMed2005

Cooling to 10 degrees C and treatment with Cyclosporine A improve cerebral recovery following prolonged hypothermic circulatory arrest in a chronic porcine model.

OBJECTIVE: This study was undertaken to assess whether cooling to 10 degrees C and/or treatment with Cyclosporine A (CsA) can reduce neurological injury during prolonged hypothermic circulatory arrest (HCA) in a chronic animal model. METHODS: In this blinded study, 24 pigs (20-23 kg) were randomized to HCA for 90 min at 20 degrees C (n=8), at 10 degrees C (n=8), or at 10 degrees C with 5 mg/kg CsA (n=8). CsA (or placebo) were given intravenously before and for 3 days after HCA. Hemodynamics and neurophysiological data were monitored periodically throughout the experiment and for 3 h after HCA, as well as intracranial pressure (ICP), which has been shown to correlate with outcome. Daily neurological/behavioral evaluation (mental status, coordination and appetite; 12=normal and 0=coma or death) was carried out until sacrifice on postoperative day (POD) 3. RESULTS: Overall survival rate was 83.3%: one 20 degrees C control, two 10 degrees C controls, and one 10 degrees C/CsA pig died and were replaced. Basic hemodynamic data revealed no significant differences between groups. ICP differed significantly among the groups during the first 3 h postoperatively (P=0.003 by repeated measures ANOVA); it was higher in the 20 degrees C group than in the 10 degrees C/CsA or 10 degrees C control groups. Recovery of visual evoked potentials was significantly better in the 10 degrees C/CsA group than in the 10 degrees C control group; no recovery was seen by 3 h in the 20 degrees C control group. Postoperative behavioral scores also differed significantly between the groups, P=0.03: a good behavioral outcome--a score >9 on POD3--was more prevalent among CsA-treated pigs (75%) than among 10 degrees C controls (50%), or 20 degrees C controls (12.5%, P=0.06). CONCLUSIONS: The data suggest that cooling to 10 degrees C and CsA treatment are both of benefit in improving cerebral recovery after HCA when compared with untreated 20 degrees C controls, and may be synergistic.

Animals↗

PubMed2005

Optimal temperature for selective cerebral perfusion.

OBJECTIVE: Although combinations of hypothermic circulatory arrest and antegrade selective cerebral perfusion are used for cerebral protection during arch surgery, there is no consensus regarding the optimal temperature during selective cerebral perfusion. This study explored the effect of different temperatures during selective cerebral perfusion on cerebral metabolism and neurologic outcome. METHODS: In this blinded study, 40 pigs (19-21 kg) were randomized into 4 groups after 30 minutes of hypothermic circulatory arrest at 20 degrees C. During a 60-minute interval of selective cerebral perfusion, with flow regulated to maintain a perfusion pressure of 50 mm Hg, pigs were perfused at 10 degrees C, 15 degrees C, 20 degrees C, and 25 degrees C. Fluorescent microspheres enabled calculation of cerebral blood flow during perfusion and recovery. Hemodynamics, intracranial pressure, cerebrovascular resistance, and oxygen consumption were also monitored. Behavioral scores were obtained for 7 days after surgery. RESULTS: Cerebral blood flow decreased significantly ( P < .002) during cooling in all groups: it was significantly higher throughout selective cerebral perfusion in the 20 degrees C to 25 degrees C versus the 10 degrees C to 15 degrees C group ( P = .0001) and remained higher during recovery ( P = .0001). Oxygen consumption decreased significantly with cooling ( P = .0001), remained low during perfusion, and rebounded with rewarming but was significantly lower at 10 degrees C to 15 degrees C than at 20 degrees C to 25 degrees C throughout selective cerebral perfusion ( P = .003) and after CPB was discontinued ( P = .001). Postoperative behavioral scores were significantly better after selective cerebral perfusion at 10 degrees C to 15 degrees C than at 20 degrees C to 25 degrees C ( P = .001). CONCLUSIONS: This study suggests that selective cerebral perfusion at 10 degrees C to 15 degrees C provides better cerebral protection than selective cerebral perfusion at 20 degrees C to 25 degrees C, even though oxygen consumption remains low for hours after selective cerebral perfusion at 10 degrees C to 15 degrees C. Prompt return of metabolism to baseline levels after hypothermic circulatory arrest/selective cerebral perfusion does not necessarily predict superior behavioral outcome.

Animals↗

PubMed2005

Importance of specimen size in accurate needle liver biopsy evaluation of patients with chronic hepatitis C.

BACKGROUND & AIMS: In patients with chronic hepatitis C (CHC), percutaneous needle liver biopsy examination establishes the severity of necroinflammatory activity and fibrosis, thus guiding treatment decisions. Optimal biopsy specimen size remains controversial. We sought to determine how varying lengths of biopsy specimens influence the grading and staging of CHC. METHODS: We used 100 liver biopsy specimens from patients with CHC. The slides were evaluated blindly using the METAVIR scoring system, after being covered with paper, so that only specific specimen lengths (5 mm, 10 mm, 15 mm, and > or =20 mm) were visible. In each case, the scores obtained with biopsies 5 mm, 10 mm, or 15 mm long were compared with the scores at 20 mm or greater by weighted kappa statistics (kappa of >.75 signified excellent agreement). A subset of specimens 20 mm or greater was selected for a blinded repeat scoring to assess intraobserver agreement. The kappa statistics for the designated features and lengths were compared using analysis of variance. RESULTS: In assessing the stage of fibrosis, the weighted kappa statistics for agreement with the 20-mm or greater score at 5 mm, 10 mm, and 15 mm were .75, .85, and .92, respectively. In assessing the histologic activity score, the corresponding figures were .73, .81, and .77, respectively. Average kappa statistic comparisons showed that intraobserver agreement was significantly better than agreement between the 20-mm or greater scores and those at shorter lengths; the 5-mm kappa scores were significantly lower than the others; and there was no significant difference between the 10-mm and 15-mm kappa scores. CONCLUSIONS: Liver biopsy specimens measuring at least 10 mm usually reflect the grade and stage of CHC reliably. Relatively little improvement in diagnostic accuracy is obtained with longer specimens.

Biopsy, Needle↗

PubMed2005

Effect of labor epidural analgesia with and without fentanyl on infant breast-feeding: a prospective, randomized, double-blind study.

BACKGROUND: The influence of labor epidural fentanyl on the neonate is controversial. The purpose of this study was to determine whether epidural fentanyl has an impact on breast-feeding. METHODS: Women who previously breast-fed a child and who requested labor epidural analgesia were randomly assigned in a double-blinded manner to one of three groups: (1) no fentanyl group, (2) intermediate-dose fentanyl group (intent to administer between 1 and 150 microg epidural fentanyl), or (3) high-dose epidural fentanyl group (intent to administer > 150 microg epidural fentanyl). On postpartum day 1, the mother and a lactation consultant separately assessed whether the infant was experiencing difficulty breast-feeding, and a pediatrician assessed infant neurobehavior. All women were contacted 6 weeks postpartum to determine whether they were still breast-feeding. RESULTS: Sixty women were randomly assigned to receive no fentanyl, 59 were randomly assigned to receive an intermediate dose, and 58 were randomly assigned to receive high-dose fentanyl. On postpartum day 1, women who were randomly assigned to receive high-dose fentanyl reported difficulty breast-feeding (n = 12, 21%) more often than women who were randomly assigned to receive an intermediate fentanyl dose (n = 6, 10%), or no fentanyl (n = 6, 10%), although this did not reach statistical significance (P = 0.09). There was also no significant difference among groups in breast-feeding difficulty based on the lactation consultant's evaluation (40% difficulty in each group; P = 1.0). Neurobehavior scores were lowest in the infants of women who were randomly assigned to receive more than 150 microg fentanyl (P = 0.03). At 6 weeks postpartum, more women who were randomly assigned to high-dose epidural fentanyl were not breast-feeding (n = 10, 17%) than women who were randomly assigned to receive either an intermediate fentanyl dose (n = 3, 5%) or no fentanyl (n = 1, 2%) (P = 0.005). CONCLUSIONS: Among women who breast-fed previously, those who were randomly assigned to receive high-dose labor epidural fentanyl were more likely to have stopped breast-feeding 6 weeks postpartum than woman who were randomly assigned to receive less fentanyl or no fentanyl.

Adjuvants, Anesthesia↗

PubMed2005

Is perianal Crohn's disease associated with intestinal fistulization?

BACKGROUND: When cases of Crohn's disease (CD) are described as "fistulizing," distinctions are often not drawn between perianal and intestinal fistulization. The question, therefore, remains open as to whether or not there is truly an association between perianal fistulization and intraabdominal intestinal fistulization in CD. AIMS: We have sought to determine the association between perianal and intestinal fistulization by analyzing the cases of CD recorded in databases from six international centers. PATIENTS: Six databases provided information on 5491 cases of CD in the United States, France, Italy, and The Netherlands. Of these cases, 1686 had isolated ileal disease and 1655 had Crohn's colitis. METHODS: An association between perianal disease and internal fistulae was sought by calculating relative risks for the chance of internal fistulae among patients with perianal fistulae relative to those without. Statistical significance was calculated by the Mantel-Haenszel procedure, stratifying on the separate centers. All statistical tests and estimates were implemented using SAS for the PC. RESULTS: Among the 1686 cases with isolated ileal disease, the evidence of an association between perianal disease and internal fistulization was not consistent across centers, with relative risks ranging from 0.8 to 2.2. For patients with Crohn's colitis (n = 1655), the association was much stronger and more consistent, with an estimated common relative risk of 3.4, 95% confidence interval (2.6-4.6, p < 0.0001). CONCLUSIONS: We have found a statistically significant association between perianal CD and intestinal fistulization, much stronger and more consistent in cases of Crohn's colitis than in cases limited to the small bowel.

Anus Diseases↗

PubMed2005

Predictors of hypotension after induction of general anesthesia.

Hypotension after induction of general anesthesia is a common event. In the current investigation, we sought to identify the predictors of clinically significant hypotension after the induction of general anesthesia. Computerized anesthesia records of 4096 patients undergoing general anesthesia were queried for arterial blood pressure (BP), demographic information, preoperative drug history, and anesthetic induction regimen. The median BP was determined preinduction and for 0-5 and 5-10 min postinduction of anesthesia. Hypotension was defined as either: mean arterial blood pressure (MAP) decrease of >40% and MAP <70 mm Hg or MAP <60 mm Hg. Overall, 9% of patients experienced severe hypotension 0-10 min postinduction of general anesthesia. Hypotension was more prevalent in the second half of the 0-10 min interval after anesthetic induction (P < 0.001). In 2406 patients with retrievable outcome data, prolonged postoperative stay and/or death was more common in patients with versus those without postinduction hypotension (13.3% and 8.6%, respectively, multivariate P < 0.02). Statistically significant multivariate predictors of hypotension 0-10 min after anesthetic induction included: ASA III-V, baseline MAP <70 mm Hg, age > or =50 yr, the use of propofol for induction of anesthesia, and increasing induction dosage of fentanyl. Smaller doses of propofol, etomidate, and thiopental were not associated with less hypotension. To avoid severe hypotension, alternatives to propofol anesthetic induction (e.g., etomidate) should be considered in patients older than 50 yr of age with ASA physical status > or =3. We conclude that it is advisable to avoid propofol induction in patients who present with baseline MAP <70 mm Hg.

Adult↗

PubMed2004

Axillary artery cannulation: routine use in ascending aorta and aortic arch replacement.

BACKGROUND: Ideal perfusion during ascending aorta-arch surgery should allow easy implementation of antegrade cerebral perfusion while avoiding atheroembolization or false lumen perfusion in dissections. We report favorable experience with direct axillary artery cannulation. METHODS: Between 1999 and 2003, 284 patients with a mean age of 62.2 years (25 to 85), underwent axillary artery cannulation using a right angle wire-reinforced catheter. During this interval, attempted axillary cannulation was abandoned in only 14 patients because of inadequate backflow or other complications. Eighty-five patients were female. Severe aortic arteriosclerosis or degeneration was present in 209, aortic dissection in 63, and Marfan disease or aortitis in 12. The Bentall procedure was done in 144 patients, arch replacement in 86, the Yacoub procedure in 18, thoracoabdominal aneurysm repair in 16, and coronary artery bypass grafting in 20. Reoperations were at 30.2%. RESULTS: Adverse outcome (hospital death or permanent stroke) occurred in 6.6% (n = 19). Thirteen patients (4.6%) died before hospital discharge, and 13 patients (4.6%; 9 of whom died) suffered permanent stroke. Transient neurologic dysfunction occurred in 9.2% (n = 26). Mean duration of hypothermic circulatory arrest, used in 246 patients, was 26 +/-7 minutes. Mean duration of antegrade cerebral perfusion, used in 139 patients, was 47 +/- 23 minutes. In 93%, the right axillary artery was cannulated. Complications included 2 cases (0.7%) of brachial plexus injury (one transient), and 3 (1%) of localized dissection. CONCLUSIONS: Our results suggest that axillary artery cannulation, successful in 95% of patients, may be the optimal technique for reducing perfusion-related morbidity and adverse outcome in operations for acute dissection, atherosclerotic, and degenerative aneurysmal disease. It deserves serious consideration in all patients older than 65 requiring cardiopulmonary bypass.

Adult↗

PubMed2004

Mild hypothermia protects the spinal cord from ischemic injury in a chronic porcine model.

OBJECTIVES: During thoracoabdominal aortic aneurysm repair, prolonged compromise of spinal cord blood supply can result in irreversible spinal cord injury. This study investigated the impact of mild hypothermia during aortic cross-clamping on postoperative paraplegia in a chronic porcine model. METHODS: The thoracic aorta was exposed and cross-clamped in 30 juvenile pigs (20-22 kg) for different intervals at normothermia (36.5 degrees C), and during mild hypothermia (32.0 degrees C). Three pigs were evaluated at each time and temperature. Myogenic motor-evoked potentials (MEPs) were monitored, and postoperative recovery evaluated using a modified Tarlov score. RESULTS: There were no significant hemodynamic or metabolic differences between individual animals, and the groups had equivalent arterial pressures (mean 64.3+/-3.6 mmHg). Time to recovery of MEPs correlated with severity of injury; all animals with irreversible MEP loss suffered postoperative paraplegia. At normothermia, animals with 20 min of aortic cross-clamping emerged with normal motor function, but those cross-clamped for 30 min suffered paraplegia. With mild hypothermia, animals tolerated 50 min of aortic cross-clamping without evidence of neurologic injury, but were all paraplegic after 70 min of ischemia. Animals appeared to recover normal motor function after 60 min of aortic cross-clamping at hypothermia initially, but exhibited delayed-onset paraplegia 36 h postoperatively. CONCLUSIONS: Our observations indicate that mild hypothermia dramatically increases the tolerance of the spinal cord to ischemia in the pig, and therefore suggests that cooling to 32.0 degrees C should be encouraged during surgery which may compromise spinal cord blood supply. An ischemic insult of borderline severity may result in delayed paraplegia.

Animals↗

PubMed2004

Outcome analysis of cirrhotic patients undergoing chest tube placement.

OBJECTIVES: Patients with cirrhosis can acquire pulmonary conditions that may or may not be related to their illness. Although posing a greater risk for complications, chest tubes are sometimes placed as treatment for hepatic hydrothorax and other pulmonary conditions. The aim of this study was to analyze the outcomes of chest tube placement in cirrhotic patients. METHODS: A retrospective analysis was performed of 59 adults with cirrhosis undergoing chest tube placement. Variables that were investigated included reason for chest tube placement, complications developing while having the tube in place, and outcome. RESULTS: The 59 subjects were classified as having Child-Turcotte-Pugh (CTP) class A cirrhosis (n = 3), CTP class B cirrhosis (n = 31), and CTP class C cirrhosis (n = 25). Indications for having a chest tube placed were hepatic hydrothorax (n = 24), pneumothorax (n = 9), empyema (n = 8), video-assisted thoracoscopy (VAT) [n = 7], non-VAT (n = 5), and hemothorax (n = 3). The CTP class A subjects had their chest tubes removed without further complications early in the course, and were excluded from further statistical analysis. Twenty-five subjects (42%) had significant pleural effusions requiring chest tube placement. Among the CTP class B and class C subjects, the median duration with chest tube in place was 5.0 days (range, 1 to 53 days). Serum total bilirubin levels, presence of portosystemic encephalopathy, and CTP C classification were predictors of mortality. Mortalities were seen in 5 of 31 CTP class B subjects (16%), and 10 of 25 CTP class C subjects (40%). The tubes were successfully removed in a total of 39 subjects (66%) with no further procedure. Forty-seven subjects (80%) acquired one or more of the following complications: renal dysfunction, electrolyte imbalances, and infection. CONCLUSIONS: When placed for all indications, chest tubes may be successfully removed in the majority of cirrhotic patients. However, a third of all patients still die with the chest tube still in place. Failure to remove the chest tube increases mortality in patients with increasing severity of liver disease.

Chest Tubes↗

PubMed2003

Cerebral physiology and outcome after hypothermic circulatory arrest followed by selective cerebral perfusion.

BACKGROUND: This study explored the impact of an interval of hypothermic circulatory arrest (HCA) preceding selective cerebral perfusion (SCP) on cerebral physiology and outcome. This protocol allows use of SCP during aortic surgery without the threat of embolization inherent in balloon catheterization of often severely atherosclerotic cerebral vessels. METHODS: In this blinded study, 30 pigs (20 to 22 kg) were randomized after cooling to 20 degrees C. Pigs in the HCA-CPB group (n = 10) underwent 30 minutes of HCA followed by 60 minutes of total body perfusion (CPB); HCA-SCP pigs (n = 10) underwent 30 minutes of HCA followed by 60 minutes of SCP, and SCP pigs (n = 10) had 90 minutes of SCP without prior HCA. Fluorescent microspheres enabled calculation of cerebral blood flow during perfusion and recovery. Hemodynamics, intracranial pressure, cerebrovascular resistance, and cerebral oxygen consumption were also monitored. Daily behavioral scores were obtained for 7 days postoperatively. RESULTS: In all groups, cerebral oxygen consumption fell significantly with cooling (p < 0.0001), remained low during perfusion, and rebounded promptly with rewarming; cerebral oxygen consumption was significantly (p = 0.027) greater during SCP than during HCA-CPB. Cerebral blood flow was significantly higher throughout SCP in the HCA-SCP group (p < 0.0001) than with CPB. Cerebrovascular resistance during SCP and HCA-SCP was significantly lower (p = 0.036) than during CPB. Behavioral scores were significantly better with SCP than with HCA-CPB throughout recovery, but did not differ between SCP and HCA-SCP. CONCLUSIONS: This study suggests that a short period of HCA preceding SCP provides global cerebral protection comparable to continuous SCP, implying that in clinical practice, a short period of HCA to reduce risk of embolization will not compromise the superior cerebral protection provided by SCP.

Animals↗

PubMed2003

Is the Bentall procedure for ascending aorta or aortic valve replacement the best approach for long-term event-free survival?

BACKGROUND: This retrospective analysis of a selected series of Bentall procedures may be useful in evaluating the results of valve-sparing operations, an increasingly popular alternative for replacement of the ascending aorta and aortic valve. METHODS: One hundred forty-two elective patients younger than 65 years without concomitant procedures who underwent replacement of the thoracic aorta and aortic valve between 1989 and 2000 were studied; 85% were men, and the median age was 46 years (range, 13 to 64 years). Degenerative disease of the aorta was the most common cause requiring operation (86%, including 46% with a bicuspid aortic valve); 8% had chronic dissection, and 6% had atherosclerotic aneurysms. The ascending aorta was replaced in 94 patients (66%); 45 patients (32%) underwent hemiarch replacement, and in 3 patients (2%) the total arch was replaced. A mechanical valve was used in 88%, and a biologic valve, in 12%. RESULTS: There were no intraoperative deaths. Two patients had a stroke postoperatively, one of which was fatal. Complications during follow-up included 2 cases of endocarditis, 1 peripheral thromboembolic event, and 10 instances of significant bleeding (requiring hospitalization or transfusion). Surgery for distal aortic segments was performed in 4 patients, but no patient required reoperation in the proximal aorta. Kaplan-Meier curves show overall survival is 0.95 (95% confidence intervals, 0.9 to 0.99) at 5 years and 0.93 (95% confidence intervals, 0.86 to 0.99) at 8 years, and event-free survival is 0.85 (95% confidence intervals, 0.78 to 0.92) at 5 years and 0.78 (95% confidence intervals, 0.68 to 0.88) at 8 years. CONCLUSIONS: The button Bentall procedure can be performed with excellent short-term and long-term results in relatively uncomplicated elective patients in whom aortic valve disease is combined with dilatation of the ascending aorta. Results of this traditional operation are the standard against which the long-term outcome of newer approaches, such as valve-sparing operations, should be compared.

Adolescent↗

PubMed2003

Importance of extrasegmental vessels for spinal cord blood supply in a chronic porcine model.

OBJECTIVE: Our purpose was to investigate the interaction of the important components of spinal cord blood supply in the pig model to enable its use for future studies of spinal cord protection. METHODS: Twenty-five juvenile pigs (20-22 kg) underwent serial intercostal (IC) or lumbar artery (LA) ligation until disappearance of motor evoked potentials (MEPs). Pigs underwent sequential craniocaudal IC/LA ligation alone (n=5); following clamping of both subclavian arteries (n=4), or clamping of the median sacral artery (MSA, n=4). Animals also underwent serial caudocranial clamping of LA/IC alone (n=4); preceded by clamping of the subclavian arteries (n=4), or of the MSA (n=4). Results were verified by Tarlov's scores and perioperative angiography. RESULTS: All animals with MEP loss suffered postoperative paraplegia. Groups were equivalent with regard to stable arterial pressures (64.6+/-3.1 degrees C) throughout the experiment, temperature (36+/-1.1 degrees C) and other physiological parameters. Mean number of clamped IC/LA before MEP loss for cranio-caudal clamping direction was 12.8+/-0.8 for segmental arteries isolated, 9+/-0.8 if both subclavian arteries were ligated previously and only 4.3+/-0.5 IC if the median sacral artery was clamped before. Mean number of clamped LA for caudo-cranial clamping direction was 5.8+/-0.9 for segmental lumbar arteries, 5.5+/-0.6 LA if both subclavian arteries were ligated previously and 3.5+/-0.6 if the median sacral artery was clamped before. CONCLUSION: This study confirms the importance of lumbar and MSA arteries to cord viability. It documents the interaction of the subclavian and MSA (roughly equivalent to the hypogastric arteries in humans) with segmental vessels in providing spinal cord blood supply. It also provides the physiologic basis for use of the pig model for studies of spinal cord protection in aortic surgery.

Animals↗

PubMed2003

Impact of hypothermic selective cerebral perfusion compared with hypothermic cardiopulmonary bypass on cerebral hemodynamics and metabolism.

OBJECTIVE: Hypothermic selective cerebral perfusion (SCP) is widely used for cerebral protection during aortic arch surgery, but the effect of the absence of systemic perfusion on cerebrovascular dynamics it has never been established. This study explored the physiology of prolonged SCP compared to hypothermic cardiopulmonary bypass (HCPB) in pigs. METHODS: In this blinded protocol, 29 juvenile pigs (20-23 kg) were randomized after cooling on cardiopulmonary bypass (CPB) to 20 degrees C. Group I pigs (n=14) underwent 90 min of SCP, while group II (HCPB, n=15) underwent total body perfusion. Fluorescent microspheres were injected during perfusion and recovery, enabling calculation of total and regional cerebral blood flow (CBF). Cerebrovascular resistance (CVR), oxygen consumption and intracranial pressure (ICP) were also monitored. RESULTS: CBF decreased significantly (P=0.0001) during cooling, but remained at significantly higher levels with SCP than with HCPB throughout perfusion and recovery (P<0.0001). CVR was significantly lower with SCP than with HCPB throughout perfusion (P=0.04). Oxygen consumption fell significantly with cooling (P=0.0001), remained low during perfusion, and rebounded promptly with rewarming; with SCP it was significantly higher than with HCPB throughout the perfusion interval (P=0.03), and remained higher thereafter. ICP rose significantly less with SCP than with HCPB (P=0.02). CONCLUSION: We conclude that, compared with HCPB, SCP results in beneficial cerebral vasodilatation, as evidenced by significantly higher CBF and oxygen consumption during SCP, by prompt recovery of oxygen consumption after rewarming, and by significantly lower ICP during perfusion and in the post-bypass period.

Animals↗

PubMed2003

Association of intraoperative hypotension and pulmonary hypertension with adverse outcomes after orthotopic liver transplantation.

BACKGROUND: Various preoperative, surgical, and postoperative markers of impaired outcome after orthotopic liver transplantation have been reported, but the influence of intraoperative hemodynamic aberrations has not been thoroughly investigated. SETTING: University Hospital.Study design Retrospective cohort analysis. METHODS: The authors retrospectively reviewed computerized anesthesia records to determine associations between occurrences of abnormally low or high mean pulmonary artery pressure (MPAP), cardiac output, heart rate, systolic arterial pressure, diastolic arterial pressure, and mean arterial pressure (MAP) with negative surgical outcome. Negative surgical outcome was defined as poor early graft function, primary graft nonfunction, or death attributable to hemodynamic causes. RESULTS: Of 789 patients, 142 (18.0%) had negative surgical outcome. Controlling for the influence of United Network for Organ Sharing (UNOS) status > 1, long operation time, cold donor organ ischemia time, and donor age, the only hemodynamic parameters that were independently associated with negative surgical outcome were MAP < 40 mmHg at least once during the procedure (odds ratio [OR] 2.39, p = 0.0016) and MPAP > 40 mmHg at least 3 times during the procedure (OR 2.2, p = 0.035). The occurrence of MAP < 40 mmHg was temporally associated with donor graft reperfusion. Hepatic artery thromboses were not associated with hemodynamic aberrations. CONCLUSIONS: Hemodynamic events are independently associated with adverse outcomes after orthotopic liver transplantation.

Blood Pressure↗

PubMed2003

The numeric rating scale and labor epidural analgesia.

UNLABELLED: A verbal numeric 0-10 rating scale (NRS) is widely used to evaluate pain in research studies, but its usefulness to the clinician is not well established. In this study, we define desire for additional analgesic medication as a clinically relevant outcome in research studies about pain and compare it with the results of the NRS. A post hoc analysis of three studies that we previously conducted concerning labor epidural analgesia was performed. In all three studies, a verbal NRS score was obtained before and 15 min after labor epidural analgesia. At 15 min, the woman was also asked if she wanted more pain medication. We found that very few patients (2%) with a NRS score of 0-1 wanted more medication. When the NRS score was 2 or 3, 51% of the patients wanted more medication, and when the NRS score was >3, almost all patients (93%) wanted more medication. Grouping the final NRS scores into 3 categories (0 or 1, 2 or 3, and >3) is more useful to the clinician than using individual NRS scores. IMPLICATIONS: This study demonstrated that unless the score of the verbal numeric 0-10 rating scale (NRS) is 0 or 1, most women want more analgesic medication for labor epidural analgesia. Additionally, we found that grouping the NRS values into 3 categories for analysis (0 or 1, 2 or 3, and > 3) is more useful to the clinician than using the full spectrum of NRS scores.

Adult↗