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  • 1.
    Appelblad, Micael
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences.
    Engström, Gunnar
    Fat contamination of pericardial suction blood and its influence on in vitro capillary-pore flow properties in patients undergoing routine CABG.2002In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 124, no 2, p. 377-386Article in journal (Refereed)
  • 2.
    Appelblad, Micael
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Fat content in pericardial suction blood and the efficacy of spontaneous density separation and surface adsorption in a prototype system for fat reduction.2007In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 134, no 2, p. 366-372Article in journal (Refereed)
  • 3.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Edström, Cecilia
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Side differences in cerebrovascular accidents after cardiac surgery: a statistical analysis of neurologic symptoms and possible implications for anatomic mechanisms of aortic particle embolization.2005In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 129, no 3, p. 591-598Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Aortic manipulation and particle embolization have been identified to cause cerebrovascular accidents in cardiac surgery. Recent data suggest that left-hemispheric cerebrovascular accident (right-sided symptoms) is more common, and this has been interpreted as being caused by aortic cannula stream jets. Our aim was to evaluate symptoms of cerebrovascular accident and side differences from a retrospective statistical analysis. METHODS: During a 2-year period, 2641 consecutive cardiac surgery cases were analyzed. Patients positive for cerebrovascular accident were extracted from a database designed to monitor clinical symptoms. A protocol was used to confirm symptom data with the correct diagnosis in patient records. Patients were subdivided into 3 groups: control, immediate cerebrovascular accident, and delayed cerebrovascular accident. RESULTS: Among pooled patients, immediate and delayed cerebrovascular accidents were 3.0% and 0.9%, respectively. The expected predisposing factors behind immediate cerebrovascular accidents were significant, although the type of operation affected this search. Aortic quality was a strong predictor ( P < .001). The rate of delayed cerebrovascular accident was unaffected by surgery group. Left-sided symptoms of immediate cerebrovascular accident were approximately twice as frequent ( P = .016) as on the contralateral side. This phenomenon was observed for pooled patients and for isolated coronary bypass procedures (n = 1882; P = .025). CONCLUSIONS: Immediate cerebrovascular accident and aortic calcifications are linked. The predominance of left-sided symptoms may suggest that aortic manipulation and anatomic mechanisms in the aortic arch are more likely to cause cerebrovascular accidents than effects from cannula stream jets.

  • 4.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Hansson, Magnus
    Engström, Gunnar
    Embolic material generated by multiple aortic crossclamping: a perfusion model with human cadaveric aorta2003In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 125, no 6, p. 1451-1460Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Atherosclerosis of the ascending aorta and use of aortic crossclamping are risk factors for neurologic injury during cardiac surgery. OBJECTIVES: Repeated aortic manipulation is part of the surgical approach to most cardiac operations. The aim of this study was to assess the amount and size of particulate matter that is dislodged from the aortic wall as a function of repeated aortic crossclamping. METHODS: In 10 subjects undergoing autopsy the aorta was dissected and mounted in a perfusion model. The ascending aorta was crossclamped and washed out 10 times, with the perfusate collected in aliquots (1 to 10). The aliquots were examined by computerized image processing, both macroscopically and under the microscope for calcified and cellular material. RESULTS: Aortic crossclamping produced substantial output of particulate matter. After repeated aortic crossclamping the number of particles decreased (P =.012) and approached the baseline for aliquots 6 to 10. The average particle diameter was 0.63 +/- 0.03 mm, with a maximum of 4.74 mm. Similar variability in particle outputs were recorded microscopically, with findings of both calcified and cellular material. Nine of 10 aortas had calcifications seen during simple visual inspection. CONCLUSIONS: The washouts of dislodge material at aortic crossclamping had embolic potential. During the initial aortic crossclamping procedures the amount of particles was substantial, both macroscopically and microscopically. On the microscopic scale noncalcified cellular debris represents a significant pool of embolic material. Repeated aortic crossclamping reduced the amount of particles. These findings question surgical techniques associated with repeated aortic crossclamping.

  • 5.
    Boivie, Patrik
    et al.
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Hansson, Magnus
    Umeå University, Faculty of Medicine, Medical Biosciences, Pathology.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Surgical and Perioperative Sciences, Surgery.
    Intraluminal aortic manipulation by means of intra-aortic filter, cannulation, and external clamp maneuvers evaluated versus dislodged embolic material.2006In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 131, no 2, p. 283-289Article in journal (Refereed)
    Abstract [en]

    OBJECTIVES: Aortic atherosclerosis is an important risk factor for cerebrovascular accidents in cardiac surgery. An intra-aortic filter might reduce this risk. We aimed to analyze the risks for emboli associated with intraluminal aortic manipulation and intra-aortic filter handling in relation to cannulation and external clamp maneuvers. METHODS: A model was designed with a cadaver aorta and retrograde perfusion (n = 16). A crossclamp was positioned on the ascending aorta and repeatedly opened under pressure to collect aliquots with dislodged particles. Cannulation was performed after 10 clamp maneuvers, followed by positioning and removing the intra-aortic filter, with each step followed by a washout sequence to collect perfusate. The removed filter was also analyzed. Evaluation was by means of digital image analysis, with differentiation of particles into different spectra. RESULTS: Intra-aortic filter manipulation produced a significant washout of embolic particles; in particular, this was seen for the macroscopic cellular spectrum (P = .006 and P = .002 for filter insertion and removal, respectively). Particles were also found to be collected by the filter (P = .004). In addition, cannulation and aortic crossclamp manipulation generated a notable number of particles (P = .001 and P = .013, respectively). CONCLUSIONS: The intra-aortic filter collects material during aortic manipulation. However, intraluminal aortic manipulation from filter handling can also dislodge particles, possibly related to shedding of intimal debris. This is in addition to substantial amounts of particles that are generated by aortic cannulation and aortic crossclamping.

  • 6. Mariscalco, Giovanni
    et al.
    Engström, Karl Gunnar
    Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences.
    Ferrarese, Sandro
    Cozzi, Giuseppe
    Bruno, Vito Domenico
    Sessa, Fausto
    Sala, Andrea
    Relationship between atrial histopathology and atrial fibrillation after coronary bypass surgery2006In: Journal of Thoracic and Cardiovascular Surgery, ISSN 0022-5223, E-ISSN 1097-685X, Vol. 131, no 6, p. 1364-1372Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Postoperative atrial fibrillation is common after coronary surgery. The cellular condition of atrial myocytes might play a part in the postoperative development of atrial fibrillation. Our study aimed to investigate whether patients in whom postoperative atrial fibrillation develops show pre-existent alterations in histopathology of the right atrium and how such changes are expressed in relation to the use of cardiopulmonary bypass.

    METHODS: Seventy patients undergoing elective coronary revascularization were prospectively randomized to on-pump conventional surgery (conventional coronary artery bypass grafting, n = 35) or off-pump surgery on the beating heart (off-pump coronary artery bypass grafting, n = 35). Samples from the right atrial appendage were immediately collected after opening the pericardium. In the on-pump group samples were also taken after weaning from cardiopulmonary bypass. Focusing on degenerative alterations, histology was studied by means of light microscopy and for confirmation of particular findings by means of electronic microscopy.

    RESULTS: Twenty-two (31%) patients had postoperative atrial fibrillation, with the rate not being different between the off-pump coronary artery bypass grafting and conventional coronary artery bypass grafting groups (P = .797). Left atrial enlargement and inotropic requirement were related to atrial fibrillation. Interstitial fibrosis, vacuolization, and nuclear derangement of myocytes were the histologic abnormalities associated with the development of postoperative atrial fibrillation. However, in multivariate analysis fibrosis was confounded by myocyte vacuolization (P = .002) and nuclear derangement (P = .016), representing independent atrial fibrillation predictors. As expected, the conventional coronary artery bypass grafting and off-pump coronary artery bypass grafting groups showed similar histology, but more importantly, no atrial changes were detected in relation to cardiopulmonary bypass exposure in the conventional coronary artery bypass grafting group. Atrial histology showed degenerative changes that correlated with advanced age and left atrial enlargement.

    CONCLUSIONS: Our study supports the contention that atrial fibrillation after coronary surgery is associated with pre-existing histopathologic changes of the right atrium. Patients randomly allocated to off-pump coronary artery bypass grafting procedures showed a similar rate of atrial fibrillation and a similar relationship to atrial histology as did those exposed to cardiopulmonary bypass. Cardiopulmonary bypass did not cause additional changes in tested histology variables.

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