ICVTS - Interactive Feed

[Coronary] Carbon dioxide embolism during endoscopic vein harvesting

Tamim, M., Omrani, M., Tash, A., El Watidy, A. — 2008-04-01

Endoscopic vein harvesting (EVH) is becoming common for the patients undergoing coronary artery bypass grafting. Using carbon dioxide insufflations during the vein harvest can produce rare but catastrophic CO₂ embolism. We report a case of massive right atrial CO₂ embolism due to femoral vein injury which occurred during performance of routine EVH procedure. Keywords: CO₂ embolism; Endoscopic vein harvest

[Thoracic general] The role of muscle flap in preventing bronchus stump insufficiency after pneumonectomy for malignant pleural mesothelioma in high-risk patients

Beshay, M., Carboni, G., Hoksch, B., Reymond, M. A., Schmid, R. A. — 2008-04-01

Bronchus stump insufficiency (BSI) is one of the major complications after pneumonectomy; we analyzed all patients who underwent extra pleural pneumonectomy (EPP) for malignant pleural mesothelioma (MPM) in order to detect the role of muscle flap (MF) on preventing early and late stump insufficiency. From January 2000 till December 2005, there were 42 patients admitted with MPM for further intervention at our institution. 30 patients were suitable for surgery and thus received a multimodal treatment with neo-adjuvant chemotherapy using Cisplatin® and Gemcitabin (Gemzar®), EPP followed by 54 Gray (Gy) adjuvant radiotherapy. Data were collected from the surgical and oncological records. There were 37 male patients (88%), the median age was 65 years (range 40-83 years). 7 (17%) patients had concomitant diseases. 40 patients (95%) had asbestos exposition. The operative procedures were EPP with muscle flap through an anterolateral thoracotomy. Univariate and multivariate analyses were done. One patient (3%) died on the 2nd postoperative day due to lung embolism. Mild complications were noticed in the early postoperative phase in 8 (25%) patients. There was no early or late stump insufficiency during the 15-month follow-up. Surgical techniques using muscle flap seems to play a major role in the prevention of bronchus stump insufficiency especially after neo-adjuvant chemotherapy. Keywords: Bronchus stump insufficiency; Muscle flap; Pneumonectomy; Pleural mesothelioma

[Carotid and imaging (ICVTS only)] Bilateral iliac artery dissection following severe complex unstable pelvic fracture

Teebken, O., Lotz, J., Gaensslen, A., Pichlmaier, M. — 2008-03-28

The case of an 18-year-old polytrauma patient with a complete disruption of the right external iliac artery and a dissection of the left external iliac artery mainly caused by bilateral complex pelvic fractures type C, a subluxated horizontal fracture of the right acetabulum, and a transforaminal sacrum fracture is described. Keywords: Iliac artery dissection; Polytrauma; Tile's C; Unstable pelvic fracture

[Congenital] Early atrial septal defect surgery due to a bronchogenic cyst causing congestive heart failure by left atrium compression

Mosquera, V. X., Rijlaarsdam, M., Filippini, L., Hazekamp, M. G. — 2008-03-28

We report on an uncommon case of a 10-month-old patient who required early surgical closure of an ostium secumdum atrial septal defect due to the concomitant presence of a big subcarinal bronchogenic cyst compressing the left atrium and, therefore, increasing the left-to-right shunt. It led to refractory congestive heart failure symptoms, establishing thereby an earlier indication of surgical treatment. Keywords: CHD; Septal defects; Cysts; Heart failure

[Valves] Papillary muscle realignment and mitral annuloplasty in patients with severe ischemic mitral regurgitation and dilated heart

Fumimoto, K.-u, Fukui, T., Shimokawa, T., Takanashi, S. — 2008-03-27

Chronic ischemic mitral regurgitation (IMR) is one of the leading causes of congestive heart failure and death. It is controversial whether mitral annuloplasty (MAP) per se can improve the long-term survival because IMR has been considered a disease of the left ventricle. We reviewed our experience of papillary muscle realignment in conjunction with MAP in patients with IMR. Between September 2004 and October 2007, seven patients were treated with papillary muscle realignment and MAP with coronary bypass grafting. The mean age was 60.3±3.5 years. The mean number of distal anastomoses was 3.6±1.9. Procedural success without in-hospital complications was achieved in all cases, except one patient who had a stroke and another patient with prolonged ventilation. Echocardiographic examination revealed that postoperative coaptation depth (10.2±3.1 mm preoperatively versus 6.5±2.0 mm postoperatively), tenting area (1.8±0.8 cm² versus 0.6±0.1 cm²), end-diastolic interpapillary muscle distance (36.4±4.7 mm versus 27.1±4.6 mm) and the grade of MR (3.3±0.5 versus 0.4±0.5) significantly improved. Furthermore, a six-month echocardiographic examination demonstrated that these improvements remained unchanged. The combination of papillary muscle realignment and MAP seems to be effective in patients with IMR. The duration of the effect may be expected to be long-term with these methods. Keywords: Cardiomyopathy; Ischemic heart disease; Ischemic mitral regurgitation

[Cardiac general] Imagination turns real, or vice versa?

von Segesser, L. K. — 2008-03-26

Scientific publishing has made great strides in recent years, and this not only in diffusion of the final article compositions over the web and in print, but also in manuscript preparation, uploading of text and figures, correction of proofs and on-line discussion. What has been less apparent is the steady improvement not only of the fonts and lay-out, but much more so of the illustrations. In the first issue of the European Journal of Cardio-thoracic Surgery which appeared in 1987 and had 37 articles, there were 94 figures with an average of 2.6 per article out of which 46 were line graphs, bar graphs, or drawings (49%), and 47 photographic reproductions (51%). In contrast, the last issue of the European Journal of Cardio-thoracic Surgery published in 2007 had 38 communications including 9 letters to the editor. There were 76 figures with an average of 2.7 per article out of which 38 were line graphs, bar graphs, or drawings (50%), and 38 were photographic reproductions or scans (50%). Interestingly, there were 8 three-dimensional reconstructions/images one of which included a video. Likewise, the last issue of Interactive Thoracic and CardioVascular Surgery in 2007 carried 43 articles, including 8 e-comments, the on-line equivalent of letters to the editor. There were 41 figures and two videos with an average of 1.2 figures per article out of which 8 were line graphs, bar graphs, or drawings (20%), and 33 were photographic reproductions or scans (80%). Together with three 3-dimensional reconstructions/images and two videos, there is an obvious trend away from line drawings towards more sophisticated types of illustrations for ICVTS as well as the more recent issues of the EJCTS .

[Coronary] Awake subxyphoid minimally invasive direct coronary artery bypass yielded minimum invasive cardiac surgery for high risk patients

Watanabe, G., Yamaguchi, S., Tomita, S., Ohtake, H. — 2008-03-20

Off-pump coronary artery bypass graft (CABG) surgery has become a widely used modality and has received recognized as a minimally invasive surgery with few complications. However, for patients with severely impaired pulmonary function, further considerations have to be given to reduce the complications associated with general anesthesia. We have accumulated experience in awake off-pump surgery combined with high thoracic epidural anesthesia. In this report we describe the use of alternative subxiphoid approach in patients with severe pulmonary dysfunction. A catheter for high thoracic epidural anesthesia was inserted one day before surgery. After obtaining an adequate level of anesthesia, a small subxiphoid incision was made and the pericardium was opened to expose the left anterior descending branch. The conduit for bypass, gastroepiploic artery was accessed through a minilaparotomy, and separated under the same surgical field and anatomozed under beating heart. This procedure was performed in three patients. Patency was confirmed by postoperative angiography in all three cases. All patients were discharged after an uneventful postoperative course. Awake subxiphoid approach has the advantages that both thoracotomy and sternotomy can be avoided thus permitting surgery with extremely low invasiveness. This method is recommended for patients with severe pulmonary dysfunction. Keywords: Cardiac surgery; Coronary artery; Minimally invasive surgery; Off pump bypass

[Congenital] Use of tissue microdialysis to investigate hyperlactataemia following paediatric cardiac surgery

Hosein, R. B.M., Morris, K., Brawn, W. J., Barron, D. J. — 2008-03-20

We investigated tissue lactate, pyruvate and lactate:pyruvate (LP) ratio post cardiac surgery and the relationship of cardiac index and oxygen delivery to late onset hyperlactataemia in ICU. It involved a prospective study of 10 children, mean age 4.9 (0.4) years, post-Fontan operation admitted with normo-lactataemia. Tissue lactate, pyruvate and LP ratio were monitored postoperatively every 30 min for 12 h via subcutaneous microdialysis in the abdominal wall. Cardiac index were measured by PiCCO at 0, 4, 8 and 12 h. Blood and subcutaneous tissue lactate were strongly correlated (r=0.87; p=0.001). Mean (SD) blood lactate rose from 2.23 (0.49) to 3.73 (1.16) mmol l^-1 in the first 5 h after ICU admission (p=0.008), only one child remaining normal. Microdialysis revealed lactate rising from 3.8 (0.83) to 5.3 (1.6) (p=0.011), with a parallel pyruvate rise. LP ratio remained below 20, indicating no tissue oxygen debt. Cardiac index increased from 2.83 (0.63) to 3.77 (1.34) L min^-1 m^-2 over the same period (p=0.05), with a corresponding increase in oxygen delivery from 4556 (1094) to 6076 (2322) ml min^-1 (p=0.04). Tissue microdialysis provides near-continuous measurement of tissue lactate and pyruvate, post cardiac surgery. Blood lactate rise post-Fontan is mirrored by tissue lactate and pyruvate concentrations, and not associated with a low or falling cardiac index or with tissue oxygen debt. Keywords: Late onset hyperlactataemia; Fontan; Microdialysis

[Vascular general (ICVTS only)] Lower limb ischemia after migration of a coronary artery stent into the femoral artery

Siani, A., Siani, L. M., Mounayergi, F., Baldassarre, E. — 2008-03-19

A coronary stent may be lost in the peripheral or visceral arterial system with an incidence ranging from 0.9 to 8.4%, however a limb or organ ischemia after stent migration is very uncommon. We report the case of a 83-year-old man who underwent coronary artery stenting at our Hospital's Cardiological Department. During this difficult procedure, due to the critical stenosis of the circumflex artery, the stent was accidentally lost and found at the level of the the insertion of the right common femoral on the external iliac artery. After several attempts to rescue the stent throught an omolateral and controlateral femoral approach with the hook technique, the right common, superficial and profunda femoral arteries were surgically exposed. The stent was easily removed from the origin of the profunda femoral artery by a longitudinal arteriotomy. Finally the arteriotomy was closed with a homologous saphenous vein patch. We underline the importance of an early extraction of the stent, discussing the preferable surgical approach to minimize the possible dramatic complications in the peripheral artery system. Keywords: Coronary stent; Coronary stent displacement; Stent adverse effects

[Valves] Pre-operative, post-operative and 1-year follow-up N-terminal pro-B-type natriuretic peptide levels in severe chronic aortic regurgitation: correlations with echocardiographic findings

2008-03-19

B-type natriuretic peptide is synthesized in response to increased ventricular wall stress (WS) and hypertrophy. To serially evaluate amino-terminal-pro-BNP (NT-pBNP) serum levels in patients undergoing aortic valve replacement (AVR) for severe chronic aortic regurgitation (AR), blood samples were drawn preoperatively, 15 days postoperatively, at 6- and 12-month follow-up in 25 consecutive patients. Two-dimensional echocardiography was performed concomitantly, assessing left ventricular (LV) dimensional and functional parameters, including WS. Correlations between NT-pBNP, clinical and echocardiographic data were assessed by non-parametric statistics. Median preoperative NT-pro-BNP was 276 pg/ml (IQR=85-1056), being normal or mildly increased in 20 patients, overly increased in 5. The most significant correlations of preoperative NT-pBNP were with diastolic (r=0.80, p<0.001) and systolic (r=0.75, p<0.001) meridional WS and inversely with time from symptom onset (r=-0.67, p=0.001). NT-pBNP increased 15 days post-operatively (568 pg/ml, p=0.006 versus preoperative), then decreased at 6 months (144 pg/ml, p<0.001) to remain stable at 1 year (108 pg/ml, p=0.16). Long-term follow-up NT-pBNP showed direct correlation with diastolic WS (r=0.56, p=0.02). Higher pre-operative levels of NT-pBNP predicted greater magnitude of total LV mass regression at follow-up (r=-0.65, p=0.002) independent of preoperative LV mass index, showing that NT-pBNP may have a potential prognostic usefulness in adjunct to echocardiography. Keywords: Aortic valve replacement; Chronic aortic regurgitation; B-type natriuretic peptide; Amino-terminal B-type natriuretic peptide; Left ventricular remodelling; Post-operative left ventricular mass regression

[Thoracic general] Typical and atypical pulmonary carcinoids: our institutional experience

2008-03-18

Pulmonary carcinoids are rare malignant neoplasms, accounting for 2-5% of all lung tumors, with an approximate annual incidence of 2.3-2.8 cases per million of the population. We relate our experience of 54 patients (21 M, 33 F, mean age 53±15 years) treated between July 1986 and April 2006. All the patients underwent preoperative fibrobronchoscopy: preoperative diagnosis was made in 28 patients (52%). Surgical treatment consisted in: 31 standard lobectomies, 6 pneumonectomies, 5 bilobectomies, 2 sleeve lobectomies, 2 anatomic segmentectomies, 6 wedge resections; two patients were managed with sleeve bronchial procedure of the left main bronchus without lung resection. Fifty-four patients were followed with a mean time of observation of 67 months: 6 (11%) deaths occurred, at a mean period of 49 months after surgery; there were no postoperative deaths. Overall, 5-year survival was 91%, 10-years 83%: 5-year survival was 91% for typical carcoinoids (TC) versus 88% for atypical (AC), 10-years 91% for TC and 44% for AC (significant value, p=0.0487). Carcinoid tumors are a distinct group of neuroendocrine tumors with a good prognosis in most cases. Surgery currently represents the best treatment with good results at mid- and long-term survival, according to an acceptable risk. Keywords: Pulmonary carcinoid; Neuroendocrine; Diagnosis; Treatment

[Thoracic general] Acute massive pulmonary embolism treated by thrombo-embolectomy using intermittent deep hypothermic circulatory arrest

Van Putte, B. P., Bantal, N., Snijder, R., Morshuis, W. J., Van Boven, W. J. P. — 2008-03-18

Acute massive pulmonary embolism is a life threatening medical emergency resulting in a high mortality rate. Usually, urgent thrombo-embolectomy is performed using double venous canulation without circulatory arrest. We describe a patient suffering from acute massive pulmonary embolism that was treated by emergency thrombo-embolectomy. Due to back-bleeding the view into the lobar and segmental pulmonary arteries was severely compromised. In order to achieve complete thrombo-embolectomy, intermittent deep hypothermic circulatory arrest was performed. Keywords: Acute massive pulmonary embolism; Thrombo-embolectomy; Deep hypothermic circulatory arrest

[Cardiac general] Methicillin-resistant Staphylococcus aureus preventing strategy in cardiac surgery

2008-03-17

Objectives: The aim of this survey was to elucidate the efficacy of methicillin-resistant Staphylococcus aureus (MRSA) preventing strategy in our institution by investigating the incidence and evaluating the morbidity and mortality associated with this multi-resistant virulent organism. Methods: A prospective observational cohort among patients submitted to cardiovascular surgical procedures was conducted from 01/01/97 to 31/12/05. Preventing strategy included active screening programs by nasal swabs for all patients admitted from other hospitals or being at risk for developing infectious complications. Carriers or infected patients remained isolated and were treated promptly. Furthermore all newly employed health care workers were screened for MRSA and carriers were treated with mupirocin until the eradication of the pathogen. Results: Throughout the 9-year study period 826 infectious complications were registered among 15270 cardiac surgical patients. Total infection rate was 5.4%. MRSA was identified in 86 patients; 56 patients proved carriers and 30 infected. The MRSA associated infection rate was 0.2%. During this period of time mean ICU stay was 1.7 days and ICU mortality rate 2.9%. MRSA infected patients presented a mean ICU stay of 46.5 days and a mortality rate of 30%. In 10 patients MRSA was detected in tracheal secretions, in 4 patients in swabs taken from donor site infection and in 4 patients from superficial sternal surgical wound. In 10 patients the pathogen was isolated from cultures of the surgical site drainage and the diagnosis of post-sternotomy mediastinitis was confirmed. The remaining 2 patients were defined as having severe sepsis; MRSA was documented in central venous catheter tips and blood cultures. Conclusions: The prompt determination, isolation and appropriate treatment of MRSA patients admitted from other institutions combined with the detection and elimination of carriers among new health care workers and patients at high risk of developing infectious complications prevented further spread of the pathogen. Keywords: MRSA; Preventing strategy; Cardiac surgery

[Coronary] For patients undergoing coronary artery bypass grafting at higher risk of stroke is the single cross-clamp technique of benefit in reducing the incidence of stroke?

Raja, S. G., Navaratnarajah, M., Fida, N., Kitchlu, C S. — 2008-03-14

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether for patients undergoing coronary artery bypass grafting at higher risk of stroke the single cross-clamp (SC) technique is of benefit in reducing the incidence of stroke. Using the reported search 458 papers were identified. Six randomised controlled trials (RCTs), of which one was a duplicate publication, represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. We conclude that current best available evidence, from 6 RCTs randomising 490 patients, suggests that there is no benefit of SC technique over multiple cross-clamp (MC) technique in terms of reduction in the incidence of stroke (SC=2/206 vs MC=7/284; p=ns) although there is some advantage of SC technique in causing less neuropsychological deficits and release of serum S-100 protein, a surrogate marker of cerebral injury. Keywords: Coronary artery bypass grafting; Stroke; Focal neurologic deficit; Evidence-based medicine

[Cardiac general] Is blood cardioplegia superior to crystalloid cardioplegia?

Jacob, S., Kallikourdis, A., Sellke, F., Dunning, J. — 2008-03-13

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether blood cardioplegia is clinically superior to crystalloid cardioplegia for myocardial protection. Altogether 501 papers were identified. We selected 22 papers that represented the best evidence to answer the question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. This is a difficult topic to review, as the techniques studied in the many trials performed vary widely. Factors which may vary include warm or cold blood cardioplegia, antegrade and retrograde administration, systemic hypothermia or normothermia, topical heart cooling, high and low potassium solutions, 'hot shots';, warm induction, volume of cardioplegia, patient factors and bypass times. However 3 papers stand out. The meta-analysis of 34 randomized trials by Prof Fremes (2006) found a significantly lower incidence of low output syndrome (LOS) and CK-MB release with blood cardioplegia. He found no differences in myocardial infarction or mortality. This meta-analysis was confounded however by the fact that he was unable to extract data on LOS and CK-MB from the two largest trials which contributed over half the patients in his paper and are significantly larger than all other studies. The first paper by Ovrum (2006) randomized 1440 patients to antegrade cold blood or crystalloid and found no clinical differences and the second paper by Martin (1994) of 1001 patients compared warm blood to cold crystalloid but the study had to be stopped due to a high incidence of neurological events in the warm blood group. We reviewed a further 18 randomized trials reporting over 50 patients. Of these, 10 reported some statistically significant clinical outcomes in favour of blood cardioplegia and 5 reported statistically significant differences in enzyme release in favour of blood cardioplegia. A recent survey of UK practice found that 56% of surgeons use cold blood cardioplegia, 14% use warm blood cardioplegia, 14% use crystalloid cardioplegia, 21% use retrograde infusion and 16% don’t use any cardioplegia. The papers presented in our review support most of these practices! Keywords: Cardiopulmonary bypass; Blood cardioplegia; Crystalloid cardioplegia; Cardioplegic

[Cardiac general] Excision of lipomatous hypertrophy of the interatrial septum via port-access

Caynak, B., Van Praet, F., Walcot, N., Vanermen, H. — 2008-03-12

We present the surgical resection and repair, using port-access, in a case of extensive lipomatous hypertrophy of the interatrial septum (IAS). There was tumourous lipomatous hypertrophy on the superior vena cava (SVC)-atrial junction close to the aortic root beside massive IAS hypertrophy. Resection of involved IAS and SVC was performed using bovine pericardium for the repair. Keywords: Minimally invasive surgery; Tumor; Port-access

[Thoracic general] Does re-expansion pulmonary oedema exist?

Echevarria, C., Twomey, D., Dunning, J., Chanda, B. — 2008-03-11

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was: does re-expansion pulmonary oedema exist? Altogether 233 papers were found using the reported search, of which 13 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. We conclude that re-expansion pulmonary oedema (REPO) does occur following re-expansion of a lung in pneumothorax and pleural effusion. The incidence of REPO following pneumothorax and effusion is between 0 and 1% in most studies. The British Thoracic Society guidelines suggest <1.5 l pleural fluid should be drained at a time. Provided no respiratory symptoms occur it is not unreasonable to drain larger volumes to dryness: caution should be taken to avoid high negative intrapleural pressures. Patients who appear to be at higher risk, which may warrant more gradual evacuation, are: those who have had large pneumothoraces; young patients; patients in whom the lung has been down for >7 days; and possibly those who need >3 l of pleural fluid drained. Keywords: Chest tubes; Pleural effusion; Pulmonary oedema; Thoracic surgery

[Cardiac general] Serotonin syndrome following cardiac surgery

Shanmugam, G., Kent, B., Kirby, S., Baskett, R. — 2008-03-11

Selective serotonin reuptake inhibitors (SSRIs) are widely used to treat depression. We report a case of serotonin syndrome following cardiac surgery. This syndrome is rare in the cardiac literature. The clinical features, diagnosis and management of this unusual syndrome are described. In patients with polypharmacy, it is important to take cognizance of serotonergic antidepressants and anticipate their potential interactions with drugs used peri-operatively. Early recognition and treatment is important as this condition is potentially fatal. Keywords: Serotonin syndrome; Mitral valve replacement; Paroxetine

[Valves] Aortic root motion remodeling after aortic valve replacement - implications for late aortic dissection

Beller, C. J., Labrosse, M. R., Hagl, S., Gebhard, M. M., Karck, M. — 2008-03-11

Aortic root motion was previously identified as an additional risk factor for aortic dissection. This study analyzed if the magnitude of aortic root motion changed in patients after aortic valve replacement (AVR) and acute proximal aortic dissection. An institutional database (1984 to 2005) was used to measure the downward motion of the aortic root (perpendicular to the plane of the sinotubular junction) in contrast injections in 48 patients with aortic insufficiency (AI), aortic stenosis (AS) and proximal aortic dissection pre- and postoperatively, when available. Post-operative aortic root motion was significantly reduced after AVR for AI, while it was significantly increased after AVR for AS. By contrast, aortic root motion was unchanged when functional AI due to paravalvular leak was present post-AVR for AI. In patients with acute aortic dissection, both aortic root motion and aortic diameter were unchanged from pre-dissection. However, in patients who dissected again, aortic root motion was significantly smaller than pre-dissection, and the aortic diameter was significantly less than at first dissection. Removal of aortic stenosis was associated with increased aortic root motion, theoretically heightening the threat of dissection posed to the aortic wall by mechanical stress, although this was not confirmed by our study of dissection patients. Yet, mechanical principles command to include higher magnitude of aortic root motion during follow-up of patients after AVR as an additional risk factor for dissection. Keywords: Aortic root motion; Aortic valve replacement; Aortic stenosis; Aortic insufficiency; Aortic dissection

[Congenital] Incidental dual source computed tomography imaging of ductal aortic coarctation, left subclavian artery stenosis and bicuspid aortic valve in a patient admitted for atypical chest pain

Bastarrika, G., De Cecco, C. N., Anselmi, A., Herreros, J. — 2008-03-05

A case of incidental ductal aortic coarctation with left subclavian artery stenosis at the origin, severely calcified and stenotic bicuspid aortic valve, and normal coronary arteries demonstrated by single breath hold dual source CT angiography in a 46-year-old man admitted for acute chest pain is presented. Keywords: Aortic coarctation; Dual source CT; Aorta; Congenital; Angiography

[Valves] Is a flexible mitral annuloplasty ring superior to a semi-rigid or rigid ring in terms of improvement in symptoms and survival?

Chee, T., Haston, R., Togo, A., Raja, S. G. — 2008-03-04

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether in patients with mitral regurgitation secondary to degenerative mitral valve disease requiring mitral valve repair with an annuloplasty ring, a flexible ring is superior to a semi-rigid or rigid ring in terms of improvement in symptoms and survival. Using the reported search 478 papers were identified. Twelve papers of which 7 were echocardiographic studies and 5 clinical studies including two randomised controlled trials (RCTs) represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. We conclude that current best available evidence suggests that in patients with a flexible annuloplasty ring compared to patients with a semi-rigid/rigid annuloplasty ring the improvement in LV systolic function as reported by all the 7 sophisticated echocardiographic studies with a total of 266 patients does not translate into better clinical outcomes as 5 clinical studies with a total of 941 patients, including two RCTs, report comparable clinical outcomes for patients with mitral regurgitation secondary to degenerative mitral valve disease requiring mitral valve repair with an annuloplasty ring. Keywords: Mitral valve; Mitral valve insufficiency; Annuloplasty ring; Survival; Evidence-based medicine

[Thoracic general] Re-expansion pulmonary edema following video-assisted thoracic surgery for recurrent malignant pleural effusion

Barbetakis, N., Samanidis, G., Paliouras, D., Tsilikas, C. — 2008-03-04

A rare case of a unilateral re-expansion pulmonary edema following video-assisted thoracic surgery for malignant pleural effusion is described. Keywords: Pulmonary edema; Unilateral; VATS

[Vascular thoracic] Endovascular treatment of pseudoaneurysm of the thoracic aorta from a firearm injury

Petrucci, O., de Oliveira, P. P. M., Martins, A. S., Vieira, R. W. — 2008-02-26

A 24-year-old male patient was victim of a firearm wound that penetrated the thorax. He arrived at another hospital hemodynamically unstable and was submitted to exploratory surgery by means of bithoracotomy. A lesion of the left branch of the pulmonary artery was detected and successfully repaired. He was submitted for computer-aided tomography on the fifth postoperative day, and a lesion of the mid-thoracic aorta was detected, which formed a saccular image. Considering that the patient had already been submitted to a bithoracotomy and that a direct approach to repair would involve another thoracotomy within a short period of time, endovascular treatment was chosen in our hospital. The procedure was performed under fluoroscopy. A second computer-aided tomography indicated adequate treatment of the lesion, with no indication of an endoleak. He has undergone ambulatory follow-up for 36 months without any problem related to the procedure. While endovascular treatment of the aorta has developed enormously, multicenter studies are needed to better define the long-term results of this approach. Keywords: Aorta; Pseudoaneurysm; Gunshot wounds; Penetrating wounds

[Pulmonary] A home-made device for safe intraoperative aspiration of pulmonary hydatid cysts

Santini, M., Fiorello, A., Vicidomini, G., Perrone, A. — 2008-02-26

Surgical intervention is still the main modality for the treatment of hydatid disease. Different surgical procedure have been described, however in the literature there is no collectively agreement on the best surgical strategy. For intact pulmonary hydatid cysts, an enucleation or needle aspiration are possible strategies. Though, both methods need careful manipulation due to the serious complications after fluid rupture. Here, we present a novel technique that allows the aspiration of the cyst while reducing the risk of anaphylaxis and dissemination of disease. This is a home-made double suction device designed to aspirate hydatid cysts by creating a low pressure, wide mouth cylinder which holds the cyst wall against the base of the cylinder. A large thoracentesis needle is inserted across the low pressure chamber into the cyst to aspirate the fluid within. The complete evacuation of the cyst makes surgical treatment easier and facilitates its successive removal. Keywords: Pulmonary; Hydatid cyst

[Coronary] Different anticoagulation strategies in off-pump coronary artery bypass operations: a European survey

Englberger, L., Streich, M., Tevaearai, H. T., Carrel, T. P. — 2008-02-26

In order to determine anticoagulation strategies in OPCAB a questionnaire survey among 750 European cardio-thoracic surgeons was performed. Questions addressed volume of OPCAB procedures performed, intra- and perioperative heparinization and antiplatelet therapy, as well as perioperative management. A total of 325 (43.7%) questionnaires were returned and validated. Perioperative protocols for administration of antiplatelets differed among the respondent surgeons. Perioperative prophylaxis of thrombosis (low or high molecular weight heparin) is performed by 78%. Intraoperative heparin dosage range between 70 U/kg to 500 U/kg, 60% of respondents prefer a low-dose regimen (≤150 U/kg). Correspondingly, the lowest activated clotting time (ACT) during surgery is accepted to be 200 s by 24%, 250 s by 18% and 300 s by 26% of surgeons. Protamine is used by 91% of respondents, while 52% perform a 1:1 reversal. A cell-saver and antifibrinolytics are used by 70% and 40%, respectively. Interestingly, 56% of respondents think bleeding in OPCAB patients is not reduced when compared to on-pump CABG. In addition, 34% of respondents believe there is an increased risk of early graft occlusion following OPCAB. This survey demonstrates widely different intra- and perioperative anticoagulation strategies for OPCAB procedures among European surgeons. Keywords: OPCAB, Anticoagulation

[Aortic and aneurysmal (ICVTS only)] Early complication after hybrid thoracic aortic aneurysm repair

Palma, J. H., Guilhen, J. C. S., Gaia, D. F., Buffolo, E. — 2008-02-26

This brief report describes an unusual hybrid approach complication of aortic arch disease. An acute stent kinking in the first post-operative day promoted ventricular fibrillation and death. Adequate oversizing was achieved and intraoperative angiogram showed no proximal or distal leaks. Unfavorable outcomes are highly under-reported and describing complications are a key instrument to improve this technique. Keywords: Endovascular; Aortic aneurysm; Stent-graft; Hybrid

[Valves] Candida parapsilosis tricuspid native valve endocarditis: 3-year follow-up after surgical treatment

Gullu, A. U., Akcar, M., Arnaz, A., Kizilay, M. — 2008-02-22

In non-addicted patients, several states such as alcoholism, previous valvular heart disease or prosthetic valve replacement, immunodeficiency states, prolonged intravenous hyperalimentation, permanent pacemakers, and some congenital heart diseases can provide the predisposing factors for tricuspid valve endocarditis. It is an extremely rare occurrence in patients with normal native cardiac valves. In this report, we present a case of a 67-year-old woman with tricuspid native valve endocarditis related to Candida parapsilosis which is a very rare cause of infective endocarditis and carries a high mortality risk. An operation was indicated for the patient due to persistent enlarging vegetation on tricuspid valve, severe tricuspid regurgitation, septic pulmonary emboli and finally uncompensated respiratory and heart failure. She underwent tricuspid valve replacement with bioprothesis three years ago and now she is in a well condition without any medical treatment. Keywords: Tricuspid valve infection; Fungal endocarditis; Candida parapsilosis

[Thoracic general] Does video-assisted thoracoscopic pleurectomy result in better outcomes than open pleurectomy for primary spontaneous pneumothorax?

Vohra, H. A., Adamson, L., Weeden, D. F. — 2008-02-20

The question addressed by a best evidence topic approach using a structured protocol was whether pleurectomy using video-assisted thoracoscopic surgery (VATS) resulted in better outcomes than open pleurectomy for primary spontaneous pneumothorax. Altogether 45 relevant papers were identified of which 9 papers represented the best evidence to answer the question. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses were tabulated. We conclude that VATS pleurectomy has been shown to be comparable to open pleurectomy in the treatment of spontaneous pneumothorax, with a meta-analysis and several RCTs showing reductions in length of hospital stay and analgesic requirements. Post-operative pulmonary dysfunction has also been shown to be reduced after VATS pleurectomy in two RCTs, although a third study found no significant difference. A concern may be a four-fold increase in the recurrence of pneumothorax following VATS pleurectomy as compared to open pleurectomy reported in a recent meta-analysis of 4 randomised and 25 non-randomised studies performed in 2007 and published in the Lancet although a second meta-analysis of only the randomised trials did not show this difference. Keywords: VATS; Thoracic surgery; Pneumothorax; Evidence based medicine

[Congenital] Surgical repair of aortico-left ventricular tunnel arising from the left aortic sinus

Ono, M., Goerler, H., Boethig, D., Breymann, T. — 2008-02-20

Aortico-left ventricular tunnel is a rare congenital cardiac defect, which bypasses the aortic valve via the paravalvar connection from the left ventricle to the aorta. In most of the cases, the tunnel arises from the right aortic sinus. We herein report a case of aortico-left ventricular tunnel, of which the aortic orifice was arising from the left aortic sinus, requiring special attention for avoiding left coronary artery injury at the time of surgical repair. Keywords: Aortico-left ventricular tunnel; Aortic insufficiency; Coronary artery

[Thoracic general] Left upper lobe pulmonary sequestration

Berna, P., das Neves Pereira, J.-C., Cote, J.-F., Riquet, M. — 2008-02-19

A 64-year-old non-smoking woman with a left upper lobe mass underwent a wedge resection by videothoracoscopic approach. Intraoperative frozen section examination was unable to rule out a neoplastic disease and a lobectomy was performed. Microscopic analysis showed a typical pulmonary sequestration pattern including arteries with elastic layers in a systemic fashion. Pulmonary sequestration is a development lung disease: upper lobe location is considered uncommon and much controversy exists concerning this form which may be underrated. Keywords: Pulmonary sequestration

[Vascular thoracic] Large post-stenting innominate artery pseudoaneurysm

Rispoli, P., Varetto, G., Savia, F. M., Rinaldi, M. — 2008-02-19

Pseudoaneurysms of the sovra-aortic trunks are uncommon lesions that usually have a post-traumatic etiology. The singular case of a patient who developed an innominate artery pseudoaneurysm (IAP) where a stent had been inserted 12 years earlier to manage severe innominate trunk stenosis is described. A chronic and large (8 cm in diameter) IAP was successfully treated in extracorporeal circulation and deep hypothermic circulatory arrest. The distal tract of the ascending aorta and the proximal aortic arch were substituted; total replacement of the innominate trunk with a singular 8-mm Dacron graft was necessary. We reviewed the literature about the reports of IAPs and the management of this singular lesion. Keywords: Pseudoaneurysm; Innominate artery; Stenting

[Transplantation] Expression of endothelial cell-specific adhesion molecules in lungs after cardiac arrest

Chen, F., Kondo, N., Sonobe, M., Fujinaga, T., Wada, H., Bando, T. — 2008-02-15

Objectives: A method to compensate for donor shortages could be donation after cardiac death. In this study, we considered endothelial cell-specific molecules, claudin-5 and VE-cadherin, as possible biomarkers predicting lung injury against warm ischemia. We investigated how the expression of these molecules could change after cardiac arrest in a mouse lung, comparing other molecules presumably relating with ischemia. Methods: At given intervals after cardiac arrest, the lungs were harvested. Quantitative analysis of mRNA expression of claudin-5, VE-cadherin, IL-1β, IL-10, HIF-, Egr-1, VEGF, Ang-1, and Ang-2 genes in lung tissues with several periods of warm ischemia was performed. Results: Regarding endothelial cell-specific molecules, there were significant differences in both claudin-5 and VE-cadherin mRNA expression between 0 h and 4 h after cardiac arrest. IL-1β mRNA expression 1 h, 2 h and 4 h after cardiac arrest increased significantly, compared with that at 0 h. There were no significant differences with the other genes. Conclusions: We found that it took more time for claudin-5 and VE-cadherin mRNA expression to change significantly than IL-1β mRNA expression; therefore, endothelial cell-specific molecules, claudin-5 and VE-cadherin, might be no better candidates for clinical use than IL-1β. Keywords: Lung preservation; Ischemia; Lung; Non-heart-beating donor; Endothelium; Donation after cardiac death

[Aortic and aneurysmal (ICVTS only)] Abdominal aortic aneurysm surgery with mechanical support using the Impella(R) microaxial blood pump

Farhat, F., Sassard, T., Attof, Y., Jegaden, O. — 2008-02-14

A 50-year-old man with an end-stage cardiac failure was referred to our institution for pre-transplantation assessment. An infrarenal aortic aneurysm (diameter 45 mm) was discovered and progressed (up to 59 mm) over a two-month period. Decision to perform aneurismectomy with the support of an Impella® Recover LP50 microaxial blood pump was decided regarding the rapid evolution of the disease. The patient had uneventful cardiac-wise during surgery and postoperative period. Keywords: Aortic surgery; Impella®; Microaxial; Assist device

[Coronary] Minimally invasive coronary artery bypass grafting using the inferior J shaped ministernotomy in high risk patients

2008-02-14

In the last years the population of patients referred for coronary surgery has changed toward a high-risk profile. In selected cases minimally invasive approach could be a good option to reduce mortality and morbidity. Between September 2005 and September 2007 twenty-one consecutive patients underwent minimally invasive bypass surgery using the J-shaped inferior mini-sternotomy approach. All patients had a EuroSCORE higher than 6. The operative mortality was 0%. Conversion to on-pump surgery was not necessary. The mean operation time was 89±18 min, the mean ventilation time was 2.4±2.2 h, the mean intensive care unit stay was 47.2±36.5 h. In four patients a hybrid approach to achieve a complete revascularization was used. After six months from the operation the graft patency was evaluated with the 64-slice computed tomography. In high-risk coronary patients the use of minimally invasive technique appeared a good option to achieve low morbidity and mortality. Through a mini-sternotomy approach, single- or double-vessel revascularization can be performed safely off-pump even in high-risk patients without compromising the accuracy of the anastomosis. Nevertheless a further investigation is required to evaluate the long-term results in a larger cohort of patients. Keywords: Minimally invasive coronary bypass surgery; Coronary disease; High thoracic epidural anesthesia; Ministernotomy; Atherosclerosis; Hybrid revascularization; Cardiac surgery

[Aortic and aneurysmal (ICVTS only)] Saccular ascending aorta aneurysm: report of an unusual presentation

Borrello, B., Nicolini, F., Beghi, C., Gherli, T. — 2008-02-14

We describe an unusual presentation of a large saccular aneurysm of the ascending aorta, mimicking an acute coronary syndrome. The compression of the aneurysm on the left main coronary artery was probably the cause of these confusing symptoms. Our experience confirms the fundamental role of modern cardiac imaging techniques in the differential diagnosis of these unusual cases and in the planning of the correct surgical procedure. Keywords: Aortic aneurysm; Cardiac surgery

[Cardiac general] The importance of an organized follow-up for the evaluation of mortality after hospital discharge in cardiac surgery

Noyez, L., Verheugt, F. W.A., van Swieten, H. A. — 2008-02-13

Objective: Does a structured follow-up, after cardiac surgery in an adult, provide additional information on the operation related mortality certainly if mortality is used as an outcome parameter within the quality control? Method: Mortality data of 1132 patients undergoing cardiac surgery in 2003 and 2004 in the Academic Hospital Nijmegen, the Netherlands were registered by a structured follow-up one year after surgery. Results: One year after surgery this follow-up is missing information of 8 patients (0.7%). Six patients (0.5%) refused further follow-up. Of the 31 patients who died during the first postoperative year 21 (68%) were registered thanks to this structured follow-up. In 29 patients it was possible to retrieve the cause of death. Conclusion: A structured follow-up one year after cardiac surgery has a high response and not only provides a better total picture of mortality, but also information on the cause of death. Both aspects are important if mortality is used as a parameter for quality control in cardiac surgery. Keywords: Mortality; Cardiac surgery; Follow-up; Quality control

[Cardiac general] Should angiotensin converting enzyme inhibitors/angiotensin II receptor antagonists be omitted before cardiac surgery to avoid postoperative vasodilation?

Raja, S. G., Fida, N. — 2008-02-13

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether the omission of angiotensin converting inhibitors (ACEI)/angiotensin II receptor antagonists (AIIA) before cardiac surgery leads to avoidance of postoperative vasodilation. Using the reported search 421 papers were identified. Eleven papers including three randomised controlled trials (RCTs) represented the best evidence on the subject. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated for these. Whereas the three small RCTs on this topic provided conflicting evidence, the remaining 7 large cohort and case control studies confirmed that preoperative ACEI therapy resulted in postoperative low systemic vascular resistance (SVR)/vasoplegia. Only two small RCTs with conflicting conclusions specifically addressed the issue of omitting ACEI/AIIA before cardiac surgery. We conclude that preoperative administration of ACEI/AIIA in patients undergoing cardiac surgery contributes to lowering of SVR/vasoplegia postoperatively thereby making omission of ACEI/AIIA before cardiac surgery a rational strategy to avoid postoperative vasodilation. However, the current available evidence to support this strategy is weak. Keywords: Angiotensin converting enzyme inhibitors; Angiotensin II receptor blockers; Systemic vascular resistance; Cardiac surgery; Evidence-based medicine

[Venous (ICVTS only)] The management of arterial and venous injury during saphenous vein surgery

Marcucci, G., Accrocca, F., Antonelli, R., Siani, A. — 2008-02-13

Objectives: Arterial injury of the lower limb is rare but catastrophic complication of the saphenous veins stripping with important morbidity and severe medico-legal implications. Diagnosis is often delayed and outcome depend to the severity of injury. We report two cases of severe ischemia due to arterial lesion during varicose vein surgery. Methods: In the first case, a superficial femoral artery ligature after a operation for recurrent varicose vein surgery occurred; in the second case, an intraoperative ligature of the superficial femoral artery and vein was detected. In the first case, an angiography was carried out and a superficial-superficial femoral artery interposition graft with PTFE was performed. In the other case, an interposition graft with controlateral saphenous vein between common and superficial femoral artery and an end-to-end anastomosis of the superficial femoral vein were carried out. Results: No amputation occurred, good patency rate of the graft were achieved and no neurologic-muscle complications were revealed. Conclusions: Femoral artery injury after venous stripping show an high amputation rate due to delayed diagnosis and severity of arterial involvement. Angiography must be reserved in any case of late ischemia. Prompt diagnosis and aggressive management is mandatory. Keywords: Femoral artery; Varicose veins; Vascular injuries

[Thoracic general] Surgical repair of post-traumatic lung hernia using a video-assisted open technique

Khalil, M. W., Masala, N., Waller, D. A., Cardillo, G. — 2008-02-13

Post-traumatic lung herniation through a defect in the chest wall is an uncommon injury, with only about 300 reported in the literature. Various methods of treatment and repair have been described, including both purely thoracoscopic to full open techniques. We repaired a case by using a combination of minithoracotomy and video-assistance through the minithoracotomy wound. Patient did well and there was minimal post-operative pain. Keywords: Lung; Hernia; Trauma

[Thoracic general] Exercise capacity after lobectomy in patients with chronic obstructive pulmonary disease

Kushibe, K., Kawaguchi, T., Kimura, M., Takahama, M., Tojo, T., Taniguchi, S. — 2008-02-12

The aim of this study is to clarify whether patients with chronic obstructive pulmonary disease (COPD) lose less exercise capacity after lobectomy than do those without COPD to the same extent as ventilatory capacity and lobectomy for selected patients with severe emphysema improve exercise capacity like ventilatory capacity. Seventy non-COPD patients (N group), 16 mild COPD patients (M group), and 14 moderate-to-severe COPD patients (S group) participated. Pulmonary function and exercise capacity tests were performed on the same day preoperatively and 6 months to 1 year after lobectomy. The S group lost significantly less FEV₁ (forced expiratory volume in 1 s) after lobectomy than did the N or M group (p<0.0001 and p<0.005). However, their loss of exercise capacity was equivalent to that for the N and M groups. For the S group, there was a significant, negative correlation between preoperative FEV₁ % of predicted and percentage change in FEV₁ and maximum oxygen consumption (V_O2max) after lobectomy (r=-0.93, p<0.0001 and r=-0.64, p=0.01. In moderate-to-severe COPD patients, patients with a lower preoperative FEV₁ % of predicted experienced a smaller decrease in FEV₁ and V_O2max after lobectomy. Keywords: Lung cancer; Exercise capacity; Lobectomy; Chronic obstructive pulmonary disease

[Cardiac general] Should additional antibiotics or an iodine washout be given to all patients who suffer an emergency re-sternotomy on the cardiothoracic intensive care unit?

Yap, E. Y. L., Levine, A., Strang, T., Dunning, J. — 2008-02-07

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether it is beneficial to give additional antibiotics or an iodine washout after an emergency re-sternotomy on the intensive care unit. Using the reported search, 527 papers were identified. 9 papers represented the best evidence on the subject and the author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results and study comments and weaknesses were tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. For patients who require an emergency re-sternotomy on the intensive care unit, the incidence of sternal wound infection or sepsis after this emergency treatment is around 5%. We found only 7 papers that documented the incidence of infection after emergency re-sternotomy. Of these 7 papers, 5 documented that they routinely gave additional intravenous antibiotics and a povodine-iodine washout. The other two papers did not report whether this was done. We conclude that even though the incidence of subsequent infection is low in the cardiac arrest situation, full aseptic technique including gown and gloves might be regarded as best practice. It is common practice also to give additional antibiotics and a povodine-iodine washout although we could identify no studies other than uncontrolled cohort studies in support of this. Keywords: Thoracic surgery; Antibiotics; Prophylaxis; Resuscitation

[Cardiac general] Hepatic tear as an elusive cause of hemoperitoneum complicating cardiac surgery

Kunstyr, J., Tosovsky, J., Korinek, J., Stritesky, M. — 2008-02-07

We report an unusual source of intraoperative bleeding in a patient undergoing cardiosurgical reoperation. After sternotomy, hematocrit dropped significantly. Only intra-thoracic bleeding from adhesions was considered to be responsible for the anemia. During reperfusion, abdominal wall was distended with a bluish bulge in the right hemidiaphragm. Immediate laparotomy revealed bleeding from a tear in the right hepatic lobe without any diaphragm injury. The tear was likely caused by blunt trauma from an oscillating saw. We emphasize cautious use of oscillating saw in patients with hepatic congestion undergoing a repeat sternotomy. We propose that lifting the sternum in redo procedures might prevent the hepatic tear. Keywords: Hemoperitoneum; Cardiac surgical procedures; Intra-operative complication

[Cardiac general] The use of intra-aortic balloon pump as cerebral protection in a patient with moyamoya disease undergoing coronary artery bypass grafting

Kashima, I., Inoue, Y., Takahashi, R. — 2008-02-07

We performed coronary artery bypass grafting in an urgent and rare case of acute coronary syndrome with moyamoya disease in a 75-year-old female. Because of collateral dependent severe cerebrovascular obstruction, additional support for brain protection was necessary; we used high pressure pulsatile perfusion assist to maintain cerebral circulation with an intra-aortic balloon pump support throughout the cardiopulmonary bypass, giving a successful outcome. Keywords: CABG; ACS; Moyamoya disease; Pulsatile perfusion; Brain protection; IABP

[Coronary] Biochemical markers of myocardial injury in the pericardial fluid of patients undergoing heart surgery

Fernandez, A. L., Garcia-Bengochea, J. B., Alvarez, J., Gonzalez Juanatey, J. R. — 2008-02-07

The purpose of this study was to compare cardiac markers in the pericardial fluid and serum in order to evaluate preoperative myocardial injury. Thirty patients were divided into three groups. The first group (AVR; n=10) received an aortic valve replacement. The second group (SA; n=10) included patients with stable angina who underwent elective coronary artery bypass grafting (CABG). The third group (ACS; n=10) included patients with acute coronary syndrome who underwent urgent CABG. Pericardial fluid and venous samples were taken after opening the pericardium and 24 h postoperatively. Serum and pericardial concentration of troponin I (cTnI), creatine kinase (CK), its MB isoenzyme (CK-MB) and myoglobin were determined. Preoperative pericardial cTnI was significantly (p<0.01) higher than in serum in all groups. Preoperative pericardial CK, CK-MB and myoglobin were significantly (p<0.01) lower than in serum in groups AVR and SA. Preoperative pericardial and serum cTnI were significantly higher in the ACS than in AVR and SA groups (p<0.01). Postoperative pericardial concentration of all markers was significantly higher (p<0.01) than in serum in all groups. We conclude that preoperative pericardial accumulation of cTnI may reflect subclinical injury which may not be demonstrated by the usual laboratory tests. Keywords: Pericardium; Pericardial fluid; Troponin; Myocardial ischemia

[Cardiac general] Should adrenaline be routinely used by the resuscitation team if a patient suffers a cardiac arrest shortly after cardiac surgery?

Tsagkataki, M., Levine, A., Strang, T., Dunning, J. — 2008-02-06

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether adrenaline might be a useful addition to a protocol for the management of cardiac arrests for patients shortly after cardiac surgery. Altogether 889 papers were found using the reported search, of which 16 represented the best evidence to answer the clinical question. The authors, journal, date and country of publication, patient group studied, study type, relevant outcomes and results of these papers are tabulated. The quality and level of evidence was assessed using the International Liaison Committee on Resuscitation guideline recommendations. We conclude that the European Resuscitation Council and the American Heart Association both recommend 1 mg of adrenaline as soon as pulseless electrical activity or asystole is identified or after the second failed shock if the rhythm is VF/pulseless VT. However they acknowledge that the evidence behind this recommendation is lacking and based entirely on animal studies which have as yet not been successfully replicated in human studies to show a benefit of survival to hospital discharge. They acknowledge that the current evidence is insufficient to support or refute the use of adrenaline in arrests and the International Liaison Committee on Resuscitation grade the recommendation to give adrenaline in cardiac arrests as 'indeterminate'. Thus in the particular situation of a patient who arrests shortly after cardiac surgery where the chance of restoring sinus rhythm either by defibrillation or by an emergency re-sternotomy is high, and where adrenaline could in this situation be highly dangerous once sinus rhythm is restored, we recommend that 1 mg of adrenaline forms no part of the resuscitation protocol for patients who arrest after cardiac surgery. Keywords: Thoracic surgery; Cardiopulmonary resuscitation; Epinephrine; Adrenaline; Evidence based medicine.

[Vascular general (ICVTS only)] Unilateral adrenal haemorrhage following systemic thrombolysis

Steensrud, T., Muller, L.-S. O., Sorlie, D. G. — 2008-02-06

We report a case of unilateral adrenal bleeding, worsened or initiated by systemic thrombolytic therapy given for a suspected myocardial infarction. Initial clinical diagnosis was ruptured aortic aneurysm or aortic dissection. A preoperative contrast-enhanced computer tomography (CT) showed a possible bleeding from the left adrenal gland. An emergency left subcostal retroperitoneal approach revealed a ruptured and bleeding adrenal gland and its arteries were ligated. Keywords: Adrenal haemorrhage; Thrombolysis; Complication

[Assisted circulation] EuroSCORE directed intraaortic balloon pump placement in high-risk patients undergoing cardiac surgery - retrospective analysis of 267 patients

Diez, C., Silber, R.-E., Wachner, M., Stiller, M., Hofmann, H.-S. — 2008-02-06

Objectives: The IABP is the most widely used circulatory assist device today and is utilized in a wide range of serious cardiovascular conditions. We examined the effects on mortality of pre-, intra-, or postoperative IABP support in patients undergoing cardiac surgery compared to high-risk patients without IABP support. Methods: Between June 2001 and April 2004, 267 patients either received preoperative IABP support (n=62), an intra- or postoperative IABP (n=113) or had no IABP (n=92). Perioperative mortality was calculated with the EuroSCORE. Results: Patients with preoperative IABP and without IABP support had a lower ejection fraction (37 (29; 50) % and (39 (30; 53)) % versus (50 (39; 65)) %, p=0.0001), more frequent unstable angina (38/62 and 53/92 versus 37/113, p=0.0004) and recent myocardial infarctions (33/62 and 51/92 versus 26/113, p=0.0001). The number of emergency procedures was also significantly higher (36/62 and 65/92 versus 27/113, p=<0.01). Patients with intra-, or postoperative IABP support and patients without IABP support had a longer ICU-stay (7.5 (5; 17.75)) and (7 (5; 15.5)) days versus (6 (3; 10)) days, p=0.023, p=0.015). The overall hospital stay of patients without IABP (18.5 (14; 29) days) and intra-/postoperative IABP support (19, (14; 28) days) were significantly longer (p=0.007) compared to patients with preoperative support (14 (11.5; 20.5) days). Whereas we found a trend towards reduced mortality in high-risk non-emergency patients with preoperative support, emergency patients and patients receiving intra- and postoperative support had significantly higher mortality rates than predicted by the EuroSCORE. Both emergency and non-emergency patients without IABP insertion had a significantly higher actual mortality than predicted (29.5% versus 13.7%, p=0.03 and 38.1% versus 26.3%, p< 0.0001. The overall actual mortality between patients with preoperative IABP insertion and patients without preoperative IABP did not significantly differ (14/62 versus 29/92, p=0.27). The EuroSCORE proved to be a valid predictor for perioperative mortality among high risk non-emergency and emergency patients with preoperative IABP support at lower score sums, but failed at higher score sums (>8) and among patients with intra- and postoperative IABP insertion. Conclusion: Preoperative IABP support is indicated in high-risk non-emergency patients. The benefit of preoperative IABP insertion in emergency patients and intra- and postoperative IABP support still remains controversial and needs to be elucidated in further prospective, randomized studies. Keywords: Intraaortic balloon pump; EuroSCORE; Mortality

[Congenital] Late desaturation due to collateral veins 10 years after total cavopulmonary shunt in left atrial isomerism: surgical closure

Usta, E., Schneider, W., Sieverding, L., Ziemer, G. — 2008-01-18

The development of systemic collateral veins after palliative surgery in children with univentricular circulation is a common complication, however manifestation as late as 10 years postoperatively is rare. Massive systemic to hepatic venous collaterals developed in a 14-year-old girl with univentricular heart, situs inversus atriovisceralis and hemiazygos continuity to the left-sided superior vena cava, 10 years after Kawashima operation. The resulting azygoportal shunt had led to a progressive systemic desaturation and reduction in ventricular function. Interventional occlusion was supposed to be risky for renal failure due to potential closure of the renal vein so that surgical closure was performed. The saturation persistently increased from 65% to more than 85% postoperatively. Keywords: Congenital heart disease; Cavopulmonary shunt; Fontan procedure; Kawashima operation

[Aortic and aneurysmal (ICVTS only)] Repair of aortic arch and the impact of cross clamping time, New York Heart Association stage, circulatory arrest time, and age on operative outcome

Schwartz, J. P., Bakhos, M., Patel, A., Botkin, S., Neragi-Miandoab, S. — 2007-12-10

Background: Aortic arch replacement is associated with high morbidity and mortality. Methods: We evaluated the postoperative complications and risk factors in 32 consecutive patients after aortic arch replacement. Results: The mean age was 61±15 years and male to female ratio was 24/8. Diameter of ascending aorta was 6.0±0.8 cm and diameter of aortic arch was 5.2±1.2 cm. The average NYHA class was 2±1. The 30-day mortality was 6.2% (2 of 32 patients), one patient died intraoperatively (3%); all surviving 30 patients had f/u for at least 6 months, a total of 3 of 32 patients had died within 6 months, actuarial survival was 90% at 6 months. The overall incidence of neurologic adverse events was 9%; however, only one patient had a CVA with a focal deficit (3%). The other two patients had global neurologic dysfunction. Other significant postoperative complications included atrial fibrillation in 15 patients (46%), ventricular fibrillation requiring CPR in one patient (3%), and pericardial effusion requiring pericardicentesis in 8 patients (25%). The need for blood transfusion correlated with the cross-clamping length (Pearson r 0.62; 95% confidence interval 0.35-0.79; P value 0.0001, R²=0.38). Cross-clamp time (139±58 min) did not have an impact on length of ICU stay (Pearson r -0.09; 95% confidence interval -0.39-0.23; P 0.58; R²=0.008) nor did the length of circulatory arrest (95% confidence interval -0.44-0.21, P=0.44). The length of stay in the ICU (142±128 h) correlated with the NYHA stage of the patient (95% confidence interval 0.001-0.62, P=0.04). The LOS (12±6 days) correlated with age of the patients (95% confidence interval 0.03-0.57, P=0.03). Conclusion: Elderly patients and patients with high NYHA class need close postoperative monitoring in the ICU. A short circulatory arrest and aortic clamp time do not extended the LOS in ICU or in the hospital. Keywords: Thoracic aorta; Aortic arch; Aortic rupture; Hypothermic circulatory arrest

[Cardiopulmonary bypass] Heparin induced thrombocytopenia diagnosis in cardiac surgery: is there a role for thromboelastography?

2007-12-03

The aim of the present protocol is to investigate the potency of thromboelastography (TEG) to screen postcardiac HIT patients suspicious for HIT type II, and to differentiate which of them are subject to suffer thrombotic complications from those who will suffer hemorrhagic complications. Keywords: Thromboelastography; Heparin induced thrombocytopenia (HIT); DIC; Screening test; CPB; Complications

[Coronary] WITHDRAWN - Radial artery grafts' string-sign - role of graft spasm and competitive flow

Chong, C. F., Moat, N. E., Collins, P. — 2007-01-05

WITHDRAWN - OWING TO AN AUTHORSHIP DISPUTE AND SUBSEQUENT REFUSAL TO SIGN OVER COPYRIGHT, THIS PAPER WAS DEFINITIVELY WITHDRAWN ON 3 JANUARY 2007.