Journal of Cardiothoracic and Vascular Anesthesia - Articles in Press

The Relationship Between Cerebral Oxygen Saturation Changes and Postoperative Cognitive Dysfunction in Elderly Patients After Coronary Artery Bypass Graft Surgery - Corrected Proof

2010-07-23

Objective: The aim of this study was to evaluate the predictive value of cerebral regional oxygen saturation (rSO2) in the occurrence of postoperative cognitive dysfunction (POCD) in elderly patients undergoing coronary artery bypass graft (CABG) surgery.Design: A prospective study.Setting: University hospital.Participants: A total of 61 patients (84% male) with a mean age of 70.39±4.69 on a waiting list for CABG surgery were enrolled in the study.Intervention: A complete neurocognitive evaluation was performed 1 day before surgery as well as 4 to 7 days and 1 month after surgery. During surgery, rSO2 was monitored continuously.Measurements and Main Results: POCD was defined as a reduction of 1 standard deviation on 2 or more neuropsychologic indices. Forty-six patients (80.7%) developed early POCD, and 23 (38.3%) showed late POCD. Patients whose rSO2 decreased to less than 50% during the surgery experienced more POCD 4 to 7 days after surgery (p = 0.04). In addition, a decrease of more than 30% from the patient's baseline rSO2 was associated with POCD 1 month after surgery (p = 0.03).Conclusion: Intraoperative cerebral oxygen desaturation is associated with early and late POCD in elderly patients. Cerebral oximetry is a promising tool in the prediction of subtle neuropsychologic deficits and further studies are needed.

The Impact of Immediate Extubation in the Operating Room After Cardiac Surgery on Intensive Care and Hospital Lengths of Stay - Corrected Proof

2010-07-23

Objective: To determine if lengths of stay in intensive care and the hospital are associated with extubation in the operating room at the conclusion of cardiac surgery.Design: A nonrandomized, observational study with propensity score–guided case-control matching of prospectively collected data.Setting: Three interrelated, university-affiliated, community hospitals.Participants: Three thousand three hundred seventeen patients undergoing elective or urgent coronary artery, valve repair or replacement, or combined surgery between 2000 and 2006.Interventions: Tracheal extubation occurred, based on history and intraoperative events, either immediately in the operating room or in the intensive care unit.Measurements and Main Results: Of 3,317 patients in the institutions' Society of Thoracic Surgeons database, 3,089 were extubated within 24 hours, 69% of them in the operating room. Only 0.6% of patients extubated in the operating room required reintubation, compared with 5.9% extubated in the intensive care unit (p < 0.0001). By logistic regression, 12 of 25 preoperative and intraoperative factors generated a propensity score for each of the 2,595 patients with complete data, representing the likelihood of immediate extubation (c-statistic = 0.727). A “greedy 5 to 1” propensity score-matching technique created 713 matched pairs of patients by extubation pathway. Those undergoing immediate extubation had reductions in intensive care duration by 23 hours on average (median from 46 to 27 hours, p < 0.0001) and in hospital length of stay by 0.8 days on average (median = 6 for each, p < 0.0001). Cox regression, using matched pairs as strata, identified the following independent predictors of length of stay in the intensive care unit and hospital: immediate extubation in the operating room, need for reintubation, postoperative renal failure, and postoperative atrial fibrillation.Conclusions: Selection of patients for immediate extubation in the operating room by experienced clinicians was associated with shorter ICU and hospital stays. Immediate extubation rarely resulted in tracheal re-intubation.

Intraoperative Assessment of Mitral Valve Area After Mitral Valve Repair for Regurgitant Valves - Corrected Proof

Andrew Maslow, Arun Singh, Feroze Mahmood, Athena Poppas — 2010-07-23

ACCURATE INTRAOPERATIVE assessment of the mitral valve (MV) after repair is important to determine the success of the repair and whether or not rerepair is necessary. Inherent in the repair of the MV is an immediate reduction in mitral valve area (MVA). Further reduction in MVA is possible during follow-up.

An Unusual Cause of Massive Gastrointestinal Bleeding After Transesophageal Echocardiography - Corrected Proof

Fred Cobey, Bryan L. Balmadrid, Daniel M. Wild, Donald Glower, Ian J. Welsby — 2010-07-23

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) performed by experienced operators has been reported to have an acceptable risk profile. In 2 large series, the overall morbidity was between 0.18% and 0.2% with only 1 mortality reported in more than 17,000 patients. The risk of gastrointestinal (GI) bleeding was small. Indeed, no difference in the incidence of blood in nasogastric aspirates could be found between cardiac patients who had TEE performed and those who did not. In this context, Spier et al recently argued in favor of using TEE in the setting of known esophageal varices caused by cirrhosis. Nonetheless, the prospect of using TEE in such high-risk patients, especially those who have been anticoagulated, increases the level of concern in most clinicians. In contrast to TEE's safety record, the authors present a very unusual case of a man with a massive GI bleed after routine TEE, originating from a gastric Dieulafoy lesion. To the authors' knowledge, this is the first such case in the literature.

Postoperative Delirium and Short-term Cognitive Dysfunction Occur More Frequently in Patients Undergoing Valve Surgery With or Without Coronary Artery Bypass Graft Surgery Compared With Coronary Artery Bypass Graft Surgery Alone: Results of a Pilot Study - Corrected Proof

2010-07-23

Objective: The authors tested the hypothesis that patients undergoing valve repair or replacement surgery with or without coronary artery bypass graft (CABG) surgery using cardiopulmonary bypass (CPB) had a greater incidence of postoperative delirium and cognitive dysfunction compared with patients undergoing CABG surgery alone.Design: Prospective study.Setting: Veterans Affairs medical center.Participants: Forty-four age- and education-balanced male patients (≥55 years of age) undergoing elective cardiac surgery with CPB (n = 22 valve ± CABG surgery and n = 22 CABG surgery alone) and nonsurgical controls (n = 22) were recruited.Interventions: None.Measurements and Main Results: Delirium was assessed with the Intensive Care Delirium Screening Checklist before and for 5 consecutive days after surgery. Recent verbal and nonverbal memory and executive functions were assessed using a psychometric test battery before and 1 week after cardiac surgery or at 1-week intervals in nonsurgical controls. Intensive care unit stay, hospital stay, and 30-day readmission were significantly (p = 0.03, p = 0.01, and p = 0.04, respectively) longer in patients undergoing valve surgery ± CABG surgery versus CABG surgery alone. Postoperative delirium occurred more frequently (p = 0.01) in patients undergoing valve ± CABG surgery versus CABG surgery alone. Overall cognitive performance (composite z score) after surgery also was impaired significantly (p = 0.004) in patients undergoing valve ± CABG surgery compared with CABG surgery alone. The composite z score after surgery decreased by at least 1.5 standard deviations in 11 patients (50%) versus 1 patient (5%) without valve surgery compared with nonsurgical controls (p = 0.001, Fisher's exact test). The presence of delirium predicted a composite z score decrease of 1.2 points (odds ratio = 0.30; 95% confidence interval, 0.13-0.68).Conclusions: The results indicated that patients undergoing valve surgery with or without CABG surgery have a higher incidence of postoperative delirium and cognitive dysfunction 1 week after surgery compared with those undergoing CABG surgery alone.

Brain Natriuretic Peptide (BNP) as a Biomarker of Myocardial Ischemia-Reperfusion Injury in Cardiac Transplantation - Corrected Proof

David R. McIlroy, Sophie Wallace, Nicholas Roubos — 2010-07-23

Objectives: To evaluate brain natriuretic peptide (BNP) as a biomarker of ischemia-reperfusion injury in cardiac transplantationDesign: A prospective cohort study.Setting: A single academic medical center.Participants: Adult patients undergoing orthotopic cardiac transplantation (n = 25).Interventions: None.Measurements and Main Results: The authors performed serial measurements of BNP and troponin-I in cardiac allograft donors and recipients, determining the relationship between these biomarkers and established risk factors for and measures of early graft dysfunction. Postoperative BNP correlated moderately with allograft ischemic time (ρ = 0.52, p = 0.01), donor BNP (ρ = 0.45, p = 0.03), and donor troponin-I (ρ = 0.49, p = 0.01). Postoperative BNP was higher in patients with persistently elevated inotrope requirements and enabled the early identification of such patients. In contrast, there was no association between postoperative troponin-I and these same parameters.Conclusions: Postoperative BNP is associated with preimplantation and clinical performance parameters related to allograft ischemia-reperfusion injury at the time of cardiac transplantation, providing preliminary evidence to support its potential use as an ischemia-reperfusion injury biomarker in this context.

Stroke Volume Variation as a Predictor of Fluid Responsiveness in Patients Undergoing One-Lung Ventilation - Corrected Proof

Koichi Suehiro, Ryu Okutani — 2010-07-20

Objectives: To investigate the ability of stroke volume variation (SVV) calculated by the Vigileo-FloTrac system (Edwards Lifescience, Irvine, CA) to predict fluid responsiveness in patients undergoing one-lung ventilation (OLV).Design: Prospective, observational study.Setting: Clinical hospital.Participants: Thirty patients scheduled for a pulmonary lobectomy requiring OLV for at least 1 hour under combined epidural/general anesthesia.Interventions: After starting OLV, hydroxyethyl starch, 500 mL, was administered for 30 minutes.Measurements and Main Results: Hemodynamic variables including heart rate, mean arterial pressure, cardiac index, stroke volume index (SVI), and SVV were measured before and after volume loading. SVV before volume loading was significantly correlated with the absolute changes in SVV (ΔSVV) and percentage changes in stroke volume index (ΔSVI) after volume loading (ΔSVV: p < 0.05, r = −0.893; ΔSVI: p < 0.05, r = 0.866). Of the 30 patients, 15 (50%) were responders to intravascular volume expansion (an increase in SVI ≥25%), and 15 (50%) were nonresponders (an increase in SVI <25%). The area under the ROC curve was 0.900 for SVV (95% confidence interval, 0.809-0.991), whereas the optimal threshold value of SVV to discriminate between responders and nonresponders was 10.5% (sensitivity: 82.4%, specificity: 92.3%).Conclusions: The authors found that SVV measured by the Vigileo-FloTrac system was able to predict fluid responsiveness in patients undergoing surgery with OLV with acceptable levels of sensitivity and specificity.

Preoperative Statin Treatment Is Associated With Reduced Postoperative Mortality After Isolated Cardiac Valve Surgery in High-Risk Patients - Corrected Proof

2010-07-20

Objective: The aim of the present study was to assess the influence of preoperative statin therapy on postoperative mortality in high-risk patients after isolated valve surgery.Design: An observational cohort study.Setting: A 1,200-bed university hospital.Participants: All consecutive patients undergoing isolated nonemergent valve surgery with cardiopulmonary bypass between November 2005 and December 2007 were included.Intervention: None.Measurements and Main Results: During the period, 772 consecutive patients underwent nonemergent isolated valve surgery. Among them, 430 were high cardiovascular risk (defined by patients with 2 or more cardiovascular risk factors). In the high-risk cardiovascular patients, statin pretreatment was administered in 222 patients (52%). In multivariate analysis, after adjustment with a propensity score analysis, preoperative statin therapy was associated with a significant reduction of postoperative mortality in patients with high risk (odds ratio = 0.41; 95% confidence interval, 0.17-0.97; p = 0.04). Low left ventricular ejection fraction and elevated pulmonary artery pressure also were independently associated with increased postoperative mortality. By contrast, in the low-risk patient group, few patients received preoperative statin therapy (7%).Conclusions: This study suggests that preoperative statin therapy may have a potential beneficial effect on postoperative mortality after isolated cardiac valve surgery in high-risk cardiovascular patients.

The Endovascular Coronary Sinus Catheter in Minimally Invasive Mitral and Tricuspid Valve Surgery: A Case Series - Corrected Proof

2010-07-20

Objectives: To determine the safety and efficacy of a standardized approach to the use of an endovascular coronary sinus (CS) catheter during minimally invasive cardiac surgery.Design: Case series.Setting: University hospital.Participants: Patients undergoing mitral and/or tricuspid valve surgery using a minimally invasive cardiac surgery approach.Interventions: An endovascular CS catheter was placed to enable the administration of retrograde cardioplegia using transesophageal echocardiography (TEE), fluoroscopy, and CS pressure measurements.Measurements and Main Results: Data were collected from 96 patient records. A total of 95 (99.0%) endovascular coronary sinus catheters were positioned. The mean time to insert the catheter into the sinus ostium under TEE guidance was 6.3 ± 8.4 minutes. Confirmation of adequate positioning with fluoroscopy took an average of 9.1 ± 10.6 minutes for a mean total procedure time of 16.1 ± 14.1 minutes. Successful positioning, as defined by the ability to generate a perfusion pressure in the CS greater than 30 mmHg during surgery, was achieved in 87.5% of cases. During positioning, ventricularization of the CS pressure curve was observed in 86.0% of cases. The presence of ventricularization was associated with an increase in positioning success (odds ratio = 15.8; 95% confidence interval, 3.713-67.239). One patient developed extravasation of contrast agent after CS catheter placement, without evidence of CS rupture.Conclusions: Endovascular CS catheter insertion can be performed with a high rate of success for positioning and a low complication rate. During positioning, obtaining ventricularization is associated with an increased success rate.

Feeling the Pressure? Anterior Mitral Leaflet Immobility in a Patient With Bicuspid Aortic Valve Disease - Corrected Proof

Kishan Dwarakanath, Christopher J. Plambeck, Sandeep Markan, Paul S. Pagel — 2010-07-20

A 32-YEAR-OLD, 87-kg, 173-cm man with a past medical history of a congenital bicuspid aortic valve was admitted to the authors' hospital for evaluation of dyspnea on exertion. The patient had been a frequent participant in strenuous athletic activities including full-court basketball. He reported that his stamina during these activities had declined substantially in recent months. The patient also described unusual episodes of fatigue while performing his job as a biomedical engineer. He denied a history of angina pectoris, syncope, palpitations, orthopnea, paroxysmal nocturnal dyspnea, and peripheral edema. The physical examination was notable for a grade III of VI holodiastolic murmur heard best along the left sternal border. An Austin Flint murmur was not appreciated. The remainder of the physical examination was noncontributory. Noninvasive measurements of arterial blood pressure indicated the presence of a widened pulse pressure (75-80 mmHg). A plasma brain natriuretic peptide concentration was normal. Transesophageal echocardiography (TEE) was performed as part of the evaluation and confirmed the presence of a bicuspid aortic valve with thickened anterior-lateral (left and right coronary cusp fusion; type A) and posterior-medial leaflets of approximately equal size. The TEE examination also revealed that the middle scallop of the anterior mitral leaflet (A2) was essentially immobile throughout the cardiac cycle ( and [supplementary videos are available online]). What is the cause of this anterior mitral leaflet immobility?

Unusual Variance at the Main Carina During Bronchoscopy - Corrected Proof

Mruthunjaya Danappa Hulgur, Vincent Hong, Mohhamed Loubani — 2010-07-20

An 84-year-old man came for resection of a right lower-lobe tumor for squamous cell carcinoma staged at T2 N0 M0. Apart from having had TIA 20 years previously, he did not have any significant past medical history. Bronchoscopy revealed the main carina being divided into 3; the right upper lobe was arising from the distal end of the trachea (). The rest of the bronchoscopy was normal.

Linear Object in the Ascending Aorta Discovered on Routine Transesophageal Echocardiography for Coronary Artery Bypass Graft Surgery - Corrected Proof

Peter Frank Mueting-Nelsen, Henry Tannous, Andrey Apinis — 2010-07-20

A 71-YEAR-OLD man with a medical history of hypertension, non–insulin-dependent diabetes and coronary artery disease presented with unstable angina. The patient previously had undergone percutaneous coronary interventions (PCI), and bare metal stents had been placed in the right coronary (RCA) and left circumflex arteries. Upon presentation, the patient underwent coronary angiography, revealing 3-vessel disease with in-stent restenoses. The patient was referred for 3-vessel coronary artery bypass grafting (CABG).

Routine Extraluminal Use of the 5F Arndt Endobronchial Blocker for One-Lung Ventilation in Children up to 24 Months of Age - Corrected Proof

Lianne L. Stephenson, Christian Seefelder — 2010-07-20

THORACIC SURGERY in neonates, infants, and small children increasingly is performed with minimally invasive techniques including thoracoscopy. One-lung ventilation (OLV) optimizes exposure during thoracoscopic surgery. The pediatric size 5F Arndt Endobronchial Blocker (AEB) (Cook Medical Inc, Bloomington, IN) has been used successfully for lung isolation in children. A removable loop protruding through its central lumen is used to guide it with a fiberoptic bronchoscope (FOB) into the mainstem bronchus. Because a 4.5-mm inner-diameter (ID) endotracheal tube (ETT) or larger is required to accommodate the blocker concomitant with a pediatric FOB for blocker placement, its endoluminal use is limited to children 2 years and older. The authors performed a retrospective review of their practice of placing the blocker outside the ETT (extraluminal) and to position the blocker with guidance by a bronchoscope inserted through the ETT (endoluminal) in children up to 24 months of age.

Hemodynamic Stability During Biventricular Pacing After Cardiopulmonary Bypass - Corrected Proof

2010-07-20

Objective: To assess the stability of cardiac output, mean arterial pressure, and systemic vascular resistance during biventricular pacing (BiVP) optimization.Design: Substudy analysis of data collected as part of a randomized controlled study examining the effects of optimized temporary BiVP after cardiopulmonary bypass (CPB).Setting: A single-center study at a university-affiliated tertiary care hospital.Participants: Cardiac surgery patients at risk of left ventricular failure after CPB.Interventions: BiVP was optimized immediately after CPB. Atrioventricular delay (7 unique settings) was optimized first, followed by the left ventricular pacing site (3 unique settings) and then the interventricular delay (9 unique settings). Each setting was tested twice for 10 seconds each time. Vasoactive medication and fluid infusion rates were held constant.Measurements and Main Results: Aortic flow velocity and radial artery pressure were digitized, recorded, and averaged over single respiratory cycles. Least squares and linear regression/Wilcoxon analyses were applied to the first 7 patients studied. Subsequently, curvilinear analysis was applied to 15 patients. Changes in mean arterial pressure and systemic vascular resistance were statistically insignificant or too small to be meaningful by least squares analysis. During interventricular synchrony optimization, cardiac output and mean arterial pressure decreased (mean changes −5.7% and −2.5%, respectively; with standard errors 2.3% and 1.5%, respectively), whereas SVR increased (mean change 3.1% with standard error 3.4%). Only the change in cardiac output was statistically significant (p = 0.043). Curvilinear fits to data for 15 patients demonstrated progressive hemodynamic stability over the total testing period.Conclusion: BiVP optimization may be done safely in patients after CPB. With continuous monitoring of mean arterial pressure and cardiac output, the procedure results in no harmful hemodynamic perturbation.

N-acetylcysteine in Cardiac Surgery: Do the Benefits Outweigh the Risks? A Meta-Analytic Reappraisal - Corrected Proof

Guyan Wang, Daniel Bainbridge, Janet Martin, Davy Cheng — 2010-07-20

Objective: N-acetylcysteine (NAC) reduces proinflammatory cytokines, oxygen free-radical production, and ameliorates ischemia reperfusion injury; therefore, it may theoretically reduce postoperative complications in cardiac surgery. The aim of this study was to determine, through systematic review and meta-analysis of all relevant randomized trials, whether NAC reduces mortality, morbidity, or resource utilization in cardiac surgery.Design: Meta-analysis.Setting: University hospitals.Participants: A total of 1,407 patients from 15 randomized studies were included in the analysis.Interventions: None.Measurements and Main Results: All randomized trials searched up to May 2009 comparing the use of NAC versus placebo during cardiac surgery in any language and reporting at least 1 predefined outcome were included. The random effect model was used to calculate odds ratios (ORs, 95% confidence intervals [CIs]) and weighted mean differences (WMD, 95% CI) for dichotomous and continuous variables, respectively. During cardiac surgery, the use of NAC did not significantly decrease acute renal failure requiring renal replacement therapy (OR = 1.05; 95% CI, 0.52-2.11; p = 0.90), new atrial fibrillation (OR = 0.67; 95% CI, 0.37-1.22; p = 0.19), or mortality (OR = 0.81; 95% CI, 0.39-1.68; p = 0.57). There were no differences in the incidence of incremental increase in serum creatinine concentration greater than 25% above baseline (OR = 0.86; 95% CI, 0.66-1.12; p = 0.26), acute myocardial infarction (OR = 0.69; 95% CI, 0.29-1.61, p =0.39), stroke (OR = 0.78; 95% CI, 0.30-2.03; p = 0.61), red blood cell transfusion requirement (OR = 0.77; 95% CI, 0.45-1.31; p = 0.33), re-exploration (OR = 1.33; 95% CI, 0.70-2.26; p = 0.29), or postoperative drainage (WMD = 33 mL; 95% CI,−125 to 191 mL; p = 0.69) between NAC and placebo.Conclusion: Current evidence shows that the perioperative use of NAC has no proven benefit or risk on clinically important outcomes in patients undergoing cardiac surgery.

Clostridium difficile–Associated Disease Acquired in the Cardiothoracic Intensive Care Unit - Corrected Proof

2010-07-20

Objectives: To determine the prevalence, severity, and outcome associated with Clostridium difficile–associated disease (CDAD) acquired while in the cardiothoracic intensive care unit (CTICU).Design: A 5-year retrospective study.Setting: The CTICU.Participants: All CTICU patients with a positive C difficile stool toxin assay 48 hours after admission.Interventions: None.Measurements and Main Results: The results of all CTICU patients with a positive C difficile stool toxin assay were obtained from the Microbiology Department. Each patient's medical notes and charts then were reviewed in turn. A total of 27 of 5,199 (0.5%) CTICU patients acquired CDAD. The median age was 74 years (IQR 68-77), and 17 (63%) patients were male. There were 21 (78%) surgical patients; 13 (62%) were elective admissions. The most frequent diagnosis on admission was valvular heart disease (10 [37%] patients). Sixteen (59%) patients underwent coronary artery bypass graft (CABG) surgery and/or valvular heart surgery. The median interval between CTICU admission and CDAD diagnosis was 10 days (IQR 5-18). Previously identified risk factors for ICU-acquired CDAD included age >65 years (23), antibiotic use (26), and medical device requirements (27). At the time of diagnosis, 14 (52%) patients had moderate CDAD. After treatment initiation, 8 (30%) patients developed worsening CDAD. The 30-day in-hospital mortality rate for CTICU-acquired CDAD was 26% (7 patients).Conclusions: C difficile–associated disease rarely is acquired in the CTICU. Approximately one third of patients may experience disease progression, and just over a quarter may die within 30 days of diagnosis. The implementation of recommended severity definitions and treatment algorithms may reduce complication rates and merits prospective evaluation.

Prosthetic Valve Malfunction Caused by Chordal Entrapment Detected by Transesophageal Echocardiography - Corrected Proof

2010-07-20

PROSTHETIC MALFUNCTION after mitral valve replacement (MVR) is a medical emergency. In particular, pathologic transvalvular regurgitation caused by a prosthetic malfunction immediately after cardiopulmonary bypass is a problem. The authors present a case in which increasing pathologic transvalvular regurgitation after MVR was diagnosed with transesophageal echocardiography (TEE), prompting re-exploration and resection of the subvalvular apparatus.

Evaluation of the Internal Jugular Vein With Transesophageal Echocardiography as a Surface Probe: A Real Alternative to Current Practice? - Corrected Proof

Gabor Erdoes, Reto Basciani — 2010-07-12

We read with interest the article by Stevenson et al about a proposed novel use of the transesophageal echocardiographic (TEE) probe. Placing the tip of the TEE probe over the patient's anterior triangle of the neck, both internal jugular veins (IJVs) were evaluated; the authors opted to use the left-sided one for the placement of the central venous catheter (CVC) because of its greater diameter. On the basis of the presented case, the authors concluded that the surface use of TEE is a favorable screening method for IJV cannulation resulting in an increased use of ultrasound for CVC placement in cardiac anesthesia departments. Although it is an interesting report, we believe that the presented use of the TEE probe does not provide any advantage under clinical conditions.

An Indwelling Nasogastric Tube Interferes With Intubation Assisted by the Pentax Airway Scope - Corrected Proof

Hirotoshi Kitagawa, Yasuhiko Imashuku, Toji Yamazaki — 2010-07-12

The Pentax Airway Scope (AWS; Hoya Co, Tokyo, Japan) integrates a wide view of the glottis and tube guidance function by elevating the epiglottis. Therefore, the Pentax AWS is used routinely for tracheal intubation, including double-lumen tube (DLT) and tube exchange from a DLT to a single endotracheal tube (ETT). In patients undergoing general anesthesia, a nasogastric tube (NG) is routinely placed to prevent postoperative nausea and vomiting in the operating room. In such cases, we occasionally have experienced difficulty with the Pentax AWS–assisted tube exchange from DLT to ETT. Herein, we describe interference of the indwelling NG tube with intubation.

Sectional Wall Motion Detected by Epiaortic Echocardiography - Corrected Proof

2010-07-09

Objective: To evaluate in vivo cross-sectional conformational changes of ascending aortic wall excursion in patients undergoing resection for aortic aneurysm with those undergoing elective coronary artery bypass grafting (CABG) using epi-aortic echocardiography.Design: A prospective observational investigation.Setting: A single tertiary care university hospital.Participants: Thirty-four patients undergoing elective ascending aorta resection and 23 elective CABG patients.Intervention: In an open-chest model and with use of an epi-aortic echocardiographic probe, measurements of aortic wall excursion were made on the ascending aortic aneurysms. Control measurements were made on the transitional neck portions of the aneurysmal aortas (internal control) and CABG aortas (external control).Measurements and Main Results: The aortic aneurysm measurements exhibited no difference (2.8%, p < 0.62) between the excursion of the anterior and posterior walls. In contrast, under similar hemodynamic conditions, the anterior wall of the aneurysm neck moved 48.2% (p < 0.0004) more than the posterior wall. Similarly, in the CABG control group, the anterior wall moved 24% (p < 0.027) more than the posterior wall.Conclusion: This in vivo study documented a lack of asymmetric aortic wall motion in ascending aortic aneurysms. In contrast, both the internal and external control groups (aneurysm neck and CABG) demonstrated asymmetric wall motion. The lack of asymmetric wall motion may be an important aspect of aneurysm pathophysiology and key to the development of management strategies for timing of surgical intervention.

Effects of a Novel Benzodiazepine Derivative, JM-1232(-), on Human Gastroepiploic Artery In Vitro - Corrected Proof

Takahiro Moriyama, Isao Tsuneyoshi, Yuichi Kanmura — 2010-07-05

Objective: To investigate the effects of JM-1232(-) on norepinephrine (10−6 mol/L)- and high K+ (40 mmol/L)-induced contractions in isolated human gastroepiploic arteries (GEA), and to compare them with the effects of midazolam and propofol. In addition, to investigate whether the benzodiazepine-receptor antagonist, flumazenil, or μ-opioid-receptor antagonist, naloxone, influenced the vascular effects of JM-1232(-).Design: An in vitro experimental study.Setting: University laboratory.Participants: GEA segments were used from 69 patients undergoing coronary artery bypass graft surgery.Measurements and Main Results: JM-1232(-) produced dose-dependent relaxation effects in the rings. Although these effects of JM-1232(-) were greater than those of midazolam and propofol at high concentrations (10−5-10−4 mol/L), there were no significantly different relaxation effects at the clinical concentrations of 3 × 10−6 mol/L JM-1232(-), 3 × 10−6 mol/L midazolam, and 1 × 10−5 mol/L propofol. In addition, all these effects were independent of the presence of a functional endothelium. Vasorelaxation induced by JM-1232(-) on norepinephrine-preconstricted GEA was inhibited by flumazenil, but not by naloxone.Conclusions: These results indicate that JM-1232(-) dose-dependently relaxes smooth muscle in human GEA, this effect being independent of the endothelium. Within the ranges of plasma concentrations achieved in clinical practice, JM-1232(-) had similar vasorelaxation effects to midazolam and propofol. JM-1232(-)-induced vasorelaxation was inhibited by flumazenil, indicating that JM-1232(-)-induced vasorelaxation occurred via peripheral benzodiazepine receptor activation in the GEA.

Outcome in Patients Who Require Venoarterial Extracorporeal Membrane Oxygenation Support After Cardiac Surgery - Corrected Proof

2010-07-05

Objective: The authors analyzed hospital mortality in adult cardiac surgery patients who required postoperative venoarterial extracorporeal membrane oxygenation (ECMO) support for circulatory failure and identified perioperative patient variables associated with hospital mortality in these patients.Design: A retrospective study.Setting: A single institution, tertiary academic center.Participants: Adult patients requiring venoarterial ECMO support after cardiac surgery from January 1995 to December 2005 were identified from the Anesthesiology Institute Patient Registry. Twenty-two preselected patient variables were entered into a logistic regression model of hospital death.Interventions: None.Results: Two hundred thirty-three of 40,116 (0.58%) adult cardiac surgery patients required postoperative venoarterial ECMO, and among these, 149 (64%) died in the hospital. In an unadjusted analysis, older age, higher preoperative albumin, diabetes history, coronary artery bypass graft surgery, and longer total cardiopulmonary bypass (CPB) time were associated with increased hospital mortality, and a history of cardiogenic shock was associated with decreased mortality. In an adjusted logistic regression analysis, a history of cardiogenic shock and younger age were associated with decreased hospital mortality. The overall use of postoperative venoarterial ECMO in this patient population decreased since its peak in 1996.Conclusion: Venoarterial ECMO support after cardiac surgery was required in a small fraction of patients and was associated with very high hospital mortality; but among those requiring ECMO, mortality in these patients was lower in younger, nondiabetic patients with cardiogenic shock who had shorter CPB times. The mortality associated patient variables identified are not easily modifiable and do not appear sufficiently robust to define which patients should be selected for this potentially life-saving therapy.

Unusual Cause of Chest Pain at an Unusual Age - Corrected Proof

2010-07-05

ANOMALOUS ORIGIN of the left coronary artery from the pulmonary artery (ALCAPA), also known as the Bland-White-Garland syndrome, is a rare congenital heart defect with an incidence of 1 in 300,000 live births, which is less than 0.5% of all congenital cardiac anomalies. However, it is the most common cause of myocardial infarction in children, and only 10% to 15% of patients survive to adulthood. This case report is unique because it describes ALCAPA as a rare cause of angina in an adolescent, and to the best of the authors' knowledge it is the first case reported in which off-pump coronary artery bypass (OPCAB) surgery was performed to correct the anomaly.

An Unusual Arterial Pressure Waveform - Corrected Proof

Deepak K. Tempe, Mukesh Garg, Sanjula Virmani, Devesh Dutta — 2010-07-05

A 37-YEAR-OLD man presented with the complaint of episodes of paroxysmal nocturnal dyspnea. On the routine physical examination, the radial artery pulse was hyperdynamic, regular (88 beats/min), and the blood pressure was 180/50 mmHg. The chest was hyperdynamic with a diastolic decrescendo murmur in the second right intercostal space. Preoperative echocardiography revealed a bicuspid aortic valve with prolapsing cusp causing severe eccentric regurgitation. The left ventricular (LV) internal diastolic and systolic dimensions were 88 and 74 mm, respectively, with an ejection fraction of 35% to 40%. The patient was scheduled for elective aortic valve replacement (AVR). After standard anesthesia and cardiopulmonary bypass (CPB) techniques, the aortic valve was replaced with a 28-mm prosthetic valve (ATS Medical Inc, Minneapolis, MN). The total ischemia and bypass times were 54 and 88 minutes, respectively. The patient was weaned from CPB with epinephrine, 0.1 μg/kg/min; dopamine, 5 μg/kg/min; and nitroglycerin, 1 μg/kg/min. After CPB, the patient's heart rate was 130 to 140 beats/min, and the invasive arterial pressure (measured by right radial artery cannulation) was 70 to 80 mmHg systolic. However, the beat-to-beat pressure waveform () did not correspond with the simultaneously recorded electrocardiogram (ECG). After a few hours, the arterial pressure improved to 90 to 100 mmHg with the heart rate of 130 to 140 beats/min, and the arterial pressure waveform normalized (). What is the diagnosis?

Early Postoperative Statin Therapy Is Associated With a Lower Incidence of Acute Kidney Injury After Cardiac Surgery - Corrected Proof

Frederic T. Billings, Mias Pretorius, Edward D. Siew, Chang Yu, Nancy J. Brown — 2010-07-05

Objective: To test the hypothesis that perioperative statin use reduces acute kidney injury (AKI) after cardiac surgery.Design: A retrospective analysis of prospectively collected data from an ongoing clinical trial.Setting: A quaternary-care university hospital.Participants: Three hundred twenty-four adult elective cardiac surgery patients.Interventions: None.Measurements and Main Results: The authors assessed the association of preoperative statin use, early postoperative statin use, and acute statin withdrawal with the incidence of AKI. Early postoperative statin use was defined as statin treatment within the first postoperative day. Statin withdrawal was defined as the discontinuation of preoperative statin treatment before surgery until at least postoperative day 2. Logistic regression and propensity score modeling were used to control for AKI risk factors. Sixty-eight of 324 patients (21.0%) developed AKI. AKI patients stayed in the hospital longer (p = 0.03) and were more likely to develop pneumonia (p = 0.002) or die (p = 0.001). A higher body mass index (p = 0.003), higher central venous pressure (p = 0.03), and statin withdrawal (27.4 v 14.7%, p = 0.046) were associated with a higher incidence of AKI, whereas early postoperative statin use was protective (12.5% v 23.8%, p = 0.03). Preoperative statin use did not affect the risk of AKI. In multivariate logistic regression, age (p = 0.03), male sex (p = 0.02), body mass index (p < 0.001), and early postoperative statin use (odds ratio = 0.32; 95% confidence interval, 0.14-0.72; p = 0.006) independently predicted AKI. Propensity score–adjusted risk assessment confirmed the association between early postoperative statin use and reduced AKI (odds ratio = 0.30; 95% confidence interval, 0.13-0.70; p = 0.005).Conclusions: Early postoperative statin use is associated with a lower incidence of AKI among both chronic statin users and statin-naive cardiac surgery patients.

Acute Hemodynamic Instability in an Infant After Pulsatile Bidirectional Cavopulmonary (Glenn Shunt) Anastomosis: Mechanisms and Resolution - Corrected Proof

2010-07-05

Bidirectional superior cavopulmonary shunt (bidirectional Glenn shunt [BDG]) generally is performed as a first- or second-stage procedure in situations of left- or right-heart hypoplasia (eg, hypoplastic but potentially partially usable right ventricle, and patients with tricuspid atresia having single-ventricle physiology). The antegrade flow (if present) to the pulmonary artery (PA) is either interrupted or preserved. In selected patients, the preservation of antegrade flow results in better palliation in terms of improvement of atrioventricular valve regurgitation and the reduction of ventricle size. However, excessive antegrade flow and pressures may lead to the development of pulsatile BDG and superior vena cava (SVC) syndrome. We describe the pathophysiology of unstable hemodynamics and low oxygen saturation with the preservation of antegrade pulmonary blood flow (PBF) and the mechanism of improved hemodynamics with controlled PA banding.

The Role of Continuous Thoracic Paravertebral Block for Fast-track Anesthesia After Cardiac Surgery via Thoracotomy - Corrected Proof

Paula Carmona, José Llagunes, Sergio Cánovas, José de Andrés, Ignacio Marqués — 2010-07-05

Minimally invasive cardiac surgery via minithoracotomy (MICS) was devised to reduce morbidity because of its potentially less inflammatory response, reduced transfusion requirements and minimal scarring, reduced recovery times, and the consequent cost. Although this technique is associated with a smaller incision, the pain from thoracotomy persists. The management of postthoracotomy pain is very challenging and may diminish the advantage of this surgery.

Myocardial Protection with Isoflurane During Off-Pump Coronary Artery Bypass Grafting: A Randomized Trial - Corrected Proof

2010-06-28

Objectives: To analyze the hemodynamic effects and myocardial injury using troponin-T and creatine phosphokinase (CPK-MB) with isoflurane and compare it with a control group in patients undergoing off-pump coronary artery bypass (OPCAB) surgery.Design: This prospective, randomized study was performed in patients scheduled for elective OPCAB surgery during February 2007 to February 2009.Setting: Tertiary care, university teaching hospital.Participants: Forty-five patients undergoing elective OPCAB surgery.Interventions: Patients were randomly allotted to receive either isoflurane (inspired concentration between 1.0% and 2.5%) or propofol (1.5 to 3.5 mg/kg/h) during OPCAB surgery. The concentration of these agents was titrated such that the BIS value was maintained between 50 and 60.Measurements and Main Results: The hemodynamic data were measured and recorded after induction of anesthesia (baseline), during the distal anastomosis of each coronary artery, and 5 and 30 minutes after giving protamine. In addition, blood samples for troponin-T and CPK-MB were obtained after induction (baseline), after 6 hours and 24 hours postoperatively. The cardiac index was significantly higher in the isoflurane group at all stages, except during distal anastomosis of the diagonal branch of the left anterior descending artery (p < 0.05). There was a significant increase in troponin-T levels at 6 and 24 hours after surgery in the propofol group (from 0.037 ± 0.013 ng/mL to 0.098 ± 0.045 ng/mL and 0.081± 0.025 ng/mL, respectively, p < 0.05). Significant increases in the troponin-T levels were observed at 6 hours (from 0.033 ± 0.011 ng/mL to 0.052 ± 0.025 ng/mL, (p < 0.05) in the isoflurane group, and the levels in the propofol group were significantly higher than the isoflurane group at 6 and 24 hours after surgery (p < 0.05). The CPK-MB levels increased in both groups, but were not statistically different.Conclusions: Isoflurane provides protection against myocardial damage in a clinically used dosage as documented by lower levels of troponin-T in patients undergoing OPCAB surgery.

Preliminary Experience in the Use of Preoperative Echo-guided Left Stellate Ganglion Block in Patients Undergoing Cardiac Surgery - Corrected Proof

2010-06-28

Objective: Pulmonary arterial (PA) vasoconstriction in cardiac surgery can originate from the action of combined humoral, endothelial, and sympathetic tone changes. The consequence of PA vasoconstriction is pulmonary hypertension (PHT) and, when present after cardiopulmonary bypass (CPB), can predispose to right ventricular dysfunction. Right ventricular dysfunction after CPB is a serious complication with high mortality rates. The extent to which sympathetic blockade could reduce PA vasoconstriction and reduce PHT is unknown. Pharmacologic stellate ganglion block (SGB) has been associated with a reduction in PHT, but its role and mechanism in cardiac surgery have not been described. Thus, the goal of the study was to test the hypothesis that echo-guided left SGB, performed before the induction of general anesthesia, could prevent PA pressure increases during CPB weaning.Design: A prospective cohort study in cardiac surgical patients.Setting: A tertiary care university hospital.Participants: Forty cardiac surgical patients.Interventions: A left SGB was performed immediately before the induction of general anesthesia under ultrasound guidance and was compared with matched control patients. Standard hemodynamic and electrocardiographic monitoring was performed, and blood gas samples were drawn at specific predetermined time points for analysis. Rhythm disorders, echocardiographic parameters that included wall motion abnormalities, and biochemical parameters of myocardial ischemia were measured by an observer blinded to the allocated group.Measurements and Main Results: Marked improvement in the PaO2/FIO2 ratio in the SGB group was observed (mean difference = 77 mmHg, p = 0.0001). There were no differences between the groups in PA pressure over time during the procedure; central venous pressure was higher in the SGB group (p =0.0184). Reductions of right ventricular fractional area change (p = 0.0331) and tricuspid annulus displacement (p = 0.0048) were observed in the SGB group. The CK-MB was 1.5 times higher in the SGB group (p = 0.0211), but no patients developed myocardial infarction.Conclusions: Left SBG was associated with improved oxygenation that could partially explain its mechanism in acute PHT. Further studies are necessary to evaluate the usefulness of this technique in patients with a high risk of PHT during separation from CPB.

Double-Envelope Continuous-wave Doppler Flow Profile Across a Tilting-Disc Mitral Prosthesis: Intraoperative Significance - Corrected Proof

Shrinivas Gadhinglajkar, Narayanan Namboodiri, Vivek Pillai, Rupa Sreedhar — 2010-06-28

INTRAOPERATIVE TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) is useful in estimating flow velocities and pressure gradients across prosthetic valves. A double-envelope velocity-time integral (VTI) curve typically is observed on continuous-wave Doppler (CWD) interrogation of aortic valve prosthesis, which is attributed to a difference in the flow velocities across the left ventricular outflow tract and the prosthesis.

Incomplete Left Atrial Appendage Ligation Diagnosed Intraoperatively Using Transesophageal Echocardiography Following Mitral Valve Repair - Corrected Proof

2010-06-28

The left atrial appendage (LAA) plays an important role in maintenance and regulation of cardiac function, especially in cardiovascular disorders like hypertension, heart failure, and valvular heart disease (VHD). Of note is its importance in VHD in which the LAA helps in decompressing the left atrium (LA) when the LA pressure is high. This act of decompression by the LAA ultimately results in its dilatation and dysfunction, which increases the possibility of thromboembolic phenomena. Anticoagulant administration is needed in patients with large LAA and atrial fibrillation (AF) to prevent thromboembolic episodes. However, LAA elimination from the circulation by either occlusion or resection is an effective alternative to anticoagulation in patients with VHD with or without AF.

Left Atrial Dissection and Intramural Hematoma After Aortic Valve Replacement - Corrected Proof

2010-06-28

LEFT ATRIAL (LA) dissection is a severe but rare complication of cardiac surgery, occurring in up to 0.84% of mitral valve replacements. The authors report a case of left atrial dissection and subsequent LA intramural hematoma caused by disruption of the left ventricular outflow tract (LVOT) after aortic valve replacement (AVR). This complication was identified by intraoperative transesophageal echocardiography (TEE).

Avulsion of a Bronchial Blocker Cuff in the Trachea When Using a Parker Flex-Tip Endotracheal Tube - Corrected Proof

Tinu Thomas, Galina Dimitrova, Hamdy Awad — 2010-06-24

We report a case illustrating a complication involving avulsion of an Arndt wire-guided endotracheal bronchial blocker cuff into the trachea during its use with a single Parker Flex-Tip endotracheal tube (ETT) (Parker Medical, Highland Ranch, CO) and discuss how one might manage and prevent similar complications.

Response: Spinal Analgesia with Opioids Has No Clinically Relevant Impact in Cardiac Surgery - Corrected Proof

Elena Bignami, Giovanni Landoni, Stefano Turi, Alberto Zangrillo — 2010-06-23

The use of specific anesthetic drugs and techniques, together with drugs managed mainly by cardiac anesthesiologists have recently been associated with improved perioperative survival in cardiac surgery. The numbers needed to treat are impressive ().

Low Cardiac Output After Surgical Correction of Tetralogy of Fallot: Hidden Culprits - Corrected Proof

2010-06-23

A 9-MONTH-OLD 8.2-kg, 74-cm boy underwent total intracardiac repair of tetralogy of Fallot. Through a transatrial approach, the ventricular septal defect (measuring approximately 9 mm) was closed with a Gore-Tex patch (W.L. Gore & Assoc, Flagstaff, AZ) using continuous 4-0 Prolene sutures (Ethicon Inc, Somerville, NJ). The main pulmonary artery was opened longitudinally, and the incision was extended proximally into the right ventricular outflow tract across the pulmonary annulus. Muscle bands were resected to release the right ventricular outflow obstruction and the outflow tract was reconstructed with a transannular pericardial patch.

Left Atrial Mass During a Minimally Invasive Thoracic Mitral Valve Replacement - Corrected Proof

2010-06-23

A 72-YEAR-OLD man with a history of mitral regurgitation presented for minimally invasive mitral valve surgery through a right thoracotomy approach. Two introducers were inserted into the right internal jugular vein for the placement of retrograde cardioplegia and pulmonary artery venting catheters (Endoplegia and Endovent, Edwards Lifesciences Inc, Irvine, CA). The retrograde catheter was guided percutaneously through the coronary sinus ostium using a modified bicaval transesophageal echocardiographic view and was advanced slowly while monitoring its position. The final position was confirmed when inflation of the balloon with 0.25 mL of saline resulted in a ventricularized waveform. After routine administration of antegrade cardioplegia, retrograde cardioplegia was initiated through the coronary sinus catheter. The catheter delivery pressure was approximately 180 mmHg, and the flow was initially 90 mL/min, but the sinus pressure was 14 to 16 mmHg. The surgeon opened the left atrium to expose the mitral valve. Subsequent administration of retrograde cardioplegia was accompanied by a catheter delivery pressure between 180 and 200 mmHg, concomitant with bulging of the left atrial wall. Retrograde cardioplegia was stopped, and the transesophageal echocardiographic images shown in through were obtained. What is the diagnosis?

Case XX—2010Successful Use of Transesophageal Echocardiography After Esophagogastrectomy - Corrected Proof

2010-06-21

TRANSESOPHAGEAL ECHOCARDIOGRAPHY (TEE) commonly is used in the intraoperative management of patients undergoing cardiac surgery. Despite the increasing evidence that it generates new clinical findings in up to 40% of cases and that surgical management is thereby altered in up to 25% of patients undergoing cardiac surgery, its routine use in all cardiac surgical patients is not universal in the United States. Like most interventions, TEE is not risk free, and a variety of complications associated with its use have been reported, including esophageal mucosal tears and perforations, compression of airways and major vascular structures, cardiac arrhythmias, and injuries to other abdominal viscera. Of these, esophageal injury has been the predominant type of complication noted in large observational studies of adverse sequelae of intraoperative TEE, and, therefore, pre-existing esophageal pathology commonly is cited as a contraindication to its use. There are reports of successful use of TEE in other forms of esophageal pathology, such as Zenker diverticulum, but to date there are no reports of its use in patients with a previous esophagogastrectomy, and, therefore, the risks of injury to the reconstructed esophagus and the quality of imaging obtainable are unknown. Two patients with previous esophageal resection in whom high-quality intraoperative transesophageal echocardiographic TEE images were obtained and who did not sustain any clinically evident injury to their reconstructed esophagus as a result are presented.

2010 Standard of Care for Central Nervous System Monitoring During Cardiac Surgery - Corrected Proof

Harvey L. Edmonds — 2010-06-21

THE ARTICLE BY Baulig et al in this issue compares the performance of 2 quantitative electroencephalographic (EEG) monitors during coronary artery bypass graft (CABG) surgery. Typical of many neuromonitoring articles, it focuses on the process (ie, monitor A seems to perform differently from monitor B) instead of the influence of technology on patient outcome or cost-effectiveness. Historically, the dearth of outcome-oriented studies led many cautious and appropriately skeptical anesthesiologists to only hesitatingly use central nervous system monitoring for cardiac and major vascular surgical procedures. More recently, outcome studies have begun to appear. Thus, now seems to be an appropriate time to update the neuromonitoring status for cardiac and vascular surgery.

Progress in Platelet Medicine: Focus on Stent Thrombosis and Drug Resistance - Corrected Proof

Prakash A. Patel, John G.T. Augoustides — 2010-06-21

The outcome importance of coronary stent thrombosis has mandated the careful management of these devices and their associated platelet blockade during the perioperative period. Recent trials have highlighted the catastrophic outcomes after stent thrombosis. The maintenance of clinically effective platelet blockade not only is essential to prevent stent thrombosis but also to optimize outcome in the integrated management of acute coronary syndromes. Dual antiplatelet blockade with aspirin and clopidogrel must balance the risks of ischemia and bleeding in patients with acute coronary syndromes, especially in the subset who require urgent surgical coronary revascularization. Platelet resistance to thienopyridines such as clopidogrel and prasugrel may be a significant risk factor for adverse cardiovascular outcomes. This phenomenon is detectable by point-of-care assays although standardized definitions and standardized testing batteries have yet to be formulated. The determinants of platelet resistance to thienopyridine therapy include genetic polymorphisms (especially related to hepatic drug metabolism) and drug interactions (especially the proton pump inhibitors). Novel platelet blockers are currently in late clinical development and will likely induce more consistent platelet blockade because of pharmacokinetic advantages including the lack of hepatic metabolism for activation. These agents will likely supersede clopidogrel and prasugrel if randomized trials show superior efficacy and clinical safety.

Morphology Identification Using Transesophageal Echocardiography in Migratory Renal Cell Carcinoma Surgery - Corrected Proof

Russell Clarke, Jason Wells, Christopher Finn — 2010-06-07

RENAL CELL CARCINOMA WITH INFERIOR VENA CAVAL (IVC) extension presents many difficulties for intraoperative management. Transesophageal echocardiography (TEE) has been recognized as a valuable intraoperative tool to monitor the tumor during surgical resection. Real-time monitoring of the tumor during surgery allows rapid diagnosis of tumor embolization. This is a relatively rare complication, occurring in less than 0.4% of all renal cell carcinomas and less than 5% of renal cell carcinomas involving the IVC, but is feared because of its disastrous complications.

The Impact of Moderate–to–End-Stage Renal Failure on Outcomes After Coronary Artery Bypass Graft Surgery - Corrected Proof

2010-05-31

Objectives: Currently, established renal failure is a well-recognized risk factor for operative mortality in patients undergoing coronary artery bypass graft (CABG) surgery. The authors aimed to establish the relative impact of dialysis-dependent renal failure (DRF) and nondialysis-dependent renal failure (NDRF) on early and late outcome after CABG surgery.Design: A retrospective cohort study.Setting: A single teaching hospital.Participants: The authors analyzed prospectively collected data from 2,960 adult patients who underwent isolated CABG surgery between 1998 and 2006 at the authors' institution, according to whether they had preoperative NDRF based on preoperative creatinine >2.5 mg/dL, DRF, or neither (controls).Interventions: CABG surgery.Measurements and Main Results: Outcome measures included hospital mortality, postoperative complications, length of stay, and survival. Hospital mortality was 1.8% (n = 52). Patients in the NDRF and DRF groups had a significantly increased mortality (8.3%, n = 13) compared with the control group (1.4%, n = 39), and both NDRF (odds ratio [OR] = 6.2; 95% confidence interval, 2.3-16.5; p < 0.001) and DRF (OR = 4.0; 95% confidence interval, 1.6-10.0; p = 0.004) were found to be independent predictors of operative mortality. The overall mean follow-up was 3.9 ± 2.5 years. Multivariate analysis revealed DRF (OR = 5.1) to be an independent predictor of late mortality after cardiac surgery, whereas NDRF was not found to be an independent predictor of late mortality.Conclusions: Preoperative renal failure is an independent risk factor for adverse early and late outcomes after CABG surgery. NDRF is associated with increased hospital mortality and major morbidity compared with patients with lesser degrees of renal dysfunction, but also compared with DRF patients.

Spinal Analgesia in Cardiac Surgery - Corrected Proof

Nicholas B. Scott — 2010-05-31

I read with interest the article by Zangrillo et al entitled “Spinal analgesia in cardiac surgery: a meta-analysis of randomized controlled trials”. The results seem quite conclusive that clinically relevant outcome measures such as mortality and cardiovascular morbidity are not affected by the use of spinal analgesia, confirming the findings of a previous meta-analysis by Liu. Furthermore, this latest meta-analysis confirms that spinal opioid analgesia is associated with an increased incidence of pruritus. The authors conclude that “the present results strongly discourage spinal analgesia to improve clinically relevant outcomes....”

Intrathecal Lactate Concentration and Spinal Cord Injury in Thoracoabdominal Aortic Surgery - Corrected Proof

2010-05-31

Objective: The aim of this study was to evaluate the role of lactate as an early predictor of spinal cord injury during thoracoabdominal aortic aneurysm repair.Design: Observational study.Setting: University hospital.Participants: Sixteen consecutive patients (10 men and 6 women) scheduled to undergo thoracoabdominal aortic aneurysm repair were enrolled in the study. All patients were affected by atherosclerotic aneurysmal pathology.Interventions: None.Measurements and Main Results: During surgery, the authors simultaneously withdrew samples of cerebrospinal fluid and arterial blood to evaluate pO2, pCO2, pH, and lactate concentration. Samples were collected at 5 fixed times during and after surgery: T1 (before aortic cross-clamping), T2 (15 minutes after clamping), T3 (just before unclamping), T4 (end of surgery), and T5 (4 hours after the end of surgery). Lactate levels in cerebrospinal fluid rose consistently during aortic cross-clamping (T1 = 1.89 mmol/L, T2 = 2.21 mmol/L, T3 = 2.88 mmol/L, T4 = 3.655 mmol/L, and T5 = 3.16 mmol/L). Lactate concentrations in the cerebrospinal fluid were significantly higher in the 4 patients who developed neurologic injury, even at T1 (before surgery), than in those who did not end in spinal cord injury with the 4 highest values belonging to the 4 patients who later developed spinal cord injury.Conclusions: This study has the potential to elucidate the time course of early lactate level elevation during thoracoabdominal aortic aneurysm repair and its clinical use in predicting the development of postoperative spinal cord injury.

Atrial Fibrillation After Cardiac Surgery: Incidence, Risk Factors, and Economic Burden - Corrected Proof

2010-05-31

Objective: To evaluate the incidence of postoperative atrial fibrillation (POAF), the predisposing factors, the results of treatment before discharge, and the impact on duration and costs of hospitalization.Design: A prospective observational study.Methods: Patients who underwent cardiac surgery from January 1, 2007 to December 31, 2007.Interventions: Electrocardiography was continuously monitored after surgery. Patients with symptomatic new-onset atrial fibrillation or lasting >15 minutes were treated with amiodarone and with DC shock in prolonged cases.Results: POAF occurred in 29.7%, with the higher incidence between the 1st and 4th postoperative day. Age (p < 0.001), atrial size >40 mm (p < 0.001), previous episodes of AF (p < 0.001), female sex (p = 0.010), and combined valve and bypass surgery (p = 0.012) were multivariate predictors of POAF at logistic regression. Sinus rhythm was restored by early treatment in 205 of 215 patients. This was associated with a low incidence of cerebrovascular events (<0.5%) and with a limited increase of average length of hospitalization (24 hours) in patients with POAF.Conclusions: The overall incidence of POAF in the authors' center is close to 30%; 95.3% of patients were discharged in sinus rhythm. The increase in length and costs of hospitalization (on average, 1.0 day with a burden of about €1,800/patient) were significantly lower than in previous investigations.

Protective Effects of Steroids in Cardiac Surgery: A Meta-Analysis of Randomized Double-Blind Trials - Corrected Proof

2010-05-31

Objective: Cardiac surgery and cardiopulmonary bypass (CPB) induce an acute inflammatory response contributing to postoperative morbidity. The use of steroids as anti-inflammatory agents in surgery using CPB has been tested in many trials and has been shown to have good anti-inflammatory effects but no clear clinical advantages for the lack of an adequately powered sample size. The aim of this study was to evaluate the effects of steroid treatment on mortality and morbidity after cardiac surgery.Design: A systematic meta-analysis of randomized double-blind trials (RDBs).Setting: A university hospital.Participants: Adult patients who underwent cardiac surgery.Measurements and Main Results: A trial search was performed through PubMed and Cochrane databases from 1966 to January 2009. Among 104 clinical trials reviewed, 31 RDB trials (1,974 patients) were considered suitable to be analyzed. A quality assessment of the trials was performed using the Jadad score. The types of steroid used in these trials were methylprednisolone (51.4%), dexamethasone (34.3%), hydrocortisone (5.7%), prednisolone (2.9%), or a combination of methylprednisolone and dexamethasone (5.7%). Steroid prophylaxis provided a protective effect preventing postoperative atrial fibrillation (odds ratio = 0.56; confidence interval [CI] 0.44-0.72, p < 0.0001), reducing postoperative blood loss (mean difference = −204.2 mL; CI from −287.4 to −121 mL; p < 0.0001), and reducing intensive care unit (mean difference = −6.6 hours; CI from −10.5 to −2.7 hours, p = 0.0007) and overall hospital stay (mean difference = −0.8 days; CI from −1.4 to −0.2 days, p = 0.01). Steroid prophylaxis had no effect on postoperative mortality, mechanical ventilation duration, re-exploration for bleeding, and postoperative infection.Conclusions: A systematic review of RDB trials reveals that steroid prophylaxis may reduce morbidity after cardiac surgery and does not increase the risk of postoperative infections.

The Incidence of Intraoperative Awareness in Cardiac Surgery Fast-track Treatment - Corrected Proof

2010-05-31

Objective: To determine the occurrence of intraoperative awareness with recall in cardiac surgery patients undergoing fast-track anesthetic management in a direct-admission postanesthetic care unit.Design: Prospective.Setting: University-affiliated heart center.Participants: Five hundred thirty-four patients undergoing fast-track anesthesia.Interventions: Using a structured interview process as part of the quality-assurance program.Methods and Main Results: All fast-track patients during an 8-month period were entered into the study at a university hospital. Each patient was interviewed by research staff with the same standard set of questions within the first 24 hours of surgery. Follow-up interviews were performed on day 3 or 4 as well as on day 6 or 7 postsurgery. Awareness was defined by the presence of explicit memory of any event from the induction of anesthesia to the recovery of consciousness in the postanesthetic care unit (PACU). A final study population of 514 patients was evaluated. None of the answers given by any patient during any of the 3 interviews indicated intraoperative awareness, with the exception of one 54-year-old male patient. Most likely, this potential awareness did not take place during the operation but was caused by inadequate awakening in the PACU.Conclusion: Therefore, the authors conclude that, with respect to intraoperative awareness, the “Leipzig Fast-Track Concept” with the use of ultra–short-acting opioids should be considered as a safe method of management of patients undergoing a wide variety of cardiac operations.

History of Post-traumatic Stress Disorder Is Associated With Impaired Neuropsychometric Performance After Coronary Artery Surgery - Corrected Proof

2010-05-24

Objective: To determine if preoperative history of post-traumatic stress disorder (PTSD) is associated with postoperative cognitive impairment.Design: An observational study.Setting: Veterans Affairs Medical Center.Participants: Cardiac surgical patients.Interventions: None.Measurements and Main Results: Age- and education-balanced patients (≥55 years of age) undergoing cardiac surgery (n = 30 with a history of PTSD+, n = 56 without a history of PTSD−) and nonsurgical controls (n = 28) were recruited. Recent verbal and nonverbal memory and executive functions were assessed before and 1 week after cardiac surgery or at 1-week intervals in nonsurgical controls. Demographic and medical parameters were similar between groups with the exception of preoperative depression and a history of alcohol dependence. Preoperative depression scores were significantly (p = 0.02) higher in PTSD+ compared with PTSD− groups. Immediate Word List Recall and Delayed Word List Recall under baseline conditions were worse in PTSD+ compared with PTSD− patients. Cognitive performance after surgery decreased by at least 1 standard deviation in 27 PTSD− patients (48%) and in 25 PTSD+ patients (83%) (p = 0.002) versus nonsurgical controls. Multivariate regression analysis (including a history of depression and alcohol dependence) revealed that a history of PTSD was significantly associated with overall (including nonverbal recent memory, verbal recent memory, and executive functions) postoperative cognitive dysfunction (p = 0.005).Conclusions: The current findings suggest that patients with a history of PTSD undergoing coronary artery surgery using cardiopulmonary bypass may be especially vulnerable to postoperative cognitive impairment.

Perioperative Management of Deep Hypothermic Circulatory Arrest - Corrected Proof

Marina Svyatets, Kishore Tolani, Ming Zhang, Gene Tulman, Jean Charchaflieh — 2010-05-17

THE GOAL OF this article is to provide a review of deep hypothermic circulatory arrest (DHCA), covering major issues including pathophysiology of ischemic injury, organ protection (both pharmacologic and nonpharmacologic), temperature control, and perfusion methods. The purpose of this review is to serve as a resource for board review or as introductory material for a cardiac anesthesia rotation. The reference list should help in directing the reader for more in-depth review of particular areas.

Manifestation of Aortic Root Abscess From Acute Bacterial Endocarditis - Corrected Proof

Amanda J. Rhee, Gregory W. Fischer, David L. Reich — 2010-05-03

A 71-YEAR-OLD man with a history of coronary artery disease, moderate aortic stenosis, and arterial hypertension was scheduled for aortic valve replacement and possible aortic root replacement. One month before admission, he was treated for methicillin-sensitive Staphylococcus aureus endocarditis. A transthoracic echocardiogram revealed a lesion on the mitral valve that was suspected to be vegetation associated with mild mitral regurgitation. The patient began a course of intravenous oxacillin as an outpatient. Two weeks later, the patient was admitted to the hospital with signs of worsening acute congestive heart failure. At that time, a transesophageal echocardiogram (TEE) was reported to show a mobile density on the mitral valve, a flail posterior mitral leaflet, and severe mitral regurgitation. A small fluid collection was noted in the posterolateral wall of the aortic root. After optimization, the patient was brought to the operating room for mitral valve and aortic valve replacement surgery.

Prophylaxis Against Atrial Fibrillation After Cardiac Surgery: Effective, But Not Routinely Used—A Survey of Cardiothoracic Units in the United Kingdom - Corrected Proof

Jan M. Lutz, Umakanth Panchagnula, Julian M. Barker — 2010-05-03

Objective: To establish whether international recommendations on chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients are implemented locally in cardiothoracic units in the United Kingdom; to determine which drugs are being used, how long they are given, and whether outcomes are monitored.Design: Survey of local cardiothoracic center guidelines.Setting: Postal and telephone survey.Participants: Senior anesthesiologists and critical care staff in all 37 public cardiothoracic units in the United Kingdom.Intervention: None.Measurements and Main Results: Results were obtained from all contacted cardiothoracic units. Five units (14%) have local guidelines for chemoprophylaxis against atrial fibrillation in place. All use β-antagonists as their primary prophylactic drugs; only one unit uses amiodarone as a secondary prophylactic drug. Duration of prophylactic treatment varies, from 5 days to 6 weeks postoperatively. Thirty-two units (86%) have no local guidelines for chemoprophylaxis in place.Conclusion: Chemoprophylaxis against postoperative atrial fibrillation in cardiac surgery patients remains underused, despite its effectiveness and recommendations for its routine use by several international organizations.Departmental guidelines help to ensure routine use, but this survey shows that so far only a minority of cardiothoracic units in the United Kingdom have implemented such guidelines. Awareness of the advantages of routine prophylaxis against atrial fibrillation should be improved and departmental prescribing policies encouraged.