Gelatin, ringer or modern hydroxyethyl starch solutions: which is better after coronary artery bypass graft?

Hemodynamic stability in patients after coronary artery bypass graft surgery [CABG] with the cardiopulmonary bypass pump [CPB], especially during transfer to ICU ward and the early hours of ICU admission is very important. Adequate fluid therapy and intravascular volume maintenance as a matter of principle is essential using various intravenous fluids, but there is always the question of what is the ideal intravenous fluid?. The aim of this study is to compare the effects of gelatin, hydroxyethyl starch [HES 6%, Voluven], and Ringer's solution to maintain hemodynamic status after cardiopulmonary bypass in patients undergoing coronary artery bypass surgery. In this randomized double blind clinical trial, 92 patients who were candidates for onpump CABG were studied. After discontinuation of CPB, all patients were transferred to the ICU and were put randomly into three groups. The first group received Ringer's solution, the second group gelatin 4%, and the third group HES 6% [Voluven]. Hemodynamic parameters like heart rate, mean arterial pressure, systolic blood pressure, diastolic blood pressure, central venous pressure, cardiac output and the presence of arrhythmias were documented. The volume that was needed for maintaining normal blood pressure and central venous pressure [CVP] in the range of 10 to 14 mmHg was less in the HES group than the other groups, but was similar in the gelatin 4% and Ringer's groups in the first 24-hours after surgery. Urinary output in the first four hours and 24 hours after surgery were significantly higher in the HES group than the other two groups, and mean creatinine levels were significantly lower in the HES group. HES 6% has better volume-expanding effects than gelatin 4% and Ringer's solution and its short-term effects on renal function are also better

Evaluation of 56 cases of long-segment anastomosis of LITA to LAD in Rajaei Heart Center

Long-segment reconstruction of the diffusely diseased left anterior descending artery [LAD] with left internal thoracic artery [LITA] is one of the methods offered in order to deal with complicated, multiple, and long-segment lesions in the LAD. In this prospective study. we analyzed the results obtained with this technique. Between Feb. 2007 and Feb. 2009, 56 patients underwent surgery via this technique. The LITA was used as a patch along the opened narrow segment of the LAD from 2 to 8cm. Data on all the patients were collected, and all the patients were worked up for postoperative complications such as postoperative myocardial infarction, ECG changes, NIHA class, enzymatic changes, and postoperative bleeding. CT-Angiography was performed between 6 to 18 months after surgery in some cases. Fifty-six eases, comprising 42 [75%] men and 14 [25%] women between 43 and 78 years of age [mean age 59.8 +/- 9.3 years] with multiple and long-segment lesions in the LAD were included in this study. Preoperative risk factors were hypertension [66.1%], diabetes [57.1%], hyperlipidemia [50%], cigarette smoking [50%], renal failure [1.8%], and positive family history [7.1%]. Twenty-three [41.1%] patients had remote and 9 [16.1%] had recent myoeardial infarction. Significant left main lesions were found in 7 [12.5%] patients, peripheral vascular disease in 3 [5.3%], and preoperative arrhythmias in 2 [3.6%]. The mean number of grafts was 2.85 +/- 1.5. Postoperative complications were arrhythmias in 10 [17.8%] patients, postoperative myocardial infarction in 1 [1.8%], surgical bleeding in 7 [12.5%], infections in 3 [5.3%], plural effusion in 3 [5.3%], tamponade in 2 [3.6%], and pericardial effusion in 1[1.8%]; there was no mortality amongst the patients. CT-angiography, performed in 6 patients between the six and eighteenth postoperative months, revealed patent anastomoses in all the patients. Long segment and multiple lesions in the LAD pose a challenge for cardiac surgeons. The results of long-segment LAD reconstruction using the LITA are very encouraging

Evaluation and comparison of use of low-dose aprotinin and tranexamic acid in CABG: a double-blind, prospective, randomized study of 150 patients

Cardiovascular operations are associated with an inherent bleeding tendency that sometime leads to severe bleeding and transfusion requirement. Pharmacologic intervention to minimize post-bypass bleeding and blood product transfusions has received increasing attention for both medical and economic perspectives. In this double-blind, randomized, placebo-controlled clinical trial, three groups of patients, each comprising 50 patients undergoing on-pump coronary artery bypass grafting surgery [CABG] were blindly randomized to receive either low aprotinin, tranexamic acid, or placebo; the results were subsequently evaluated and compared between the groups. The following variables were similar in the groups, and there were no statistically significant differences in these variables: age [p value=0.308], sex [p valuco.973], hyperlipidemia [p value=0.720], hypertension [p value=0.786], smoking [p value=0.72], and diabetes [p value=0.960]. The amounts of drainage from chest tubes were less in the aprotinin and tranexamic acid groups compared to the placebo group, and this was statistically significant [p value<0.001]. There was no statistically significant difference in need for reoperation for bleeding between the three groups [p value=0.998]. Complications following surgery in the three groups were statistically the same and not significantly different [Table below]. All the complications had a good course, and all the patients were discharged from hospital uneventftilly. There was no mortality in any group. Low-dose aprotinin and tranexamic acid can significantly reduce blood loss and transfttsion requirement in CABG without importantly increasing mortality and morbidity

Evaluation of 56 cases of long-segment anastomosis of LITA to LAD in Rajaei heart center

Long-segment reconstruction of the diffusely diseased left anterior descending artery [LAD] with left internal thoracic artery [LITA] is one of the methods offered in order to deal with complicated, multiple, and long-segment lesions in the LAD. In this prospective study, we analyzed the results obtained with this technique. Between Feb. 2007 and Feb. 2009, 56 patients underwent surgery via this technique. The LITA was used as a patch along the opened narrow segment of the LAD from 2 to 8 cm. Data on all the patients were collected, and all the patients were worked up for postoperative complications such as postoperative myocardial infarction, ECG changes, NIHA class, enzymatic changes, and postoperative bleeding. CT-Angiography was performed between 6 to 1 8 months after surgery in some cases. Fifty-six cases, comprising 42 [75%] men and 14 [25%] women between 43 and 78 years of age [mean age= 59.8 +/- 9.3 years] with multiple and long-segment lesions in the LAD were included in this study. Preoperative risk factors were hypertension [66.1%], diabetes [57.1%], hyperlipidemia [50%], cigarette smoking [50%], renal failure [1.8%], and positive family history [7.1%]. Twenty-three [41.1%] patients had remote and 9 [16.1%] had recent myocardial infarction. Significant left main lesions were found in 7 [12.5%] patients, peripheral vascular disease in 3 [5.3%], and preoperative arrhythmias in 2 [3.6%]. The mean number of grafts was 2.85 +/- 1.5. Postoperative complications were arrhythmias in 10 [1 7.8%] patients, postoperative myocardial infarction in 1 [1.8%], surgical bleeding in 7 [12.5%], infections in 3 [5.3%], plural effusion in 3 [5.3%], tamponade in 2 [3.6%], and pericardial effusion in 1 [1.8%]; there was no mortality amongst the patients. CT-angiography, performed in 6 patients between the six and eighteenth postoperative months, revealed patent anastomoses in all the patients. Long segment and multiple lesions in the LAD pose a challenge for cardiac surgeons. The results of long-segment LAD reconstruction using the LITA are very encouraging

Outcomes of ventricular septal defect repair in various anomalies: a single institute experience and literature review

This is a single institute retrospective study [from 2007 to 2008] to evaluate how patient related factors [age, weight] and type of anatomical location of ventricular septal defect [VSD] could affect the outcome of surgery. Patients with any diagnosis who had undergone ventricular septal defect repair [a total of 25 patients] from 2007 till early 2008 at our center were evaluated retrospectively for factors which might be responsible for developing residual ventricular septal defects and heart block. Data were analyzed through univariate and multivariate analysis. There was 2 deaths among 252 patients [0.8%]. The incidence of postoperative residual ventricular septal defect was 28.2% +/- 2.8* [71 of 252], but only 3 of them [4.2%] needed reoperation. Neither patch material [p=0.572], nor type [p=0.349] or size [p=0.599] of ventricular septal defect had any effect on this complication. The mean age and weight of patients who had residual ventricular septal defect compared to those who did not were not significantly different, although they were somewhat lower [4.7 +/- 0.7 vs. 5.2 +/- 0.4 years, p=0.537; and 15.4 +/- 1.7 vs. 17.9 +/- 1.1 kg, p=0.222, respectively]. There were five patients [2.05] with postoperative complete heart block [CHB] and again this was independent of the patients' age, weight and surgical approach [transatrial or transventricular]. Patients with history of previous Blalock-Taussig [BT] shunt proved to have postoperative bleeding more commonly [13%, 6 of 46 patients] than patients who had not [3.4%, or 7 of 206 patients, p=0.009]. Also in patients with a history of BT shunt compared to those without it, postoperative pericardial effusion [6.5% versus 1.5%, P=0.04] and pneumonia [4.35 versus 0.5%, P=0.025] were more common. It seems that for VSD repair, there are no limitations such as wight or age to proceed with the definitive surgery. Also the incidence of complications is independent of the type of anomaly or approaches for closing the defect. Finally, BT shunt has its own complications which are neither rare nor minor, so it is advisable to proceed with the definitive surgery at the first time to avoid the complications associated with BT shunt

Evaluation of pulmonary regurgitation following tetralogy of fallot repair

Pulmonary regurgitation [PR] is the most important residual lesion remaining after the repair of Tetralogy of Fallot [TOF]. Through a thorough review of the data, statistics of patients undergoing pulmonary valve replacement following total correction for TOF and analyzing these data, the following study was performed and presented below. Database search for medical records of patients undergoing pulmonary valve replacement following total correction for TOF was performed and the data gathered, analyzed, and presented. The age of the patients [22.21 +/- 6.98 years old], time elapsed between the two operations, right ventricular ejection fraction [mildly decreased, 18.6%; moderately decreased, 67.9%; and severely decreased, 12.2% of cases], aneurysm in the outflow tract of the right ventricle [20.8%], tricuspid regurgitation [56.6%], tricuspid steno sis [1 case], valve type used for pulmonary valve replacement [biologic, 86.6%; metallic, 11.2%; and homograft, 1.9%], pulmonary artery pressure [<25mmHg, 34 cases [64.2%]; 25mmHg - 50mmHg, 7 cases [13.2%]; 50mmHg-75mmHg, 1 case [1.9%], and > 75mmHg, 1 case] were evaluated. Although right ventricular volume overload due to severe pulmonary regurgitation after repair of TOF can be tolerated for years, there is now evidence that the compensatory mechanisms of the right ventricular myocardium ultimately fail and that if the volume overload is not eliminated or reduced, this dysfunction may be irreversible. In light of those data and with better understanding of risk factors for adverse outcomes late after TOF repair, many centers are now recommending early pulmonary valve replacement before symptoms of heart failure develop