Comparison of the effectiveness of continuous versus intermittent cefazolin for the prevention of infection after off-pump coronary artery bypass graft

Surgical site infection is known as a common complication after cardiac surgery, and Cefazolin is the best prophylactic antibiotic to prevent this complication. The goal of this study was to evaluate the effect of continuous and intermittent Cefazolin for the prevention of superficial surgical site infection following off-pump coronary artery bypass [OPCAB]. This prospective randomized clinical trial study was conducted on 141 patients candidated for OPCAB and divided into two groups. This study was performed between February 2011 and February 2012 in the Iranian city of Yazd. Patients in both groups received 2 g of Cefazolin as a starting dose and at 30 minutes before incision. Definition of surgical site infections was according to the Centers for Disease Control and Prevention Criteria [CDC-criteria]. In the continuous infusion group [n = 74], 3 g of Cefazolin was infused over a 2 4-hour period after surgery. In the intermittent group [n = 67], 1 g of Cefazolin was administered at 3, 11, and 19 hours after the starting dose. Hyperlipidemia, diabetes, hypertension, smoking, history of heart disease, and incidences of superficial infection were compared between the two groups. Duration of follow- up was 4 weeks. The mean age of the patients was 60.49 +/- 10.63 years. The patients were 30.5% female and 69.5% male. There were no significant differences in age, body surface area, duration of operation, number of distal grafts, number of proximal grafts, and duration of hospital stay before heart surgery between two groups. The incidence of infection in intermittent group was [7.5%] and in continuous groups was [2.7%]. There was no significant difference in the incidence of infection between the two groups [p value = 0.26]. Our findings in this study showed no significant differences between continuous and intermittent Cefazolin for the prevention of superficial surgical site infections after OPCAB

Adenosine preconditioning versus ischemic preconditioning in patients undergoing off-pump coronary artery bypass [OPCAB]

During off-pump coronary artery bypass [OPCAB], the heart is subjected to ischemic and reperfusion injury. Preconditioning is a mechanism that permits the heart to tolerate myocardial ischemia. The aim of this study was to compare the effects of Adenosine preconditioning with ischemic preconditioning on the global ejection fraction [EF] in patients undergoing OPCAB. In this single-blind, randomized controlled trial, sixty patients undergoing OPCAB were allocated into three equally-numbered groups through simple randomization: Adenosine group, ischemic group, and control group. The patients in the Adenosine group received an infusion of Adenosine. In the ischemic group, ischemic preconditioning was induced by the temporary occlusion of the left anterior descending coronary artery twice for a 2-minute period, followed by 3-minute reperfusion before bypass grafting of the first coronary vessel. The control group received an intravenous infusion of 0.9% saline. Blood samples at different times were sent for the measurement of creatine kinase isoenzyme MB [CK-MB] and cardiac troponin I [cTnI]. We also recorded electrocardiographic indices and clinical parameters, including postoperative use of inotropic drugs and preoperative and postoperative EF. History of myocardial infarction, hyperlipidemia, diabetes mellitus, kidney disease, preoperative arrhythmias, and utilization of postoperative inotrope was the same between the three groups. The incidence of postoperative arrhythmias was not significant between the three groups. Also, there were no significant differences in preoperative and postoperative EF and the serum levels of enzymes [cTnI and CK-MB] between the groups. Based on the findings of this study, there was no significant difference in the postoperative EF between the groups. Although the incidence of arrhythmias was higher in the ischemic preconditioning group than in the other groups, the difference between the groups did not constitute statistical significance

N-acetylcysteine instead of theophylline in patients with COPD who are candidates for elective off-pump CABG surgery: is it possible in cardiovascular surgery unit?

Forced expiratory volume in one second [FEV1] is a good predictor of chronic obstructive pulmonary disease [COPD]. COPD is characterized by a chronic limitation of airflow. This study was designed to compare the effects and complications of theophylline alone, N-acetylcysteine [NAC] alone, and a combination of the two drugs on the rates of FEV1 in patients with COPD who were candidates for off-pump coronary artery bypass graft [CABG] surgery. This clinical trial was performed on 100 patients who had a smoking history of 27 pack years with a range of 20 to 40 pack years but were not heavy smokers and were candidates for elective off-pump CABG surgery in Afshar Cardiovascular Hospital, Yazd, Iran. The patients with a history of asthma and bronchospasm and non-COPD respiratory disorders were excluded. There were three groups, that is, the theophylline group [n=33] that received theophylline 10 mg/kg TDS after consumption of food, NAC group [n=33] who received NAC 10-15 mg/kg BD after consumption of food, and the combined group [n=32] who received theophylline and NAC together. Data were analyzed by analysis of variance [ANOVA], Chi-square, and exact test for quantitative and qualitative variables. One hundred patients with COPD enrolled in this study as possible candidates for CABG surgery. Average age of the patients was 60.36 +/- 10.21 years. Of the participants, 83 [83.3%] were male and 17 [17%] were female. Rate of postoperative FEV1 to basal FEV1 was 0.76 +/- 0.32, 0.66 +/- 0.22, and 0.69 +/- 0.24 in the treatments with theophylline, NAC, and the combination, respectively. Theophylline, NAC, and a combination of these drugs can decrease the rate of postoperative FEV1 compared to basal FEV1 significantly. [P=0.0001] Theophylline alone, NAC alone, and a combination of these drugs improve pulmonary function, and there are no significant differences between these protocols. Stomach discomfort and cardiac complications in treatment with theophylline alone is significantly higher than NAC alone and the combination

What is the exact predictive role of preoperative white blood cell count for new-onset atrial fibrillation following open heart surgery?

Atrial fibrillation [AF] occurs in 30% patients on the second or third day post operation; therefore, it is the most prevalent and complicated arrhythmia after open heart surgery. White blood cell [WBC] count seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate the exact relationship between preoperative WBC count and post-Coronary artery bypass graft [CABG] AF in patients with severe left ventricle [LV] dysfunction who underwent elective off-pump coronary artery bypass. This study was conducted on 104 patients from among 400 patients with severe LV dysfunction undergoing elective off-pump CABG surgery from February 2011 to February 2012, in Afshar Cardiovascular Center, Yazd, Iran. Patients with emergency surgery, unstable angina creatinine higher than 2.0 mg/dL, malignancy, or immunosuppressive disease were excluded. Preoperative serological tests of the participants, such as WBC counts, were saved in their medical dossiers. Of the 400 patients undergoing CABG, AF was found in 54 cases; these 54 male patients formed the experimental group and 60 other patients in the intensive care unit [ICU] and hospital stay without postoperative AF were part of the control group. The average age of the patients was 68.5 +/- 12.8 years. WBC counts in patients with and without AF three days before surgery were 12,340 +/- 155 and 8,950 +/- 170, respectively. On surgical day, WBC counts in the patients with and without AF were 13,188 +/- 140 and 9,145 +/- 255, respectively [P value three days before surgery: 0.04; P value on surgical day: 0.01]. Of the 54 male patients with postoperative AF [POAF], duration of AF was more in cases with elevated WBC count [12,000-14,000] than in those with lower elevated WBC count [10,000-12,000] [P=0.025], but there was no relationship between frequency of recurrence of AF and grading of elevation of WBC count [P=0.81]. These findings show that three days before surgery and on surgery day, there was a difference in WBC count between both groups. So, preoperative WBC count may predict the incidence and duration of AF; however, it cannot be a predictor of the frequency of recurrence of AF. Finally, WBC count is an independent marker for POAF and duration of AF

On pump versus off pump coronary artery bypass surgery in patients over seventy years old with triple vessels disease and severe left ventricle dysfunction: focus on early clinical outcomes

Cardiovascular disease is the leading reason of morbidity in older people. Coronary artery bypass graft [CABG] surgery is the most common type of operations in world. This study was designed to characterize comparison of early clinical outcome following on pump vs. off pump in patients over 70 years old with triple vessels disease and severe left ventricle dysfunction. 80 patients were divided into two groups: In group A [n=40] on pump CABG was performed with hypothermic cardiopulmonary bypass and cold blood cardioplegic arrest and in group B [n=40] the patients had off pump coronary artery bypass [OPCAB] surgery. Exclusion criteria included emergency or urgent operation, combined valve surgery, history of renal insufficiency [Cr >2 mg/dl], stroke. Early postoperative complications such as occurrence, duration and frequency of recurrence of atrial fibrillation were recorded. All patients underwent Holter monitoring after ICU discharge during their hospital stay. The average age of patients was 79.5 +/- 7.5 years. Post operative atrial fibrillation [POAF] occurred in 24 cases [30%]; 17 cases [42.5%] related to on pump CABG group and 7 cases [17.5%] related to OPCAB group [P=0.03]. The frequency of the recurrence of AF in the on pump group was 3.8 +/- 1.3 days and in the off pump group was 2.4 +/- 1.1 days [P=0.02]. ICU stay in on pump group was 3.6 +/- 1.80 days, while for the off pump was 2.5 +/- 0.6 days [P=0.001]. Also hospital stay duration was 8.5 +/- 2.1 days for the on pump group compared to the other group that was 6.34 +/- 1.06 days. Off pump in patients over 70 years old with triple vessels disease and severe LV dysfunction is safer than on pump and can reduce POAF, ICU and hospital stay and some early surgical complications

Immediate, short, intermediate and long-term results of balloon valvuloplasty in congenital pulmonary valve stenosis

Transluminal balloon valvuloplasty is an alternative to surgical valvotomy for congenital pulmonary valve stenosis. The aim of this study was to evaluate the long term results [to 13.5 years] of balloon pulmonary valvuloplasty. From June 1998 to January 2012, percutaneous balloon pulmonary valvuloplasty for congenital pulmonary valve stenosis was performed in 98 patients [50 males, 48 females, with a median age of 6.75 years] underwent balloon valvuloplasty of pulmonary valve stenosis. Follow-up was performed based on the Doppler echocardiographic data and clinical findings. Forty three of ninety eight patients were 10 years of age or older. The mean peak to peak pressure gradient across pulmonary valve before and immediately after balloon pulmonary valvuloplasty [BPV] was 88.7 +/- 36.4 mmHg and 21.8 +/- 15.9 mmHg [P<0.001] respectively. Doppler pressure gradient across pulmonary valve before BPV, at 3 month [short term], at 1 year [intermediate term] and long term follow-up were 93.2 +/- 41.3 mmHg, 18.7 +/- 15.8 mmHg [P<0.001], 15.8 +/- 13.1 mmHg [P0.001] and 13.6 +/- 7.4 mmHg [P<0.017] respectively. Mild pulmonary regurgitation [PR] was observed in 55 [57%] patients immediately after BPV and 30 [31%] patients at late follow up. Rupture of the right ventricular outflow tract was the major complication in two patients with fatal event. Short, intermediate and long-term results of BPV for typical valvular pulmonary stenosis are excellent. Therefore, it can be considered as treatment of choice for patients with typical valvular pulmonary stenosis

Preoperative C-reactive protein can predict early clinical outcomes following elective off-pump CABG surgery in patients with severe left ventricle dysfunction

Atrial fibrillation [AF] is the most common type of arrhythmia following elective off-pump coronary bypass graft [CABG] surgery, occurring on the 2[nd] or 3[rd] postoperative day. Postoperative atrial fibrillation and early complications may be the cause of long term morbidity and mortality after hospital discharge. High sensitive C-reactive protein [hsCRP] seems to be most significantly associated with cardiovascular disorders. This study was designed to evaluate whether preoperative hsCRP [>/=3 mg/dl] can predict post-elective off-pump CABG, AF, and early complications in patients with severe left ventricle dysfunction [Ejection Fraction [EF] < 30%]. This study was conducted on 104 patients with severe left ventriclar dysfunction [EF < 30%], undergoing elective off-pump CABG surgery during April to September 2011 at the Afshar Cardiovascular Center in Yazd, Iran. Patients undergoing emergency surgery and those with unstable angina, creatinine higher than 2.0 mg/dl, malignancy, or immunosuppressive disease were excluded from the study. The subjects were divided into two groups: Group I with preoperative increased hsCRP [> 3 mg/dl] [n=51] and group N with preoperative normal hsCRP [< 3 mg/dl] [n=53]. We evaluated post-CABG variables including incidence, duration, and frequency of AF, early morbidity [bleeding, infection, vomiting, renal and respiratory dysfunctions], ICU or hospital stay and early mortality. Data were then analyzed by Analysis of Variance [ANOVA], Chi-square and Fisher exact test for quantitative and qualitative variables. The average age of the patients was 62.5 years, 75 cases [72.1%] were male, and 39 [37.5%] were female. Postoperative AF occurred in 19 cases [18.2%]; 17 cases [33.3%] had hsCRP >/= 3 mg/dl and 2 cases [3.8%] had hsCRP 0.05]. Preoperative hsCRP >/= 3 mg/dl can predict incidence of postoperative atrial fibrillation and early complications such as midsternotomy infection, respiratory dysfunction, and hospital stay following elective off-pump CABG

effect of ondansetron and meperedin on preventing shivering after off-pump coronary artery bypass graft

One of the most common complications of operation and anesthesia is shivering. The purpose of this study was to compare the effectiveness of Ondanseton and Meperedine in preventing shivering after off pump coronary artery bypass graft [OPCAB]. In this double-blind randomized clinical trial, the sample consisted of 90 patients, who were candidates of CABG under general anesthesia. These patients were assigned to three groups, each containing 30 subjects: meperedine group [A], ondansetron group [B] and control group [C]. Group [A] received 0.4 mg/Kg/IV of meperedine, group [B] received 8mg/IV of ondansetron and group [C] received Normal Saline. All these drugs were injected 15 minutes before the end of surgery. After the end of surgery, the intubated patients were transferred to the ICU and their body temperature was assessed through eardrum by a specialist who was blind to the research. The incidence of shivering in groups A, B, and C was 46.48%, 31.18%, and 60.83%, respectively [P=<0.01]. The incidence of shivering was 64.4% in males and 35.6% in females [P=0.222]. Also, the amount of incidence of shivering up to 3 hours after surgery was 75.87% [P=0.064]. Bradycardia was 3.3% in group [A] and 0.0% in group [B]. Other variables [myoclonus, seizure and rash] showed no statistically significant difference [P=0.353]. According to the findings, it was demonstrated that ondansetron is more effective in preventing shivering after Off-pump CABG than meperedine

Clinical outcome and cost in patients with off-pump vs. on-pump coronary artery bypass surgery

General concept and major emphasis on off-pump coronary artery bypass surgery [OPCAB] is maintaining quality of care and patient safety while reducing cost and resource utilization. OPCAB probably avoids the potential complications of cardiopulmonary bypass. However its acceptance depends on clinical and economic outcome. The aim of this study is to compare clinical and economic outcome of off-pump and on pump coronary artery bypass surgery. This is a report of an analytic cross-sectional study on 304 patients underwent coronary artery bypass surgery that were randomized into conventional on pump and off-pump groups. Variables and costs were obtained for each group and these data were analyzed using parametric methods. There was no difference between the two groups with respect to perioperative and intraoperative patient's variables. OPCAB reduced the need for postoperative transfusion requirement [P<0.05] which was statistically significant and showed a trend towards reduction of morbidity although didn't reach statistical significance [P>0.05]. There were no statistically significant differences in surgical re exploration and length of stay between the two groups. The mean cost for an on pump surgery was 8312000 +/- 2859 Rials per patient that was significantly higher than an off-pump surgery. Based on the findings of this study, clinical outcome has no statistically significant difference between on pump and off-pump CABG but the costs are significantly higher in the on pump group

Effect of prophylactic low dose of methylprednisolone on postoperative new atrial fibrillation and early complications in patients with severe LV dysfunction undergoing elective off-pump coronary artery bypass surgery

Atrial fibrillation [AF] is the most common arrhythmia after cardiothoracic surgery. AF following coronary artery bypass graft [CABG] is associated with an increase in morbidity, mortality, hemodynamic instability, thromboembolic events, severity of heart failure and ICU and hospital stay. Corticosteroids have a variety of beneficial effects on recovery after elective surgery. This study was designed to test the hypothesis that low dose of Methylprednisolone [MP] can affect post-CABG AF and early complications in patients with severe left ventricle dysfunction who underwent elective off-pump coronary artery bypass. A total of 120 patients with LV dysfunction undergoing elective off- pump CABG randomly received either MP or placebo. Diabetic patients and those who were receiving corticosteroids were excluded. The MP group received 5mg/kg of MP intravenously after induction of anesthesia and the placebo group received an equal volume of normal saline. We evaluated Post-CABG variables including incidence, duration and frequency of AF recurrence and early morbidity such as bleeding, infection, vomiting, renal and respiratory dysfunctions, ICU or hospital stay and early mortality. The mean age of patients was 62.11 +/- 12.34 years with the 2.4 male to female ratio. AF occurred in 23 [19.2%] patients. No significant difference in the incidence of new AF was found between the placebo [21.7%] and MP group [16.7%] [P=0.47]. MP did not affect postoperative bleeding, infection, vomiting, renal and respiratory dysfunction and mortality; however, MP significantly reduced ICU and hospital length of stay. MP did not affect the incidence, duration and frequency of AF recurrence in patients with severe LV dysfunction undergoing off-pump CABG. However, MP could reduce ICU and hospital stay significantly in these patients

Perioperative predictors and clinical outcome in early and late ICU discharge after off-pump coronary artery bypass surgery

The duration of ICU [intensive care unit] stay in cardiac surgery patients has an important role in the rate of complications and costs. The aim of this study was to determine the role of perioperative risk factors in clinical outcome based on the time of ICU discharge. In this descriptive study, 219 patients undergoing off-pump coronary artery bypass [OPCAB] surgery in Afshar Hospital in Yazd, an Iranian city, were divided into early [24 hrs] ICU discharge groups according to the duration of ICU stay. The preoperative, intraoperative and postoperative risk factors, the complications and the outcome were evaluated. Age, sex, hyperlipidemia, diabetes mellitus, previous myocardial infarction, renal failure, cerebrovascular accident, and level of hematocrit and creatinine were not significantly different between the two groups. Patients with hemodynamic instability, respiratory dysfunction, ejection fraction <35%, hypertension, inotrope administration, left main coronary artery involvement, use of intraaortic balloon pump [IABP] and arrhythmia had significantly higher mortality and longer ICU stay [>24 hrs] compared to others [P value <0.05]. The duration of intubation was significantly lower in the early discharge group [7.8 +/- 3.8 hrs compared to 17 +/- 9.9 hrs] than in the late discharge group. Time of ICU discharge depends on perioperative risk factors, and risk factor modification may improve clinical outcome

Relation between preoperative mild increased in serum creatinine level and early outcomes after coronary artery bypass grafting

This study evaluates the effect of preoperative increased level of serum creatinine [Cr] on early outcomes after coronary artery bypass graft surgery [CABG]. 1140 patients who underwent CABG in our center were studied. Patients with Cr >2.25 mg/dl or preoperative dialysis and who had off-pump operations were excluded. Group 1 consisted of 892 patients with normal Cr [0.5-1.2 mg/dl] and group 2 consisted of 248 [21.8%] patients with mild increased level of serum Cr [1.3-2.2 mg/dl]. Patients in group 1 were younger than group 2. There were more patients with hypertension in group 2, but there were not statistically significant difference between two groups in terms of the frequency of diabetes, smoking, cerebrovascular disease and New York Heart Association [NYHA] class. Left ventricular ejection fraction [LVEF] was lower in group 2. Cardiopulmonary bypass time [CPB] was longer in group 2. Early mortality was 3.2% in group 1 and 8.4% in group 2 [P<0.001]. Prolonged ICU stay, low cardiac output, prolonged mechanical ventilation, postoperative atrial fibrillation, postoperative re-exploration and sepsis were more frequent in group 2. Mild increase in serum Cr level preoperatively is a marker of increased early mortality and outcome after CABG

Comparing effects of continuous insulin infusion with or without subcutaneous glargine insulin on glycemic control in diabetic patients undergoing coronary artery bypass graft [CABG]

Hyperglycemia is associated with increased morbidity and mortality in diabetic patients following coronary artery bypass grafting. Tight glycemic control in perioperative period can reduce these events. The goal of this study was to determine whether combination of continuous infusion and subcutaneous glargine as a basal insulin could improve glycemic control. Diabetic patients who were candidate for CABG were randomized to receive continuous insulin infusion with or without subcutaneous Glargine insulin for at least 72 hours which started 24 hours before surgery and continued for 48 hours after surgery. A total 84 subjects were required. In group A [n=45] continuous insulin infusion was used for glycemic control and in group B [n=39] we used continuous infusion with subcutaneous glargine insulin. Blood glucose level was significantly better in desirable range in group B in comparison to group A. Total mean blood glucose level in group A was 186.1 mg/dl and in group B was 174.3 mg/dl [P=0.008]. Frequency of hypoglycemia [blood glucose <70 mg/dl] was 0.66% in group A and 0.5% in group B that was similar [P=0.530]. The mean length of stay in the hospital was not different between two groups [P=0.288]. We found out that a combination of continuous insulin infusion and glargine insulin as main basal insulin can improve glycemic control in diabetic patients undergoing coronary artery bypass grafting