Cardiothoracic Surgery in the Caribbean

Abstract Introduction: Despite being one of the main vacation destinations in the world, health care in the Caribbean faces many difficulties. The challenges involved in these islands' medical care range from low-resource institutions to lack of specialized care. In the field of thoracic and cardiac surgery, many limitations exist, and these include the lack of access to cardiac surgery for many small islands and little governmental funding for minimally invasive approaches in thoracic surgery. Methods: Literature review was done using PubMed/MEDLINE and Google Scholar databases to identify articles describing the characteristics of thoracic and cardiac surgery departments on Caribbean islands. Articles on the history, current states of practice, and advances in cardiothoracic surgery in the Caribbean were reviewed. Results: Regardless of the middle to high-income profile of the Caribbean, there are significant differences in the speed of technological growth in cardiothoracic surgery from island to island, as well as disparities between the quality of care and resources. Many islands struggle to advance the field of cardiothoracic surgery both through lack of local cardiac surgery centers and limited financial funding for minimally invasive thoracic surgery. Conclusions: Cardiac and thoracic surgery in the Caribbean depend not only on the support from local government policies and proper distribution of healthcare budgets, but efforts by the surgeons themselves to change and improve institutional cultures. Although resource availability still remains a challenge, the Caribbean remains an important region that deserves special attention with regard to the unmet needs for long-term sustainability of chest surgery.

Perioperative central venous oxygen saturation and its correlation with mortality during cardiac surgery: an observational prospective study / Correlação entre saturação venosa central de oxigênio perioperatória e mortalidade em cirurgia cardíaca: estudo prospectivo observacional

Abstract Background: Cardiac surgery can produce persistent deficit in the ratio of Oxygen Delivery (DO2) to Oxygen Consumption (VO2). Central venous oxygen Saturation (ScvO2) is an accessible and indirect measure of DO2/VO2 ratio. Objective: To monitor perioperative ScvO2 and assess its correlation with mortality during cardiac surgery. Methods: This prospective observational study evaluated 273 patients undergoing cardiac surgery. Blood gas samples were collected to measure ScvO2 at three time points: T0 (after anesthetic induction), T1 (end of surgery), and T2 (24 hours after surgery). The patients were divided into two groups (survivors and nonsurvivors). The following outcomes were analyzed: intrahospital mortality, length of Intensive Care Unit (ICU) and hospital stay (LOS), and variation in ScvO2. Results: Of the 273 patients, 251 (92%) survived and 22 (8%) did not. There was a significant perioperative reduction of ScvO2 in both survivors (T0 = 78% ± 8.1%, T1 = 75.4% ± 7.5%, and T2 = 68.5% ± 9%; p< 0.001) and nonsurvivors (T0 = 74.4% ± 8.7%, T1 = 75.4% ± 7.7%, and T2 = 66.7% ± 13.1%; p < 0.001). At T0, the percentage of patients with ScvO2< 70% was greater in the nonsurvivor group (31.8% vs. 13.1%; p= 0.046) and the multiple logistic regression showed that ScvO2 is an independent risk factor associated with death, OR = 2.94 (95% CI 1.10−7.89) (p= 0.032). The length of ICU and LOS were 3.6 ± 3.1 and 7.4 ± 6.0 days respectively and was not significantly associated with ScvO2. Conclusions: Early intraoperative ScvO2 < 70% indicated a higher risk of death. A perioperative reduction of ScvO2 was observed in patients undergoing cardiac surgery, with high intraoperative and lower postoperative levels.

Resumo Justificativa: A cirurgia cardíaca pode produzir déficit persistente na razão entre oferta de oxigênio (DO2) e consumo de oxigênio (VO2). A Saturação venosa central de Oxigênio (SvcO2) é uma medida acessível e indireta da razão DO2/VO2. Objetivo: Monitorar a SvcO2 perioperatória e avaliar sua correlação com a mortalidade em cirurgia cardíaca. Método: Este estudo observacional prospectivo avaliou 273 pacientes submetidos a cirurgia cardíaca. Coletamos amostras de sangue para medir a SvcO2 em três momentos: T0 (após indução anestésica), T1 (final da cirurgia) e T2 (24 horas após a cirurgia). Os pacientes foram divididos em dois grupos (sobreviventes e não sobreviventes). Os seguintes desfechos foram analisados: mortalidade intra-hospitalar, tempo de permanência na Unidade de Terapia Intensiva (UTI) e de internação hospitalar, e variação na SvcO2. Resultados: Dos 273 pacientes, 251 (92%) sobreviveram e 22 (8%) não. Houve queda significante da SvcO2 perioperatória nos sobreviventes (T0 = 78% ± 8,1%, T1 = 75,4% ± 7,5% e T2 = 68,5% ± 9%; p< 0,001) e nos não sobreviventes (T0 = 74,4% ± 8,7%, T1 = 75,4% ± 7,7% e T2 = 66,7% ± 13,1%; p< 0,001). No T0, a porcentagem de pacientes com SvcO2< 70% foi maior no grupo não sobrevivente (31,8% vs. 13,1%; p = 0,046) e a regressão logística múltipla mostrou que a SvcO2 é um fator de risco independente associado ao óbito, OR = 2,94 (95% IC 1,10 − 7,89) (p = 0,032). O tempo de permanência na UTI e de hospitalização foi de 3,6 ± 3,1 e 7,4 ± 6,0 dias, respectivamente, e não foi significantemente associado à SvcO2. Conclusões: Valores precoces de SvcO2 intraoperatória < 70% indicaram maior risco de óbito em pacientes submetidos à cirurgia cardíaca. Observamos redução perioperatória da SvcO2, com altos níveis no intraoperatório e mais baixos no pós-operatório.

Implantación de stent en drenaje venoso anómalo supracardiaco obstructivo / Stent implantation in obstructive supracardiac anomalous drainage

Resumen El drenaje venoso anómalo pulmonar total representa un grupo de defectos cardíacos congénitos con baja incidencia pero alto potencial de complicaciones. Se expone el caso de una lactante menor de bajo peso al nacer, con drenaje venoso anómalo pulmonar total obstructivo, programada para implante de stent en vena vertical y posterior cirugía correctiva, evidenciando obstrucción residual mínima en la llegada de la vena pulmonar derecha y reducido tamaño auricular izquierdo, con prolongada estancia en cuidado intensivo secundaria a dificultad para el destete de la ventilación mecánica debido a edema venocapilar. Este caso demostró que la intervención endovascular es una opción en neonatos de alto riesgo con drenaje venoso anómalo pulmonar total obstructivo como parte de la estrategia de estabilización cardiovascular preoperatoria; la cirugía correctiva debe considerarse una vez las condiciones clínicas lo permitan, con el objetivo de minimizar la morbilidad asociada al compromiso de la distensibilidad de las cavidades izquierdas.

Abstract Total anomalous pulmonary venous return is a group of congenital cardiac defects. They have a low incidence but a high potential for complication. The case is presented of a young infant of low birthweight, with total obstructive anomalous pulmonary venous return, scheduled for a stent implant in a vertical vein, and subsequent corrective surgey. This showed evidence of a minimal residual obstruction on reaching the right pulmonary vein, and a reduced left atrial size. She had a long stay in intensive care secondary to difficulty in weaning off mechanical ventilation due to the presence of venous-capillary edema. This case demonstrates that endovascualr intervention is an option in high risk infants with a total obstructive anomalous pulmonary venous return as part of the strategy of pre-operative cardiovascular stabilisation. Corrective surgery should be considered when the clinical conditions permit it, with the aim of minimising the morbidity associated with the compromise of the distensibility of the left cavities.

Necessity of Bone Wax Stanching Bleeding at Sternal Edge in Patients With Cardiac Surgery by Median Sternotomy / 中国循环杂志

Objective: To explore the necessity for application of bone wax stanching bleeding at sternal edge in cardiac surgery by median sternotomy. Methods: A total of 445 patients who receive cardiac surgery by the same surgeon performing median sternotomy in our hospital from 2011-01 to 2014-12 were studied. According to application of bone wax stanching bleeding, the patients were divided into 2 groups: Bone wax group,n=210 and Non-bone wax group,n=235. Re-thoracotomy for hemostasis, 12 h, 24 h and total draining volume after the operation and time of closing incision were compared between 2 groups. Results: There were 2 patients and 1 patient received re-thoracotomy for hemostasis in Bone wax group and Non-bone wax group respectively, which was not related to bone marrow cavity bleeding. In Bone wax group and Non-bone wax group, the draining volume at 12 h post-operation were (451 ± 240) ml vs (483 ± 238) ml, at 24 h post-operation were (615 ± 304) ml vs (639 ± 285) ml and the total volume were (842 ± 467) ml vs (842 ± 364) ml, allP>0.05; the time of closing incision were (68.0 ± 23.0 ) min vs (66.0 ± 19.0 ) min,P>0.05; the total transfusion rates were 21% vs 19%,P>0.05. Conclusion: Application of bone wax at sternum edge could neither affecting the drainage nor the speed of closing incision in cardiac surgery and therefore, it might be given up.

Factors associated with blood transfusion in the postoperative period of cardiac surgery / Fatores associados à transfusão sanguínea no período pós-operatório de cirurgia cardíaca

This study aims to identify the factors associated with blood transfusion in the postoperative period of cardiac surgery, and the predominant types of blood products used. Analytical and retrospective study carried out in a large teaching hospital located in Uberaba, Minas Gerais, Brazil. Data were collected from 460 medical records of patients who underwent cardiac surgery between July 2005 and July 2010. There were 290 (63%) patients received blood transfusions in the intra- and/or postoperative period. The mean age was 57.9 years; 59.6% were male; 74.8% presented with systemic arterial hypertension as a comorbidity; and 97.2% of the surgeries were elective, with myocardial revascularization being the most prevalent type of surgery. In the intraoperative period, 75 (25.9%) patients received blood transfusions, and in the postoperative period 273 (94.1%) patients received blood transfusions, with red blood cell concentrate being the predominant type of blood product used. There was a statistically significant association between postoperative blood transfusion and the variables age group, complications and intraoperative blood transfusion. Blood transfusion remains a frequent procedure in cardiac surgeries, and age group, complications and intraoperative blood transfusion were independent predictors for postoperative blood transfusion.

Este estudo tem por objetivo identificar os fatores associados à transfusão sanguínea no pósoperatório de cirurgia cardíaca e os tipos predominantes de produtos hemocomponentes utilizados. Estudo analítico e retrospectivo realizado em um hospital de grande porte, de ensino localizado em Uberaba, Minas Gerais, Brasil. Os dados foram coletados a partir de 460 prontuários de pacientes submetidos à cirurgia cardíaca entre julho de 2005 e julho de 2010. Foram 290 (63%) pacientes que receberam transfusões de sangue no período intra e ou pós-operatório. A idade média foi 57,9 anos; 59,6% eram do sexo masculino; 74,8% apresentavam hipertensão arterial sistêmica como comorbidade; e 97,2% das cirurgias foram eletivas, com revascularização do miocárdio sendo o tipo de cirurgia mais prevalente. No intra-operatório, 75 (25,9%) pacientes receberam transfusões sanguínea, e no pós-operatório 273 (94,1%) receberam transfusões sanguínea com concentrado de glóbulos vermelhos e foi o produto predominantemente utilzado. Houve uma associação estatisticamente significativa entre transfusão sanguínea no pós-operatório e as variáveis faixa etária, transfusão sanguínea e complicações intra-operatória. A transfusão sanguínea continua a ser um procedimento frequente em cirurgias cardíacas, e faixa etária, complicações e transfusão de sangue intra-operatória foram preditores independentes para ocorrência de transfusão sanguínea no pós-operatório.

Clinical study of Coronary artery bypass grafting in the elderly / 中国基层医药

Objective To explore the characteristics of operation,curative effects and operative management in elderly patients of age older than 70 years with coronary heart disease receiving coronary artery bypass grafting.Methods 108 elderly patients of age older than 70 years with coronary heart disease were divided into two groups:OPCAB group(n = 76) and CCABG group (n = 32) The clinical curative effects, early postoperative mortality and complications of the two groups were compared and analyzed respectively. Results OPCAB group was better than CCABG group in these series(P ＜ 0.05): The early postoperative mortality (5.8%, 11.2%)、 myocardial infarction (2.9%, 10.6%), respiration failure(8.7%, 17.5%), pulmonary complications: (11.8%, 31.5%) 、complication of CNS:(1.8% ,9.8%) 、acute renal failure(1.8% ,6.2%) ,the time of intubation: (9.3 ±4.5), (25.4 ±7.5) h,ICU stay(3.1 ± 1.8) ,(7.1 ±2.9) d,hospital stay(15.5 ±8.6) ,(26.4 ±8.6)d. Conclusion OPCAB could reduce operative mortality and complication, it should be the first option for the surgery of elder patients with coronary heart disease;surgical skills and correct perioperative management were the key factors to assure surgical outcome.

Comparion between transcatheter and surgical closure of secondum atrial septal defect over 50 years of age / 中国介入心脏病学杂志

Objective To compare the safety and recent efficacy between transcatheter and surgical closure of secondum atrial septal defect over 50 years of age. Methods Retrospective analysis was done on 66 patients over 50 years of age who underwent transcatheter (30 cases) and surgical (36 cases) closure of secondum atrial septal defect.The median age was 60.8?7.1 years old in the transcatheter closure group and (57.5?6.3) years old in the surgical closure group( P=0.04).The median sizes of atrial septal defect in the transcatheter and the surgical closure group were 24.9?7.2 mm and 30.4?11.0 mm respectively (P=0.02). We compared the recent efficacy、 complications and prognosis between two groups. Results The instant procedural success rate was 93.3% for the transcatheter closure group and 100% for the surgical group (P=0.85). 2 procedures in the transcatheter closure group failed, 1 patient (2.6%) in the surgical group died during hospitalization and 9 patients (25.0%) underwent Devage tricuspid annuloplasty. Newly onset atrial arrhythmias occurred in 3.3% in the transcatheter closure group and 22.2% in the surgical closure group (P=0.03). After the procedures, right atrial and ventricular dimensions were decreased from 38.0?9.0 mm to 35.2?10.1 mm and from 44.2?8.6 mm to 36.2?9.0 mm in the transcatheter closure group whereas in the surgial group, the atrial and ventricular sizes fell from 44.1?8.2 mm to 38.2?9.5 mm and 49.0?10.2 mm to 37.1?11.0 mm respectively (P

The “edge to edge” technique: the treatment of mitral regurgitation caused by Barlow's disease / 中华胸心血管外科杂志

0.05). Follow-up of 14 patients was from 1 to 60 months (the mean value is 26. 8 months). There was no late death and re-operation. The average mitral annulus area is (3.00?0.57) cm~2. The transmitral pressure gradient decreased from (8.13?4.49) mmHg to (6.25?3.82) mmHg after operation (P=0.050). There were eight cases with minimal reflux and 6 cases with slight reflux. In all patients, the heart function returned to NYHA I～II grade. Conclusion The “edge-to-edge” technique is a feasible and effective operation for treatment of the mitral regurgitation caused by Barlow's disease.

The repair of Ebstein's anomaly with ventricular unloading / 中华胸心血管外科杂志

Objective To summarize experiences in surgical treatments of 18 patients suffered from Ebstein's anomaly with intracardiac repair and bi-directional cavopulmonary shunt from January 1999 to June 2003. Methods Of 18 patients, 10 male (55.6%) and 8 female (44.4%), mean age was (18.47?13.85) years old (range from 9 months～54 years old),and mean weight of body (36.09?19.78) kg (range from 8.5～80.0 kg). All patients were in type II of Ebstein's anomaly according to WANG (Zenwei's) classification, while 15 (83.3%) were in type B, and 3 (16.7%) in type C according to Carpentier's classification. Danielson repair of Ebstein's malformation and other intracardiac repair were performed on all patients, followed by bi-directional cavopulmonary anastomosis, on pump with heart beating. Results There was no death, and no severe heart dysfunction and refractory low cardiac output in all patients postoperatively. No reoperation for residual or recurrent tricuspid incompetence was required in all patients. At follow-up of 13 (72.2%) patients ranging from 1 to 53 months, 12 patients were in New York Heart Association ((NYHA)) class I, 1 in class II. Four were with 1 grade, 2 with 2 grades tricuspid regurgitation. The patency of bi-directional cavopulmonary anastomoses was verified by echocardiography. Conclusion Ventricular unloading added to intracardiac repair appears to be effective to improve left and right ventricular function and tricuspid valve performance in Ebstein's anomaly with moderate or massive tricuspid dysfunction and physiological right ventricular outlet tract obstruction.

Central aorto-pulmonary shunts in the tetralogy of Fallot / 中华胸心血管外科杂志

Objective To evaluate the surgical results of central aorto-pulmonary shunts in the tetralogy of Fallot. Methods Between January 1998 and December 2003, 24 patients with tetralogy of Fallot, 16 males and 8 females, with age from 7 months to 19 years [mean (5.3?4.6) years] and weight from 6.5 kg to 45.0 kg [mean (16.9?9.7)kg], were studied. Central aorto-pulmonary shunts were performed with Teflon artificial blood vessels in 10 cases and varicosity Teflon artificial blood vessels (Gore-Tex) in 14 cases. The diameter of these vessels was 3 mm to 6 mm. Results Ideal pulmonary flow in each patient was obtained. The mean SaO 2 stepped up from 0.67?0.09 to 0.93?0.04 after operation (P