Evaluations of topical application of tranexamic acid on post-operative blood loss in off-pump coronary artery bypass surgery

One of the major complications of cardiac surgery is the presence of post-operative bleeding. The aim of the present study was to investigate the topical application of tranexamic acid in the pericardial cavity on post-operative bleeding in off-pump coronary artery bypass graft [CABG] surgery. This study was on 71 patients who underwent off-pump CABG. The anesthesia and surgery methods were the same for all patients. Patients were assigned to two equal groups. In the first group, 1 g of tranexamic acid in 100 mL of normal saline solution [NSS] was applied to pericardium and mediastinal cavity at the end of surgery. In the second group, only 100 mL of NSS was applied. Chest drainage of the patients after 24 h and the amounts of blood and blood products transfusion were also recorded during this time. Patients were the same regarding demographic information and surgery. The average volume of blood loss after 24 h was 366 mL for the first group and 788 mL for the control group. There was a statistically significant difference between the two groups [P < 0.001]. The amount of packed red blood cells transfusion in the first group was less than that of the control group, which was not statistically significant. There was no statistically significant difference between the amount of hemoglobin, hematocrit, platelets, prothrombin time and partial thromboplastin time in the postoperative stage in the two groups. The topical application of tranexamic acid in off-pump CABG patients leads to a decreased post-operative blood loss.

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

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

Long-term follow-up of patent ductus arteriosus closure with the Amplatzer Duct Occluder in children

Transcatheter closure of patent ductus arteriosus [PDA] has become an alternative treatment to surgery. We evaluated the long-term results of the transcatheter closure of PDA with the Amplatzer Duct Occluder [ADO] in children. Between May 2004 and October 2012, 138 children with PDA [43 males and 95 females] underwent transcatheter PDA closure. Clinical, electrocardiographic, echocardiographic, and hemodynamic data were assessed pre and postprocedurally and at follow-up. The mean age of the patients at procedure was 3.53 +/- 2.43 years [range = 1.1 to 9.5 years], mean weight was 11.9 +/- 4.6 kg [range = 6 to 29 kg], median pulmonary end diameter of the PDA was 5 mm [range = 4 to 15 mm], and median diameter of the ADO was 8 mm [range = 6 to 16 mm]. The mean follow-up time was 43.4 +/- 23.5 months [range = 13.5 to 98 months]. The devices were successfully deployed in 136 [98.5%] patients. Device embolization occurred in 2 patients, immediately in one patient and during the first postprocedural night in the other patient. The first patient had percutaneous device retrieval, followed by implantation of a larger device. The second patient had surgical device removal and PDA ligation. Immediately after device implantation, trivial to mild residual shunts were detected in 112 [80%] patients; all the shunts, however, disappeared 24 hours after the procedure. One patient had left pulmonary artery stenosis with a gradient of 25 mm Hg at 24 hours', 40 mmHg at one month's, and 64 mmHg at 6 months' follow-up. There were no cases of late embolization, aortic obstruction, late hemolysis, infective endocarditis, or death. Transcatheter PDA closure with the ADO was safe and effective, with a high success rate at long-term follow-up

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

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

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

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

Incidence of sexual dysfunction in men after cardiac surgery in Afshar hospital, Yazd

Successful rehabilitation of cardiac surgery patients should include consideration of their sexual activity, but there is paucity of data regarding this matter. This study determined the incidence and type of sexual dysfunction in our patients. Two hundred-seventy nine men with age under 70 years old who had coronary artery bypass graft [CABG], valvular, or other types of cardiac surgery from Dec. 2006 until Dec. 2007 were enrolled in this descriptive-analytical study. They were interviewed before and 12 weeks after the operation in regard to the impact of surgery on their sexuality. The statistical methods used included analysis of variance, Kappa test, and chi-square analysis. The mean age of the patients was 55.7 +/- 10.66 [25-69] years. The incidence of sexual dysfunction was 20.1% before, and 76.4%, 12 weeks after the operation. P-valueas tested by Kappa test was 0.0001, which means that cardiac surgery had adverse effect on sexual activity of the patients. Types of sexual dysfunction were impotence, premature ejaculation, and decreased or loss of libido in 6.5%, 4.3% and 9.3%, respectively before operation, and 34.8%, 21.5% and 20.1%, respectively 12 weeks after the operation. Concurrence of more than one dysfunction was not reported. Sexual dysfunction is common after cardiac surgery, and sexual counseling is still not being addressed adequately. The role and responsibility of the physician and the rehabilitation nurse becomes evident, together with the need for the patient's partner to participate in counseling

[Tracheo-innominate artery fistula as a late onset tracheotomy complication: a case report]

Tracheo-innominate artery fistula [TIF] is a rare, life threatening and catastrophic complication, which may occur 7 to 14 days after surgery. The Incidence Rate of TIF is 0.1-1% and survival rate of patient is 14.3%. Herein, we describe TIF in a patient 50 days post tracheotomy, based on our research, it appears that our case is the first finding with the latest onset of TIF after tracheotomy, which now has been improved by early diagnosis and surgical treatment

Transcatheter closure of patent ductus arteriosus using the amplatzer ductal occluder: early results and midterm follow-up

The transcatheter closure of patent ductus arteriosus has advanced rapidly with improvements in device designs. The aim of this study was to analyze the safety, efficacy, and early and intermediate follow-up results of the percutaneous closure of persistent ductus arteriosus [PDA] with the Amplatzer ductal occluder [ADO] in children. Between May 2004 and March 2007, fifty patients between 7 months and 20 years of age underwent the transcatheter closure of PDA, using the ADO. The mean PDA diameter at its narrowest segment [pulmonary end] was 7.35 +/- 2.57 mm [range: 4 to 16mm]. Follow-up evaluations were performed via echocardiography at 24 hours, and 1, 3, 6, and 12 months and then yearly after implantation. Successful immediate occlusion of PDA was achieved in 42 [84%] of the 50 cases. In 5 cases, there were trivial intraprosthetic residual shunts. In addition, there was a small residual shunt in one case, left pulmonary artery narrowing in one case, and embolization of the device immediately after the procedure in one case. At 24 hours, color Doppler flow mapping revealed complete closure in all except one case with a small shunt. At 3 months' follow-up, occlusion was complete in all the patients. At a median follow-up of 17 months [range: 3 months to 32 months], all the patients had complete closure. We conclude that although the transcatheter closure of PDA using the ADO is a highly effective and safe treatment for most patients, several complications including embolization and left pulmonary artery narrowing may occur in certain cases