Resisting Arrest: Perioperative Confirmation and Management of an Iatrogenic Aortocoronary Arteriovenous Fistula after Coronary Artery Bypass Grafting for Redo Cardiac Surgery

Although rare, iatrogenic aortocoronary arteriovenous fistulae (ACAVF) occur when a coronary graft is mistakenly anastomosed to an epicardial vein rather than its intended arterial target. Patients may be asymptomatic, demonstrate angina, dyspnea, arrhythmias, syncope, or diminished exercise capacity, and may have wide pulse pressures with evidence of coronary steal. A thorough insight into the disordered anatomy is critical to safely manage a patient for redo cardiac surgery, especially when attempting to arrest the heart. We present a case for redo cardiac surgery of an iatrogenic ACAVF confirmed perioperatively with multiple modalities and its intraoperative management.

Clinical Predictors for Mortality in adults Undergoing Thoracic Aortic Surgery Requiring Deep Hypothermic Circulatory Arrest.

This retrospective, observational study was performed on adult patients undergoing thoracic aortic surgery (ATAS) requiring standardized deep hypothermic circulatory arrest (DHCA) with following aims. (1). To determine the mortality rate after ATAS-DHCA (2). To determine univariate predictors for mortality after ATAS-DHCA (3). To determine multivariate predictors for mortality after ATAS-DHCA A total of 144 patients operated during 2000/2001 were included. The mortality rate was 11.1%. Univariate predictors for mortality after ATAS-DHCA were preoperative ejection fraction less than 40%, stroke, packed red blood cell transfusion within first 24 hours, sepsis, mediastinal re-exploration for bleeding within first 24 hours, and renal dysfunction. Multivariate predictors for mortality after ATAS-DHCA were sepsis (odds ratio 21.3:1; confidence interval 3.8-12.1;p=0.001), postoperative stroke (odds ratio 7.4:1; confidence interval 1.9-28.7;p=0.004) and mediastinal re-exploration within first 24 hours (odds ratio 7.7:1; confidence interval 1.3-45.1;p = 0.02) We conclude that mortality after ATAS-DHCA remains high. The identified multivariate predictors merit further hypothesis-driven intervention.

Bleeding and Blood Product Utilization in Adults Undergoing Elective Aortic Root Replacement: The impact of Antifibrinolytic Exposure and Aortic Root Prosthesis.

A retrospective observational study was carried out to test the hypothesis that bleeding and blood component utilization are significantly associated with aortic root replacement (ARR). The aims of the study were as follows. (1) To determine antifibrinolytic exposure (AFE) in ARR; (2) To determine mediastinal drainage within the first 24 hours after ARR; (3) To determine blood component transfusion within the first 24 hours after ARR; (4) To determine whether AFE affects bleeding and blood component transfusion for ARR; and, (5) To determine whether type of aortic root prosthesis affects bleeding and/or blood component transfusion after ARR. All adults undergoing elective ARR from 1996-2001 at the Hospital of the University of Pennsylvania were included in the study. Cohort size was 61. Average age was 49.1 years. AFE was 52%: 23.0% aminocaproic acid, and 29% aprotinin. Mediastinal drainage averaged 384 ml for the first 24 hours. Transfusion in the first 24 hours averaged <1 unit red cells, <1 unit plasma, and <16-pack of platelets. Mediastinal drainage and blood component transfusion were not significantly related to AFE or type of surgical prosthesis. Based on these findings the hypothesis is rejected. The protocol for ARR at our institution is associated with excellent haemostatic outcome, regardless of AFE or type of aortic root prosthesis. Further clinical research in haemostatic outcome after thoracic aortic surgery should be directed at more extensive aortic procedures such as aortic arch repair with deep hypothermic circulatory arrest.