Determinants of longer duration of endotracheal intubation after adult cardiac operations.

BACKGROUND: Poor pulmonary reserve is a risk factor that is used to exclude some patients from major operations. However, the value of routine spirometry in patients undergoing cardiac operations has not been widely evaluated. METHODS: The outcomes of 586 consecutive adult patients undergoing cardiac operations were reviewed retrospectively to assess predictors of longer duration of endotracheal intubation. RESULTS: By univariate analysis, congestive failure (p < 0.001), cardiomegaly (p = 0.002), recent myocardial infarction (p = 0.039), priority of operation (p = 0.005), previous cardiac operation (p < 0.001), and renal insufficiency (p = 0.002) increased the risk of longer endotracheal intubation. Spirometry (forced vital capacity, forced expiratory volume at 1 second, the ratio of forced expiratory volume at 1 second to forced vital capacity) did not correlate with longer endotracheal intubation. Perioperative complications, such as myocardial infarction (p < 0.001), coma, reexploration for bleeding, and reduced cardiac output (p < 0.001 each), correlated with longer duration of intubation. By multiple regression, priority of operation (p = 0.03), congestive failure (p = 0.02), and previous cardiac operation (p = 0.005) among preoperative risks and bleeding, reduced cardiac output, stroke, coma, and MB fraction of creatine kinase released postoperatively (p < 0.001 each) predicted longer duration of endotracheal intubation. CONCLUSIONS: Postoperative cardiac function and the occurrence of complications are more significant than preoperative pulmonary function in determining the duration of endotracheal intubation after cardiac operation. Routine spirometry is probably unnecessary for most adult cardiac patients.

Surgical management of complete atrioventricular septal defects. A twenty-year experience.

Creation of a competent left atrioventricular valve is a cornerstone in surgical repair of complete atrioventricular septal defects. To identify risk factors for mortality and failure of left atrioventricular valve repair and to determine the impact of cleft closure on postoperative atrioventricular valve function, we retrospectively analyzed hospital records of 203 patients between January 1974 and January 1995. Overall early mortality was 7.9%. Operative mortality decreased significantly over the period of the study from 19% (4/21) before 1980 to 3% (2/67) after 1990 (p = 0.03). Ten-year survival including operative mortality was 91.3% +/- 0.004% (95% confidence limit): all survivors are in New York Heart Association class I or II. Preoperative atrioventricular valve regurgitation was assessed in 203 patients by angiography or echocardiography and was trivial or mild in 103 (52%), moderate in 82 (41%), and severe in 18 (8%). Left atrioventricular valve cleft was closed in 93% (189/203) but left alone when valve leaflet tissue was inadequate and closure of the cleft might cause significant stenosis. Reoperation for severe postoperative left atrioventricular valve regurgitation was necessary in eight patients, five of whom initially did not have closure of the cleft and three of whom had cleft closure. Six patients had reoperation with annuloplasty and two patients required left atrioventricular valve replacement. Five patients survived reoperation and are currently in New York Heart Association class I or II. On most recent evaluation assessed by angiography or echocardiography (a mean of 59 months after repair), left atrioventricular valve regurgitation was trivial or mild in 137 of the 146 survivors (94%) examined; none had moderate or severe left atrioventricular valve stenosis. By multiple logistic regression analysis, strong risk factors for early death and need for reoperation included postoperative pulmonary hypertensive crisis, immediate postoperative severe left atrioventricular valve regurgitation, and double-orifice left atrioventricular valve. These results indicate that complete atrioventricular septal defects can be repaired with low mortality and good intermediate to long-term results. Routine approximation of the cleft is safe and has a low incidence of reoperation for left atrioventricular valve regurgitation.