Transcaval migration of an acupuncture needle from the abdominal cavity to the heart.

We report the case of a patient who was noted to have inserted an acupuncture needle into his abdomen. The needle migrated to the heart and was removed from the right ventricle using cardiopulmonary bypass.

Have improvements in myocardial protection influenced a surgeon's choice of coronary artery bypass surgery?

The aim of this study is to determine whether improvements in myocardial protection strategy have influenced the surgeon's choice of coronary artery bypass surgery. Between February 2002 and April 2009, a total of 662 patients underwent coronary artery bypass surgery under the provision of a single consultant surgeon. Operative mortality was defined as in-hospital death and comparison was made based on both the observed and expected mortalities as derived from the logistic EuroSCORE. Of the 662 patients who underwent cardiac surgery, 155 had off-pump whilst 507 had conventional coronary artery bypass surgery. The observed mortalities improved over the years in line with the improvements in myocardial protection strategy despite the increasing risk as predicted by the logistic EuroSCORE, with a reduction in the ratio of observed to expected mortalities of 1.2 in the off-pump group to 0.4 in the conventional group who had better myocardial protection. This has lead to a change in practice being predominantly off-pump at the beginning to that of conventional surgery in the later part of the study. As the case mix of patients gets worse with the increasing severity of multi-vessel disease and poor ventricular function, myocardial protection becomes crucial to the surgeon's preoperative assessment.

Long term results and functional outcomes following cardiac surgery in octogenarians.

OBJECTIVE: Cardiac surgery for patients >80 years has seen a dramatic increase in the last decade. The aim was to assess the long term survival and quality of life in this patient population. METHOD: Patients who underwent cardiac surgery between 1995 and 2007 were identified and case notes reviewed. Follow-up was undertaken by personal interview with the patient or the nearest kin to complete a pre-planned questionnaire. RESULTS: Sixty six (M:F; 45:21) octogenarians had Coronary artery bypass grafting (CABG) only (55%), Aortic valve replacement (AVR) only (12%), Mitral valve replacement (MVR) only (3%), Valve and CABG (25%) and complex procedures (5%). Fifty-eight percent were elective procedures. Operative mortality was 8% (n = 5). Multivariate analysis identified complex procedures, prolonged bypass time and re-do/emergency surgery as predictors of death (p < 0.05). Median Intensive care unit (ICU) stay was 206 h (range 43-1176 h), with >70% leaving ICU in 72 h. Late mortality involved five patients (8%) who died at 10 yr; 7 yr; 3 yr; 1 yr; and 8 months; and 2 yr and 7 months, respectively. Survival by Kaplan-Meir was 8.8 yr (Standard Error (SE) = 0.66, Confidence interval (CI) 7.6-10.1), median survival was 10 yr and mean Barthel's index 17.7 (min 0, max 20). CONCLUSIONS: Cardiac surgery can be accomplished in octogenarians with good long-term survival and quality of life. However, complex procedures, prolonged bypass and re-do/emergency surgery contribute significantly to mortality.

Benefits of the preemptive intra-aortic balloon pump: an audit of practice in a regional cardiothoracic center.

BACKGROUND: Recent evidence suggests that preemptive use of an intra-aortic balloon pump (IABP) is associated with better outcomes in high-risk patients undergoing cardiac surgery. This retrospective study compares preemptive (planned) use of the IABP to emergency (unplanned) use in a regional cardiothoracic center. METHODS: All patients who required an IABP from February 2003 to June 2006 were identified from theater records. The collected data included patient demographics, preoperative state, operative details, morbidity due to the IABP, and operative mortality. Patients were divided into 2 groups: planned use (preoperative plus elective intraoperative) and unplanned use (postoperative plus emergency intraoperative). Preoperative mortality risk was calculated with the logistic EuroSCORE. RESULTS: We identified 135 patients (75% male). There were no significant differences between the groups with respect to age, preoperative state, operation type, logistic EuroSCORE, or myocardial ischemia time. The 2 groups showed a significant difference in mortality: planned IABP insertion, 17%; unplanned insertion, 45% (P = .001). A multivariate analysis of the study population showed the logistic EuroSCORE (odds ratio, 0.974; 95% confidence interval, 0.950-0.998; P = .035) and timing of IABP use (odds ratio, 4.728; 95% confidence interval, 1.932-11.566; P = .001) to be independent predictors of mortality. CONCLUSION: Preemptive use of the IABP in this patient cohort was associated with a 50% advantage in mortality compared with emergency IABP use. The logistic EuroSCORE may be used preoperatively to guide IABP use. Complications are rare and can be treated successfully. The risk-to-benefit ratio of preemptive IABP use is low in this cohort of patients.

Myocardial revascularization by off pump coronary bypass surgery (OPCABG): a ten year review.

BACKGROUND: The use of cardiopulmonary bypass (CPB) may contribute to post-operative complications and organ dysfunction. Off pump coronary artery bypass grafting (OPCABG) avoids the use of CPB and hence is proposed to reduce these complications. We present the results of OPCABG in Northern Ireland over ten years. METHODS: Data was collected retrospectively from 1995 to 2005. Follow-up was done by telephonic questionnaire and from medical records within a closing interval of two months. RESULTS: 324 patients (224 male) underwent OPCABG with a median age of 62 years (range 35 to 79 years). There were 149 patients with CCS class III/IV angina and 48 with NYHA class III/IV. 148 patients had suffered a myocardial infarction in the past. 36 patients had a pre-operative predictive mortality score (EuroSCORE) of >5 and 48 patients had a preoperative LVEF of <30%. 585 bypass grafts were constructed (LAD=260, Diagonal=27, LCX/OM=123, RCA/PDA=103, RCA/PLV=72). Four patients needed to be converted from OPCABG to CPB on table. Another four patients needed re-operation due to graft related problems in the post-operative period and 6 needed post-operative Intra-aortic Balloon Pump (IABP) support. Post-operative complications included 3 TIAs, 1 complete stroke, 9 patients with renal failure and 51 patients developed atrial fibrillation post operatively. There was one peri-operative death due to pulmonary edema. Ninety percent of patients were in CCS angina class I/II and NYHA class I/II post-operatively. Forty one patients developed significant recurrence of angina requiring medical management, with 7 patients needing PCI/stenting. At the time of follow-up (median 5 years, range 3 months to 10 years) 9 patients had died. CONCLUSIONS: Off pump coronary artery bypass (OPCABG) can be achieved with a low mortality and good medium to long term survival. OPCABG is associated with fewer post-op complications and comparable late coronary interventions.

Complete mechanical circulatory support using ventricular assist devices for post-cardiotomy biventricular failure.

Cardiopulmonary bypass (CPB) allows operations on the heart in a motionless and bloodless field while reducing cardiac workload and sustaining systemic and coronary perfusion. Failure to wean from CPB remains a significant problem. Results from recent large registry data have shown dramatic improvement in the survival following ventricular assistance for post cardiotomy failure if instituted early. We show how post-cardiotomy heart failure can be successfully treated by proactive use of biventricular assist devices (BIVAD).

Patients with Klippel-Feil syndrome should have imaging of the subclavian artery and its branches prior to coronary artery bypass grafting.

Patients with Klippel-Feil syndrome have increased incidence of subclavian artery anomalies. We report a case of a patient with this syndrome undergoing coronary artery bypass grafting. Intra-operatively, the patient was found to have the left internal mammary artery arising from the second intercostal space and the decision was taken to use it as a free graft. As other anomalies of the subclavian arteries and their branches are recognised in patients with Klippel-Feil syndrome, we propose that imaging of the internal mammary arteries is carried out pre-operatively in such patients to assess the suitability for use as conduit in coronary artery bypass grafting.

Cell salvage alters the systemic inflammatory response after off-pump coronary artery bypass grafting surgery.

BACKGROUND: Retransfused cardiotomy suction blood contains elevated inflammatory markers and is a bypass independent source of inflammatory mediators. We hypothesized that, during off-pump coronary artery bypass (OPCAB) grafting surgery, avoiding retransfusion of unwashed cardiotomy suction blood would beneficially alter both urinary and plasma cytokine concentrations and be renoprotective. METHODS: Thirty-seven OPCAB surgery patients were randomly allocated to control (retransfusion of unwashed shed blood) and treatment (retransfusion of washed shed blood or discarding of unwashed blood) groups. Over 72 hours we measured plasma (tumor necrosis factor-alpha [TNF-alpha], interleukin-8, interleukin-6, interleukin-10, TNF soluble receptor-2, and interleukin-1 receptor antagonist) and urinary TNF soluble receptor-2 and interleukin-1 receptor antagonist and markers of renal injury and dysfunction (N-acetyl beta D glucosaminidase and alpha1-microglobulin). RESULTS: We demonstrated elevated proinflammatory cytokines in cardiotomy suction blood, which were effectively eliminated by cell salvage. After retransfusion, in comparison with controls, the treatment group had reduced plasma TNF soluble receptor-2. As compared with controls, treatment group patients also demonstrated significantly reduced levels of the urinary anti-inflammatory cytokine TNF soluble receptor-2. There were no between group differences in markers of renal injury or dysfunction. CONCLUSIONS: We have demonstrated that the management of shed mediastinal blood alters perioperative, systemic, plasma and urinary cytokine homeostasis at OPCAB surgery but does not impact on subclinical renal injury or dysfunction in this low risk group of patients.

Management of a catheter-induced pulmonary artery rupture: early presentation after off-pump coronary artery bypass surgery.

A frail, 79-year-old woman with small body habitus was admitted for elective coronary artery bypass surgery. She was known to have long-standing chronic stable angina with recent deterioration. Her only risk factor for coronary artery disease was that she was an ex-smoker of 6 years.

The influence of prosthesis size and design on exercise dynamics after aortic valve replacement.

BACKGROUND AND AIM OF THE STUDY: Residual gradient following aortic valve replacement (AVR) may adversely affect clinical outcome. The size and design of the valve may influence these characteristics. The study aim was to determine the influence of prosthesis physical size and leaflet design on hemodynamic performance after mechanical AVR. METHODS: After AVR, two patient groups with a range of valve sizes were studied. Group 1 patients (n=19) each received a monoleaflet valve; group 2 patients (n=18) each received a bileaflet valve. Transthoracic echocardiography was performed at rest and after graded bicycle ergometry to assess prosthetic valve parameters, including mean and peak transvalvular gradient and effective orifice area (EOA). RESULTS: Transprosthetic gradients (mean and peak) measured at rest, maximum exercise and 3-min recovery were related to indexed geometric orifice area (IGOA) by an exponential decay function, with no significant advantage for either valve design. However, in valve sizes < or =25 mm the bileaflet valves demonstrated lower gradients, both at rest and under exercise conditions (mean gradient during exercise, bileaflet versus monoleaflet 19.9 +/- 7.2 mmHg versus 25.6 +/- 6.3 mmHg, p = 0.01). Similarly, EOAs were larger in the bileaflet group when equivalent GOAs < or =2.5 cm2 were compared (EOA: bileaflet versus monoleaflet 1.51 +/- 0.33 cm2 versus 1.14 +/- 0.26 cm2, p = 0.018). The total work performed correlated with prosthesis diameter (r2 = 0.81, p = 0.037) and was not influenced by valve design. CONCLUSION: The hemodynamic performance of mechanical aortic valves, including transprosthetic gradient and maximum exercise work performed, related principally to the prosthesis physical size. However, within the smaller valve sizes, the bileaflet design appeared to offer hemodynamic advantages.

Acute aortic dissection following non-structural failure of a prosthetic aortic valve.

Malfunction of a prosthetic aortic valve is associated with a spectrum of potentially life threatening complications. In addition, the risk of aortic dissection increases following aortic valve replacement, which relates principally to aortic root pathology rather than prosthetic type or its functional status (Circulation 100 (1999) II-287). We report a case in which a high velocity turbulent jet in the proximal aorta, resulting from prosthetic leaflet entrapment caused intimal injury with subsequent type I dissection. This highlights the desirability for regular surveillance following aortic valve replacement, particularly in those patients with an 'at-risk' aorta.