The development of cardiac surgery in an emerging country: a completed project.

The necessity to develop cardiac surgery centers in the emerging world is widely accepted. Numerous groups and organizations from the developed world are involved in such work; however, the best method in which to develop a sustainable center in the emerging world is still debated. Herein, we present an approach that we have used in several such projects, which involves regular and frequent instructional visits with progressive reduction of our instructional support. Data to support our approach are presented.

Combined surgical and endovascular treatment of aortic type A dissection.

PURPOSE: We describe a combined approach for treatment of a type A aortic dissection with surgical repair of the ascending aorta and transluminal stenting of the descending aorta, therefore minimizing the consequences on the untreated aortic arch and descending aorta. DESCRIPTION: From December 2002 to June 2003, 5 consecutive patients (4 men, 1 woman) suffering from type A aortic dissection were treated with resection of the ascending aorta or aortic hemi-arch. Before the open distal aortic anastomosis the Endofit endovascular graft (Endomed Inc, Phoenix, AZ), was deployed under direct vision distally to the origin of the left subclavian artery. EVALUATION: Intraoperative stent graft placement was successful in all patients. There was no hospital mortality. Early results were satisfactory with a completely thrombosed false lumen in 2 patients and a partially thrombosed false lumen in 3 patients, 10 days after operation. Follow-up computed tomographic scan showed a completely thrombosed false lumen in 4 patients and a partially thrombosed false lumen in 1 patient. CONCLUSIONS: This study shows that combined surgical and endovascular treatment of acute type A dissection is a feasible option, but further evaluation is necessary.

Pseudovasculitis and corticosteroid therapy.

Pseudovasculitis, vasculitis-like syndromes, vasculitis look-alikes, or mimics of vasculitis represent a heterogeneous collection of disorders that are capable of simulating vasculitis. Inappropriate diagnosis leads to delay or absence of proper management and exposure to potentially deleterious treatment modalities such as corticosteroids and cytotoxic agents. We report the case of fibromuscular dysplasia suspected to be a polyarteritis nodosa. The progression of the lesions visualized by the ultrasonographic study and computed tomography (CT) scan after 10 days of treatment led to an emergency laparotomy. The possible deleterious role of steroids given to treat the suspected vasculitis is discussed.

Opening of a new postanesthesia care unit: impact on critical care utilization and complications following major vascular and thoracic surgery.

STUDY OBJECTIVES: To assess the impact of a new postanesthesia care unit (PACU) on intensive care unit (ICU) utilization, hospital length of stay, and complications following major noncardiac surgery. DESIGN: Observational study. SETTING: University hospital. PATIENTS AND MEASUREMENTS: From 1992 to 1999, 915 patients underwent either abdominal aortic reconstruction (n = 448) or lung resection for cancer (n = 467). Demographic, clinical, surgical, and anesthetic data, as well as perioperative complications, were abstracted from two institutional databases. INTERVENTIONS: Patients were divided in two study periods, before and after the opening of a new PACU (period 1992-1995 and period 1996-1999). MAIN RESULTS: Utilization of ICU decreased from 35% to 16% for vascular patients and from 57% to less than 4% for thoracic patients during the second period. Readmission to the ICU, perioperative mortality, and respiratory complications were comparable between the two periods. Patients with congestive heart failure, chronic obstructive pulmonary disease, or renal insufficiency were more likely to be admitted to the ICU than the PACU. Following vascular surgery the frequency of cardiac complications decreased from 10.6% in 1992-1995 to 5.2% in 1996-1999 (p < 0.005), as well as the need for postoperative mechanical ventilation (25% vs. 12%; P < 0.05). CONCLUSIONS: Increased availability of PACU beds resulted in reduced utilization of ICU resources without compromising patient care after major noncardiac surgery.

The impact of a cardioprotective protocol on the incidence of cardiac complications after aortic abdominal surgery.

UNLABELLED: We analyzed a local database including 468 consecutive patients who underwent elective aortic abdominal surgery over an 8-yr period in a single institution. A new cardioprotective perioperative protocol was introduced in January 1997, and we questioned whether perioperative cardiac outcome could be favorably influenced by the application of a stepwise cardiovascular evaluation based on the American College of Cardiology/American Heart Association guidelines and by the use of antiadrenergic drugs. Clonidine was administered during surgery, and beta-blockers were titrated after surgery to achieve heart rates less than 80 bpm. We compared data of two consecutive 4-yr periods (1993-1996 [control period] versus 1997-2000 [intervention period]). Implementation of American College of Cardiology/American Heart Association guidelines was associated with increased preoperative myocardial scanning (44.3% vs 20.6%; P < 0.05) and coronary revascularization (7.7% vs 0.8%; P < 0.05). During the intervention period, there was a significant decrease in the incidence of cardiac complications (from 11.3% to 4.5%) and an increase in event-free survival at 1 yr after surgery (from 91.3% to 98.2%). Multivariate regression analysis showed that the combined administration of clonidine and beta-blockers was associated with a decreased risk of cardiovascular events (odds ratio, 0.3; 95% confidence interval, 0.1-0.8), whereas major bleeding, renal insufficiency, and chronic obstructive pulmonary disease were predictive of cardiac complications. In conclusion, cardiac testing was helpful to identify a small subset of high-risk patients who might benefit from coronary revascularization. Sequential and selective antiadrenergic treatments were associated with improved postoperative cardiac outcome. IMPLICATIONS: Implementation of American College of Cardiology/American Heart Association guidelines and use of antiadrenergic drugs were associated with better cardiac outcomes after major vascular surgery.