Physical conditioning and mental stress reduction--a randomised trial in patients undergoing cardiac surgery.

BACKGROUND: Preoperative anxiety and physical unfitness have been shown to have adverse effects on recovery from cardiac surgery. This study involving cardiac surgery patients was primarily aimed at assessing the feasibility of delivering physical conditioning and stress reduction programs within the public hospital setting. Secondary aims were to evaluate the effect of these programs on quality of life (QOL), rates of postoperative atrial fibrillation (AF) and length of stay (LOS) in hospital. METHODS: Elective patients scheduled for coronary artery bypass graft and/or valve surgery at a public hospital in Melbourne, Australia were enrolled. Patients were randomized to receive either holistic therapy (HT) or usual care (UC). HT consisted of a series of light physical exercise sessions together with a mental stress reduction program administered in an outpatient setting for the first two weeks after placement on the waiting list for surgery. A self-administered SF-36 questionnaire was used to measure QOL and hospital records to collect data on LOS and rate of postoperative AF. RESULTS: The study population comprised 117 patients of whom 60 received HT and 57 received UC. Both programs were able to be delivered within the hospital setting but ongoing therapy beyond the two week duration of the program was not carried out due to long waiting periods and insufficient resources. HT, as delivered in this study, compared to UC did not result in significant changes in QOL, LOS or AF incidence. CONCLUSIONS: Preoperative holistic therapy can be delivered in the hospital setting, although two weeks is insufficient to provide benefits beyond usual care on QOL, LOS or postoperative AF. Further research is now required to determine whether a similar program of longer duration, or targeted to high risk patients can provide measurable benefits. TRIAL REGISTRATION: This trial was conducted as part of a larger study and according to the principles contained in the CONSORT statement 2001.

Perioperative metabolic therapy improves redox status and outcomes in cardiac surgery patients: a randomised trial.

OBJECTIVE: Perioperative therapy with antioxidants and metabolic substrates has the potential to reduce oxidative stress and improve recovery from cardiac surgery, particularly in elderly and high risk cases. The aim of this study was to assess the effect of perioperative metabolic therapy at a biochemical, clinical and economic level in cardiac surgical patients. METHODS: Patients (n=117, mean age 65 ± 1.0 years, 74% male) undergoing elective coronary artery bypass graft (CABG) and/or valve surgery in 2004-2006 were randomised to receive in double blinded fashion, while on the waiting list for surgery (approximately two months) and one month after surgery, either metabolic therapy (coenzyme Q(10), magnesium orotate, lipoic acid, omega-3 fatty acids and selenium) or placebo. Biochemical and clinical outcomes were assessed. RESULTS: Cardiac surgery increased oxidative stress and decreased plasma levels of key antioxidants. Metabolic therapy for a mean of 76 ± 7.5 days increased antioxidant levels preoperatively so that the adverse effect of surgery on redox status was attenuated. Metabolic therapy reduced plasma troponin I, 24 hours postoperatively from 1.5 (1.2-1.8) (geometric mean 95% CI) µg/L, to 2.1 (1.8-2.6) µg/L (P=0.003) and shortened the mean length of postoperative hospital stay by 1.2 days from 8.1 (7.5-8.7) to 6.9 (6.4-7.4) days (P=0.004) and reduced hospital costs. Metabolic therapy was inexpensive and had no clinically significant side effects. CONCLUSIONS: Perioperative metabolic therapy for cardiac surgery is safe and inexpensive and is associated with improved redox status, reduced myocardial damage, and shortened length of postoperative hospital stay.

Skeletonized internal thoracic artery harvesting reduces chest wall dysesthesia after coronary bypass surgery.

OBJECTIVE: A pain syndrome related to intercostal nerve injury during internal thoracic artery harvesting causes significant morbidity after coronary bypass surgery. We hypothesized that its incidence and severity might be reduced by using skeletonized internal thoracic artery harvesting rather than pedicled harvesting. METHODS: In a prospective double-blind clinical trial, 41 patients undergoing coronary bypass were randomized to receive either unilateral pedicled or skeletonized internal thoracic artery harvesting. Patients were assessed 7 (early) and 21 (late) weeks postoperatively with reproducible sensory stimuli used to detect chest wall sensory deficits (dysesthesia) and with a pain questionnaire used to assess neuropathic pain. RESULTS: At 7 weeks postoperatively, the area of harvest dysesthesia (percentage of the chest) in the skeletonized group (n = 21) was less (median, 0%; interquartile range, 0-0) than in the pedicled group (n = 20) (2.8% [0-13], P = .005). The incidence of harvest dysesthesia at 7 weeks was 14% in the skeletonized group versus 50% in the pedicled group (P = .02). These differences were not sustained at 21 weeks, as the median area of harvest dysesthesia in both groups was 0% (P = .89) and the incidence was 24% and 25% in the skeletonized and pedicled groups, respectively (P = 1.0). The incidence of neuropathic pain in the skeletonized group compared with the pedicled group was 5% versus 10% (P = .6) at 7 weeks and 0% versus 0% (P = 1.0) at 21 weeks. CONCLUSIONS: Compared with pedicled harvesting, skeletonized harvesting of the internal thoracic artery provides a short-term reduction in the extent and incidence of chest wall dysesthesia after coronary bypass, consistent with reduced intercostal nerve injury and therefore the reduced potential for neuropathic chest pain.

Targeting oxidative stress in surgery: effects of ageing and therapy.

In the current era cardiac surgeons are being called upon to operate upon older, sicker patients. The effect is to augment oxidative stress and increase the rate of post-operative complications and ultimately mortality. We have developed antioxidant-based pre-treatment regimes initially based on coenzyme Q(10). A randomised trial of coenzyme Q(10) in elective cardiac surgery patients demonstrated augmented plasma and cardiac mitochondrial membrane coenzyme Q(10) content, improved mitochondrial respiration and increased myocardial tolerance of oxidative stress. The addition of omega-3 polyunsaturated fatty acids, alpha-lipoic acid, selenium and magnesium orotate in a second clinical trial, improved post-operative recovery with demonstrable reductions in myocardial damage, rate of atrial fibrillation and length of hospital stay. Finally we performed a pilot study of this combined metabolic therapy regimen to which we added preoperative physical exercise and mental stress reduction with indications of further improvements in post-operative recovery. We conclude that simultaneously targeting a number of key deficiencies with a metabolic formulation prior to surgery results in peri- and post-operative clinical and economic benefits.

What is the role of leukocyte depletion in cardiac surgery?

Leukocytes play an important pathogenic role in ischaemia-reperfusion injury. During cardiopulmonary bypass, leukocyte filters have the potential to remove leukocytes, thereby reducing contact of activated leukocytes with the endothelium of target organs. Improvement in the safety and efficacy of commercially available leukocyte filters in recent years has led to their increasing use in cardiac surgery. However, the benefits have been inconsistent. Current evidence suggests that leukocyte depletion may not have a significant impact in low risk elective coronary artery bypass grafting but may be beneficial in valve surgery and high-risk cardiac surgery. High-risk surgical groups that may benefit from leukocyte filtration are those with left ventricular hypertrophy (LV mass>300 g), poor ejection fraction (EF<40%), chronic obstructive airways disease (predicted FEV1<75%), prolonged ischaemia (cross clamp time>120 min or cardiac transplantation), paediatric cardiac surgery and patients in cardiogenic shock requiring emergency coronary artery bypass grafting. Future trials should be powered to detect important clinical end points and be designed to avoid premature exhaustion of the filter.

Antioxidant therapy for severe cardiac failure induced by iron overload secondary to dyserythropoietic anaemia.

We present a case of a patient with longstanding transfusion-dependent congenital dyserythropoietic anaemia (CDA) who developed cardiomyopathy despite iron chelation therapy. She presented with severe heart failure that responded poorly to conventional therapy, recovering only when therapy was augmented with metabolic agents including antioxidants and with increased iron chelation. The present case gives support to the concept of treating oxidatively induced heart failure with metabolic and antioxidant therapy. This therapy may have wider application in refractory heart failure and in the prevention of cardiomyopathy in patients receiving regular red cell transfusions who are at risk of transfusional haemosiderosis.

Clopidogrel and bleeding after coronary artery bypass graft surgery.

BACKGROUND: There is evidence that clopidogrel (with or without aspirin) confers superior outcomes in patients with coronary artery disease. The purpose of this study is to review the effect of preoperative clopidogrel administration on clinical outcome, bleeding complications and resource utilization after coronary artery bypass graft surgery. METHODS: Patient data were prospectively collected from 919 patients who had isolated coronary surgery during the period 2000 to 2003. Outcome comparisons were studied, firstly between patients who received preoperative clopidogrel with those who did not, and secondly between patients on clopidogrel only, aspirin only, both or neither medications. RESULTS: Twenty-four patients (2.6%) were on clopidogrel only, 598 (65.1%) were on aspirin only, 61 (6.6%) were on both, and 236 (25.7%) were on neither. Clopidogrel (n = 85) versus no clopidogrel (n = 834): there were no significant differences in the off-pump patients. In the on-pump patients, the clopidogrel group had significantly increased bleeding (p = 0.02), blood transfused (p = 0.01), intensive care (p = 0.03), and hospital stays (p = 0.03). There were no significant differences in surgical reexploration, perioperative myocardial infarction, intraoperative balloon pump use, inotropic support or 30-day mortality. Clopidogrel versus aspirin versus both versus neither: patients on both clopidogrel and aspirin had significantly more postoperative bleeding than patients on aspirin alone or on neither medication. CONCLUSIONS: The preoperative use of clopidogrel in patients undergoing coronary artery bypass graft surgery showed limited clinical benefits; however, its use significantly increased the risk of bleeding, blood transfusion, and resource utilization.