Does Remote Ischaemic Preconditioning Protect Kidney and Cardiomyocytes After Coronary Revascularization? A Double Blind Controlled Clinical Trial.

OBJECTIVE: To investigate efficacy of remote ischaemic preconditioning on reducing kidney injury and myocardial damage after coronary artery bypass grafting surgery (CABG). BACKGROUND: Ischaemic preconditioning of a remote organ reduces ischaemia-reperfusion injury of kidney and myocardium after CABG. METHOD: To reduce myocardial damage and kidney injury by applying Remote Ischaemic Preconditioning we recruited 100 consecutive patients undergoing elective coronary artery bypass grafting surgery. We applied three cycles of lower limb tourniquet, inflated its cuff for 5 minutes in study group or left un-inflated (sham or control group) before the procedure. The primary outcome was serum creatinine, creatinine clearance and troponin-I Levels at time 0, 6, 12, 24 and 48 h. Secondary outcomes were serum C-reactive protein, inotrope score, ventilation time and ICU stay. Data's were analyzed by MedCalc (MedCalc Software bvba, Acacialaan, Belgium). We compared the two group by student t test, chi-square and Mann-Whitney tests. RESULTS: The two groups were not statistically different in terms of age, gender, smoking habits, drug use, hypertension, hyperlipidemia and diabetes mellitus. This study showed a higher CRP level in study group comparing with control group (P=0.003), creatinine clearance was slightly higher in study group specially 24 h after procedure but was not statistically significant (p=0.11). Troponin-I level was significantly lower in study group (p=0.001). CONCLUSION: This study showed a lower Troponin-I level in study group which suggest a cardio-myocyte protective function of RIPC. It also showed slightly lower Creatinine clearance in control group, gap between two group increases significantly 24 hours after procedure which may suggest a potential kidney protection by RIPC. Serum CRP level was higher in study group. A multi-center randomized controlled trial with a longer time for creatinine clearance measurement may show the potential effectiveness of this non-invasive inexpensive intervention on reducing kidney injury after CABG.

What is the optimal anticoagulation management of patients post-cardiac surgery who go into atrial fibrillation?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether anticoagulation is indicated for patients in atrial fibrillation (AF) following coronary artery bypass grafting. Altogether 166 papers were found using the reported search, of which 10 presented the best evidence to answer the clinical question. In addition the American Heart Association guidelines for management of atrial fibrillation were reviewed. The author, journal, date and country of publication, patient group studied, study type, relevant outcomes, results, and study weaknesses of these papers are tabulated. We conclude that patients post-cardiac surgery require warfarinisation while in atrial fibrillation with an INR of 2-3, and full anticoagulation should be commenced within 48 h of the onset of AF as their risk of stroke is doubled by the onset of AF.

Surgical extraction of infected pacemaker leads after cardiac surgery.

Surgical extraction of permanent pacemaker leads is performed when noninvasive extraction is felt to be unsafe or has been unsuccessfully attempted. Surgical extraction in patients with previous cardiac surgery presents a particular challenge as re-sternotomy is hazardous and the presence of surgical adhesions makes video-assisted approaches difficult. We report 2 cases of successful deployment of a surgical technique using femorofemoral cardiopulmonary bypass and right anterior thoracotomy for removal of pacemaker leads.