Current smoking predicts increased operative mortality and morbidity after cardiac surgery in the elderly.

OBJECTIVES: The effect of preoperative smoking status on the outcome of cardiac surgery remains unclear. Preoperative cessation may be associated with reduced postoperative pulmonary complications and in older patients preoperative smoking status appears to have a greater impact on outcome. This study was designed to assess the relationship between age, preoperative smoking status and outcomes from cardiac surgery. METHODS: We performed a single-centre, retrospective cohort study to compare in-patient cardiac surgical mortality and morbidity in current smokers and never-smokers. We analysed the cardiac surgical population in its entirety and in age-stratified subsets using univariate and logistic regression analyses. RESULTS: During a five-year period ending March 2007, 10.8% of all patients (n=554) undergoing cardiac surgery were current smokers. Five hundred and fifty-four never-smokers undergoing cardiac surgery during the same period were identified. Overall, the smokers had a tendency towards higher in-patient mortality (4.3 vs. 2.3%, P=0.067) and increased rates of morbidity. Amongst over 70-year-olds, the current smokers had significantly higher rates of pulmonary complications (24.7 vs. 8.2%, P<0.0002), new renal replacement therapy (17.3 vs. 3.1%, P<0.0001) and infections (44.4 vs. 23.8%, P<0.0007). They had longer intensive care stay (6.2 vs. 2.8 days, P=0.002) with more intensive care unit readmissions (19.8 vs. 5.2%, P<0.0002) and significantly increased in-patient mortality (14.8 vs. 2.1%, P<0.0001). In the elderly smokers, mortality was significantly associated with the rate of pulmonary complications (P=0.03). Preoperative smoking status remained a predictor of pulmonary complications after logistic regression. CONCLUSIONS: The current data strengthen the observation that preoperative smoking status is predictive of adverse outcomes of cardiac surgery in the elderly. Further study into the effect of preoperative smoking cessation in the elderly may inform cessation counselling and the timing of surgery.

Ventricular septal defect following disobliteration of right coronary artery.

Reperfusion injury is thought to occur during coronary recanalisation but rarely produces clinically significant effects other than arrhythmia. We report an unusual case of Ventricular Septal Defect (VSD) developing after successful disobliteration of the right coronary artery. In this case clinical, electrocardiographic and biochemical evidence of myocardial injury developed 6 hours after successful percutaneous recanalization of the infarct related artery. A rapidly developing VSD soon became apparent necessitating surgical intervention to repair the defect. Unfortunately the patient died soon after surgery.

Bilateral tension pneumothoraces following coronary artery bypass grafting.

It is an unusual case of bilateral tension pneumothoraces developing in the postoperative period in a patient who underwent total arterial revascularization for two vessel coronary artery disease. The patient had been a previous heavy smoker and at operation had been noted to have thin walled lung parenchyma with multiple small bullae mainly in the left upper lobe. He suddenly developed bilateral pneumothoraces following intermittent continuous positive airway pressure requiring initially bilateral needle decompression followed by chest drain insertion. He recovered well and the air leak sealed after 3 days.

The effect of a large proximal haemodialysis arterio-venous fistula on weaning off cardiopulmonary bypass: case report.

An increasing number of renal dialysis-dependent patients with Arterio-Venous fistulae are undergoing cardiac surgery.The fistula has important effects on systemic hemodynamics in dialysis patients. The flow is significantly and positively related to cardiac output and cardiac index, and inversely related to pulmonary vascular resistance.Few problems are encountered on cardiopulmonary bypass despite left to right shunting of blood. We present an unusual case in which a large brachial Arterio-Venous fistula with large collaterals prevented weaning off cardiopulmonary bypass.

Clinical experience with assisted venous drainage cardiopulmonary bypass in elective cardiac reoperations.

Reoperative cardiac surgery is associated with substantial morbidity and mortality due to technical problems at sternal reentry, which can result in laceration of the right ventricle, innominate vein injury, or embolization from patent grafts. To minimize the risk associated with reentry, we adopted the method of assisted venous drainage in the cardiopulmonary bypass circuit with peripheral cannulation for cardiac reoperations. From March 1999 to May 2003, a series of 52 patients (38 males; mean age 48.7 years, range 4 months to 78 years) underwent cardiac reoperations performed with centrifugal pump venous-assisted cardiopulmonary bypass. EuroSCORE was 7.34 +/- 3.9 (range, 4-19). The reoperations were coronary artery bypass graft (25 patients), valve replacement/repair (18 patients), and complex pediatric procedures (11 patients). The studied adverse events were structural damage at reentry, mortality, blood loss, stroke, and hemolysis. Complications at sternotomy were damage to the innominate vein (1 patient) and aorta (1 patient) with blood loss of 625 and 225 mL, respectively. Four patients required intraaortic balloon pump or extracorporeal membrane oxygenation (n = 1) for hemodynamic support on weaning off cardiopulmonary bypass. Three patients died in the postoperative period. Our experience with centrifugal pump-assisted venous drainage in cardiac reoperations has shown excellent results, with reduced risk of damage to vital structures on sternal reentry. In cases in which structural damage did occur, blood loss was minimal.

Aortic valve replacement with the Sorin Pericarbon Freedom stentless valve: five-year follow up.

BACKGROUND AND AIM OF THE STUDY: Presumed benefits from stentless bioprostheses include larger orifice areas with lower transvalvular gradients, and improved hemodynamic flow characteristics and annular mechanics. Herein are reported the results of a large series of the Sorin Pericarbon Freedom stentless valve implanted in the aortic position. METHODS: Between July 1998 and June 2003, a total of 102 consecutive patients (58 males, 44 females; mean age 71.7+/-7.8 years; range: 28-87 years) requiring aortic valve replacement (AVR), including those undergoing concomitant procedures of coronary artery bypass, mitral valve repair and mini-maze, was recruited. The predominant lesion was aortic stenosis (n = 92; 90.2%); aortic regurgitation (AR) occurred in five patients (4.9%) (including three with endocarditis), and mixed aortic valve disease in five (4.9%). Six patients (5.9%) had undergone previous cardiac surgery. The median preoperative NYHA class was III. Thirsty-six patients (35.3%) underwent AVR alone. The mean valve size was 25 mm (range: 21-29 mm). Sixty-three patients (61.8%) had concomitant coronary artery disease that required a mean of 2.4+/-1.1 bypass grafts; three patients (3.0%) had combined AVR and mitral valve repair. The study end points observed were mortality, valve failure due to degeneration or endocarditis, reoperation, thromboembolism, transvalvular gradients and left ventricular (LV) mass regression. RESULTS: The median follow up for all patients was 31 months (range: 12 months to 5 years). The mean total cross-clamp time was 71.7+/-17.6 min without associated procedures, and 93.9+/-19.7 min with concomitant procedures. Early mortality was 4/102 (3.8%); actuarial survival over five years was 89.2%. Freedom from thromboembolism over five years was 95.9%, from reoperation 100%, and from endocarditis 99.98%. Fifty-seven patients (56.4%) had no AR detected postoperatively, and 34 (33.3%) had trivial or mild AR. A significant decline was observed in indexed LV mass regression within six months of surgery, from 190+/-72 g/m(2) at baseline to 152+/-47 g/m(2) (p = 0.01). CONCLUSION: In an elderly population with a high incidence of coronary artery disease, the Sorin Pericarbon Freedom stentless valve offers excellent hemodynamics, resulting in significant regression of left ventricular hypertrophy, together with acceptable operation times, morbidity and mortality in the medium term.

Massive bilateral pulmonary emboli complicating coronary artery bypass grafting: a case report.

We report an unusual case of massive bilateral pulmonary emboli following single coronary artery bypass grafting on cardiopulmonary bypass. The patient was admitted electively, received deep vein thrombosis prophylaxis, and had no clinical evidence of deep vein thrombosis in the perioperative period. On the tenth postoperative day he developed sudden dyspnea and a diagnosis of pulmonary embolus was made with computed tomography. Despite full anticoagulation he continued to deteriorate, and despite attempts at pulmonary embolectomy he died of right-sided heart failure. Post-mortem confirmed the diagnosis, but there was no evidence of thrombi in the pelvic and leg veins.

Does pleurotomy during internal mammary artery harvest increase post-operative pulmonary complications?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether pleurotomy during internal mammary artery (IMA) harvest increases post-operative pulmonary complications. Altogether, 154 papers were found using the reported search, of which 8 presented the best evidence to answer the clinical question. 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 all patients undergoing cardiac surgery suffer a significant deterioration in pulmonary function and chest radiograph appearance post-operatively. Pleurotomy seems to compound this with increased rates of atelectasis and pleural effusions, although no impact on clinical outcome or length of hospital stay has been demonstrated.

Is there a role for prophylaxis against atrial fibrillation for patients undergoing lung surgery?

A best evidence topic in thoracic surgery was written according to a structured protocol. The question addressed whether prophylactic anti-arrhythmic drugs may prevent atrial fibrillation (AF) following lung resection. Altogether 457 papers were found using the reported search, of which 14 presented the best evidence to answer the clinical question. 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 identified single randomized trials that have demonstrated a benefit for Diltiazem, Bupivacaine epidural and magnesium for prophylaxis against AF in patients undergoing non-cardiac thoracic surgery, with a number needed to treat of between 4 and 8 with these regimes.