Cardiovascular surgical experiences of IVC tumor and thrombus: Operative strategies Based on 51 consecutive patients.

BACKGROUND: The only beneficial treatment option for the management of inferior vena cava (IVC) tumor thrombus is complete tumor removal. The aim of this study was to report our experience in surgical and clinical outcomes in patients with tumor thrombosis in IVC. METHODS: A retrospective chart review of patients who underwent surgical resection of IVC tumor at our institution over the past 10 years was performed. The patients were identified using a prospectively maintained database. RESULTS: We identified 51 patients, the mean age was 53.4 ± 16.8 years, and 25.4% were female. They were divided into three groups based on tumor thrombosis level. Twenty patients (39.2%) required sternotomy, and cardiopulmonary bypass (CPB) was used in 19 (37.2%) patients, and 2 (3.9%) cases underwent coronary artery bypass graft. The perioperative complications were severe bleeding (3 patients), pulmonary embolism (2 patients), and duodenal perforation (1 patient). Three (5.8%) in-hospital deaths occurred, and all were due to severe abdominal bleeding. After a mean follow-up time of 46.5 ± 42.0 months, 29 (56.9%) patients were alive. The mean survival time was 75.2 ± 8.4 months. In multivariate analysis, higher age (p = 0.033) and male gender (p = 0.033) proved to be independent prognostic factors. CONCLUSIONS: Tumor thrombus extending to the IVC is a rare and challenging event. Although using CPB may be safe and result in long-term survival with acceptable function, excessive bleeding during surgery may limit the use of this method.

Successful Pregnancy after a Heart Transplant in Iran: A Case Report.

Pregnancy after a heart transplant is a concern for many female recipients, and it remains a medical challenge that raises many questions. A 24-year-old woman, gravida 3, para 0, contacted us for obstetric care in the first trimester of gestation, about 3 years after an orthotopic cardiac transplant. She was a known case of dextrocardia with congenitally corrected transposition of the great arteries. The transplant had been performed for severe retractable heart failure, manifesting during her previous lost pregnancy. The course of the current gestation was uneventful. The patient's cardiovascular function was good throughout the pregnancy. She was admitted to the hospital for dyspnea at 35 weeks and 4 days of gestational age. A cardiovascular consult and echocardiography were performed. The results were within the normal range, and labor pains explained the patient's dyspnea. Because of labor pain, a repeat Cesarean section was performed at 35 weeks and 4 days of gestational age. A male baby weighing 2700 g, with an Apgar score of 7/9, was delivered. The patient was discharged after delivery with enoxaparin (40 mg), prednisolone (5 mg), levothyroxine, and mycophenolate mofetil (500 mg) without any complications. Follow-up was carried out at 1 month, and no abnormality was found. Here, we report a case of a successful pregnancy in a young woman after a heart transplant.

Quantification of aortic valve area: comparison of different methods of echocardiography with 3-D scan of the excised valve.

Accurate determination of severity of aortic valve stenosis (AS) by aortic valve area (AVA) is essential for choosing the best treatment strategy. We compared AVA quantified by 4 different in vivo echocardiographic methods with AVA measured by 3D ex vivo scanning of the excised AV. The data on 38 patients who underwent aortic valve replacement were assessed. The AVA was determined by 4 echocardiographic methods of planimetry in 2D transesophageal echocardiography [planimetry (2D-TEE)], plainemetry by multiplanar reconstruction approach in 3D transesophageal echocardiography [MPR (3D-TEE)], and two continuity equation (CE) approaches; conventional CE (2D-TTE) in which left ventricular outflow tract [LVOT] area derived by LVOT diameter obtained in 2D transthoracic echocardiography and CE (3D-TEE) in which LVOT area obtained by 3D MPR. After the surgical removal of the AV, AVA was determined by 3D ex vivo scanning. Lowest AVA mean difference with 3D ex vivo scanning was found between CE (2D-TTE), followed by CE (3D-TEE). Planimetry (2D-TEE) in male patients as well as severely and non-severely calcified valves revealed a significant higher AVA mean difference with 3D ex vivo scanning than CE (2D-TTE) and CE (3D-TEE) methods. However, with a nonsignificant effect, CE (2D-TTE) and planimetry (2D-TEE) had the least mean difference with 3D ex vivo scanning possibly due to less frequent bicuspid AV in females. CE (2D-TTE) was more accurate than other methods of AVA calculation. Moreover, CE (3D-TEE) and MPR (3D-TEE) methods had acceptable accuracy in comparison with planimetry (2D-TEE) for definition of AS severity.

Short-term Outcome of Patients with Infective Endocarditis: A Single-center Prospective Study.

OBJECTIVES: To investigate the short-term outcome of patients with infective endocarditis (IE). PATIENTS AND METHODS: We analyzed data from 42 patients with active endocarditis which underwent different cardiac surgeries. An active endocarditis was considered due to urine analysis and/or blood culture and acute inflammation Gram stains of sample tissue and/or blood culture and acute inflammation Gram stains of sample tissue. DESIGN: Collecting data of 42 patients prospectively. SETTING: University hospital single center. PARTICIPANTS: Patients with IE from July 2014 to June 2016. INTERVENTIONS: None. MEASUREMENT AND MAIN RESULTS: We collected data of 42 patients in Imam Hospital which is a university-based 1700-bed center. Twelve patients experienced a redo operation; in which, 2 of them have had the second redo. Five patients underwent an aortic valve replacement operation, 2 mitral valve repair, and only one patient had experienced a subaortic web resection. Seven cases were addict; in which, 5 of them were intravenous abusers. There was 1 porphyric patient which suffered from pethidine reliability. Most of our cases underwent Bentall or tricuspid valve repair operation, and multivalve operation was more scarce. CONCLUSIONS: We have presented the therapeutic strategies and outcome of patients with IE and evaluated their short-term outcome.

Appropriate blood component therapy can reduce postcardiac surgery acute kidney injury through packed cell transfusion reduction.

BACKGROUND: Acute kidney injury (AKI) can happen due to different factors such as anemia. Packed cell (PC) transfusion is an important cause of AKI occurrence. The aim of the study is to investigate whether appropriate blood component (BC) therapy can reduce blood transfusion and it would result in AKI decreasing. MATERIALS AND METHODS: We conducted a cohort study of 1388 patients who underwent cardiac surgery in one university hospital. A serum creatinine higher than 2 mg/dl, renal disease history, renal replacement therapy (chronic dialysis) were our exclusion criteria. RESULTS: From our 1088 samples, 701 (64.43%) patients had normal kidney function, 277 (25.45%) were in the AKI-1 group, 84 (7.72%) had an AKI-2 function, and the rest of patients were classified as end stage. A mean of more than three PC units were transfused for the second and third stage of AKI, which was significantly higher than other AKI groups (P = 0.009); this higher demand of blood product was also true about the fresh frozen plasma, platelet, and fibrinogen. However, there were no needs of fibrinogen in the patients with normal kidney function. The cardiopulmonary bypass time had an average of 142 ± 24.12, which obviously was higher than other groups (P = 0.032). Total mortality rate was 14 out of 1088 (1.28%), and expiration among the AKI stages 2 and 3 was meaningfully (P = 0.001) more than the other groups. CONCLUSION: A more occurrence of AKI reported for the patients who have taken more units of blood. However, BC indicated to be safer for compensating blood loss because of low AKI occurrence among our patients.

Assessment of limited chest x-ray technique in postcardiac surgery management.

OBJECTIVES: The objective of this study is to investigate the safety of elimination of chest radiography in the postcardiac surgery Intensive Care Unit (ICU). METHODS AND DESIGN: We compared patients in two different groups of routine CXR (RCXR) and limited CXR (LCXR) and their diagnostic and therapeutic outcome in a University hospital-based single center from 2014 to 2016. 3 CXR in the RCXR group and 1 CXR in the limited group was performed, in addition to on-demand criteria. MEASUREMENT AND MAIN RESULTS: A total of 978 samples were acceptable for analysis which 55.21% of RCXR and 59.50% of LCXR were male patients. In total, 523 abnormalities in RCXR group and 154 occasions in LCXR group resulted in 26.73% diagnostic efficacy for RCXRs and 28.57% for LCXR. From 1956 CXR that was taken in RCXR group, 72 occasions required intervention (3.68%) and 84 cases out of 539 (15.58%) LCXR needed an action to therapy. This means a 14.40% in RCXRs' abnormalities and 56.00% of LCXRs' abnormalities were accompanied with some interventions. CONCLUSIONS: Abolishing routine CXR in the ICUs would not be harmful for the patients, and it can be managed based on their clinical status and other safer imaging techniques.

Resternotomy, a single-center experience.

Background Reoperations are technically more difficult because of the risks associated with reentry in a heart with more advanced pathology, little reserve, and more frequent comorbidities. Routine peripheral cannulation before resternotomy is inadvisable, time-consuming, and has no noticeable role in decreasing the risks of reentry. We present our experience of resternotomy without routine peripheral cannulation. Methods This was a retrospective study on 237 consecutive patients who underwent resternotomy between June 2011 and July 2013. Their mean age was 47.7 ± 18.2 years. We chose the best approach individually, according to lateral radiograph findings, patient risk factors, and previous surgery. Our goal was to observe events intraoperatively and their outcomes postoperatively. Results Mean intensive care unit stay was 3.1 ± 0.9 days. Twenty-one (8.8%) patients died during their hospital stay. The most common cause of death was renal failure in 15 (71.4%) patients, coagulopathy in 4 (19%), and cardiac failure in 2 (9.5%). We had 3 right ventricular, one right atrial, one pulmonary artery, and 2 inferior vena caval tears during resternotomy and dissection; bleeding was controlled easily without peripheral cannulation. Femoral cannulation before resternotomy was performed in one patient who needed an emergency pulmonary embolectomy. Conclusions Based on our experience, resternotomy with central cannulation is a safe strategy, and peripheral cannulation before resternotomy should be reserved for highly selected patients.

Anesthetic implication of tricuspid valve replacement in a patient with acute intermittent porphyria.

Facing a patient with acute intermittent porphyria (AIP), there is narrow safety margin which circumscribe all the therapeutic actions including choice of drugs. This would become even more complicated when it comes to a stressful and drug-dependent process like a cardiopulmonary bypass. According to author's researches, no specific AIP case of tricuspid valve (TV) replacement is reported recently. Furthermore, fast-track anesthesia was safely used in this 37-year-old male known the case of AIP, who was a candidate for TV replacement and removing the port catheter. The patient was extubated subsequently, only 3 h after entering the Intensive Care Unit.

The Relationship Between Creatine and Whey Protein Supplements Consumption and Anesthesia in Rats.

BACKGROUND: Because the trend of pharmacotherapy is toward controlling diet rather than administration of drugs, in our study we examined the probable relationship between Creatine (Cr) or Whey (Wh) consumption and anesthesia (analgesia effect of ketamine). Creatine and Wh are among the most favorable supplements in the market. Whey is a protein, which is extracted from milk and is a rich source of amino acids. Creatine is an amino acid derivative that can change to ATP in the body. Both of these supplements result in Nitric Oxide (NO) retention, which is believed to be effective in N-Methyl-D-aspartate (NMDA) receptor analgesia. OBJECTIVES: The main question of this study was whether Wh and Cr are effective on analgesic and anesthetic characteristics of ketamine and whether this is related to NO retention or amino acids' features. MATERIALS AND METHODS: We divided 30 male Wistar rats to three (n = 10) groups; including Cr, Wh and sham (water only) groups. Each group was administered (by gavage) the supplements for an intermediate dosage during 25 days. After this period, they became anesthetized using a Ketamine-Xylazine (KX) and their time to anesthesia and analgesia, and total sleep time were recorded. RESULTS: Data were analyzed twice using the SPSS 18 software with Analysis of Variance (ANOVA) and post hoc test; first time we expunged the rats that didn't become anesthetized and the second time we included all of the samples. There was a significant P-value (P < 0.05) for total anesthesia time in the second analysis. Bonferroni multiple comparison indicated that the difference was between Cr and Sham groups (P < 0.021). CONCLUSIONS: The data only indicated that there might be a significant relationship between Cr consumption and total sleep time. Further studies, with rats of different gender and different dosage of supplement and anesthetics are suggested.

Comparison of blood electrolytes and glucose during cardiopulmonary bypass in diabetic and non-diabetic patients.

BACKGROUND: Cardiopulmonary bypass (CPB) during coronary artery bypass grafting is thought to contribute significantly to increased blood glucose level and altered blood electrolytes balance during the operation. In this (CABG) study, blood electrolytes and glucose during CPB in insulin-dependent diabetic and non-diabetic patients were assessed with special emphasis on the trend of the changes. MATERIALS AND METHODS: Blood glucose and electrolytes were assessed in 30 insulin-dependent diabetic and 30 non-diabetic patients, classified as class II and III American Society of Anesthesiologist, before, during, and after CPB. Repeated-measures analysis of variance (ANOVA) was used to compare the trend of the changes during CPB for the two groups. RESULTS: The trend in blood glucose level did not show any significant difference between two groups (P = 0.59). For other blood factors, no significant between-group difference was detected except for PaCO2 (P = 0.002). CONCLUSION: The study suggested that the changes in blood electrolytes and the increase in blood glucose level do not differ between insulin dependent diabetic and non-diabetic patients.