Corrigendum to "Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery".

[This corrects the article DOI: 10.1155/2017/2753962.].

Amiodarone plus Ranolazine for Conversion of Post-Cardiac Surgery Atrial Fibrillation: Enhanced Effectiveness in Reduced Versus Preserved Ejection Fraction Patients.

PURPOSE: Ranolazine (RAN) added to amiodarone (AMIO) has been shown to accelerate termination of postoperative atrial fibrillation (POAF) following coronary artery bypass surgery in patients without heart failure (HF). This study aimed to investigate if treatment efficacy with AMIO or AMIO + RAN differs between patients with concomitant HF with reduced or preserved ejection fraction (HFrEF or HFpEF). METHODS: Patients with POAF and HFrEF (n = 511, 446 males; 65 ± 9 years) and with HFpEF (n = 301, 257 males; 66 ± 10 years) were enrolled. Onset of AF occurred 2.15 ± 1.0 days after cardiac surgery, and patients within each group were randomly assigned to receive either AMIO monotherapy (300 mg in 30 min + 1125 mg in 36 h iv) or AMIO+RAN combination (500 mg po + 375 mg, after 6 h and 375 mg twice daily thereafter). Primary endpoint was the time to conversion of POAF within 36 h after initiation of treatment. RESULTS: AMIO restored sinus rhythm earlier in HFrEF vs. in HFpEF patients (24.3 ± 4.6 vs. 26.8 ± 2.8 h, p < 0.0001). AMIO + RAN converted POAF faster than AMIO alone in both HFrEF and HFpEF groups, with conversion times 10.4 ± 4.5 h in HFrEF and 12.2 ± 1.1 h in HFpEF patients (p < 0.0001). Left atrial diameter was significantly greater in HFrEF vs. HFpEF patients (48.2 ± 2.6 vs. 35.2 ± 2.9 mm, p < 0.0001). No serious adverse drug effects were observed during AF or after restoration to sinus rhythm in any of the patients enrolled. CONCLUSION: AMIO alone or in combination with RAN converted POAF faster in patients with reduced EF than in those with preserved EF. Thus, AMIO + RAN seems to be a valuable alternative treatment for terminating POAF in HFrEF patients.

Pregabalin Effect on Acute and Chronic Pain after Cardiac Surgery.

Introduction. Pain after cardiac surgery affects long-term patient wellness. This study investigated the effect of preoperative pregabalin on acute and chronic pain after elective cardiac surgery with median sternotomy. Methods. Prospective double blind study. 93 cardiac surgery patients were randomly assigned into three groups: Group 1 received placebo, Group 2 received oral pregabalin 75 mg, and Group 3 received oral pregabalin 150 mg. Data were collected 8 hours, 24 hours, and 3 months postoperatively. Results. Patients receiving pregabalin required fewer morphine boluses (10 in controls versus 6 in Group 1 versus 4 in Group 2, p = 0.000) and had lower pain scores at 8 hours (4 versus 3 versus 3, p = 0.001) and 3 months (3 versus 2 versus 2, p = 0.000) and lower morphine consumption at 8 hours (14 versus 13 versus 12 mg, p = 0.000) and 24 hours (19.5 versus 16 versus 15 mg, p = 0.000). Percentage of patients with sleep disturbances or requiring analgesics was lower in the pregabalin group and even lower with higher pregabalin dose (16/31 versus 5/31 versus 3/31, p = 0.000, and 26/31 versus 16/31 versus 10/31, p = 0.000, resp.) 3 months after surgery. Conclusion. Preoperative oral pregabalin 75 or 150 mg reduces postoperative morphine requirements and acute and chronic pain after cardiac surgery.

Management of isolated sternal fractures using a practical algorithm.

BACKGROUND: The implementation of seat belt legislation has led to an increase in the frequency of isolated sternal fractures (ISFs) in motor vehicle crash. AIMS: We reviewed retrospectively the medical records of our tertiary center in order to find out the frequency of ISFs, review our experience in their management, and define the mean length of hospitalization. MATERIALS AND METHODS: From January 2008 to April 2012, 64 patients were admitted to the accident and emergency department of the University Hospital of Larissa, Greece, suffering from sternal fractures (SFs). Of these 64 patients, 45 had sustained ISF, while the remaining 19 had SF and additional injuries (intrathoracic and extrathoracic). The files of these 45 patients were further investigating as concerning the mechanism of injury, hospitalization days, morbidity, and mortality. RESULTS: All the patients had been involved in motor vehicle crashes and most of them were wearing seat belts during the accident (91%). The hospital length of stay (LOS) was 1.85 ± 1.67. All the patients had upon admission chest radiograms, serial electrocardiographs (ECGs), echocardiograms, and cardiac enzyme levels. Two patients had abnormal ECG and abnormal cardiac enzymes which contributed in prolonged hospitalization. However, there was no incidence of cardiac complications or deaths. CONCLUSIONS: ISFs, with normal electrocardiogram, cardiac enzymes, and chest X-ray in the absence of complications, require no further investigation.

Ranolazine enhances the antiarrhythmic activity of amiodarone by accelerating conversion of new-onset atrial fibrillation after cardiac surgery.

Ranolazine is a relatively novel antiischemic/antianginal compound with antiarrhythmic properties. We investigated its ability to shorten the time to conversion of postoperative atrial fibrillation (POAF) when added to amiodarone after coronary artery bypass graft (CABG) surgery. In this prospective, randomized, allocation-concealed, single-blind, single-site clinical trial, we enrolled consecutive eligible patients who developed POAF after elective on-pump CABG surgery. Participants were randomized to receive either ranolazine 375 mg twice daily orally plus intravenous amiodarone (active group) or intravenous amiodarone alone (control group). We enrolled 41 patients; 20 in the active and 21 in the control group. There were no significant differences between the groups in terms of age, procedural duration, extracorporeal circulation time, and aortic cross-clamp time. Mean time of conversion was significantly shorter in the active group (19.9 ± 3.2 vs 37.2 ± 3.9 hours, P < .001), suggesting that compared to amiodarone alone, the ranolazine-amiodarone combination had a superior antiarrhythmic effect against POAF.

Monitoring of brain oxygen saturation (INVOS) in a protocol to direct blood transfusions during cardiac surgery: a prospective randomized clinical trial.

BACKGROUND: Blood transfusions are common in cardiac surgery, but have been associated with increased morbidity and long-term mortality. Efforts to reduce blood product use during cardiac surgery include fluid restriction to minimize hemodilution, and protocols to guide transfusion decisions. INVOS is a modality that monitors brain tissue oxygen saturation, and could be useful in guiding decisions to transfuse. However, the role of INVOS (brain tissue oxygen saturation) as part of an algorithm to direct blood transfusions during cardiac surgery has not been evaluated. This study was conducted to investigate the value of INVOS as part of a protocol for blood transfusions during cardiac surgery. METHODS: Prospective, randomized, blinded clinical trial, on 150 (75 per group) elective cardiac surgery patients. The study was approved by the Institution Ethics committee and all patients gave written informed consent. Data were initially analyzed based on "intention to treat", but subsequently were also analyzed "per protocol". RESULTS: When protocol was strictly followed ("per protocol analysis"), compared to the control group, significantly fewer patients monitored with INVOS received any blood transfusions (46 of 70 patients in INVOS group vs. 55 of 67 patients in the control group, p = 0.029). Similarly, patients monitored with INVOS received significantly fewer units of red blood cell transfusions intraoperatively (0.20 ± 0.50 vs. 0.52 ± 0.88, p = 0.008) and overall during hospital stay (1.31 ± 1.20 vs. 1.82 ± 1.46, p = 0.024). When data from all patients (including patient with protocol violation) were analyzed together ("intention to treat analysis"), the observed reduction of blood transfusions in the INVOS group was still significant (51 of 75 patients transfused in the INVOS group vs. 63 of 75 patients transfused in the control group, p = 0.021), but the overall number of units transfused per patient did not differ significantly between the groups (1.55 ± 1.97 vs. 1.84 ± 1.41, p = 0.288). CONCLUSIONS: Our data suggest that INVOS could be a useful tool as part of an algorithm to guide decisions for blood transfusion in cardiac surgery. Additional data from rigorous, well designed studies are needed to further evaluate the role of INVOS in guiding blood transfusions in cardiac surgery, and circumvent the limitations of this study.

Ranolazine-induced postrepolarization refractoriness suppresses induction of atrial flutter and fibrillation in anesthetized rabbits.

Ranolazine (Ran) is a novel anti-ischemic agent with electrophysiologic properties mainly attributed to the inhibition of late Na(+) current and atrial-selective early Na(+) current. However, there are only limited data regarding its efficacy and mechanism of action against atrial flutter (Afl) and atrial fibrillation (AF) in intact animals. Therefore, we aimed to investigate the electrophysiologic mechanism of Ran in a rabbit model of inducible atrial tachyarrhythmias elicited by acetylcholine (ACh). Arrhythmias were produced in 19 rabbits by rapid atrial burst pacing during control, after intravenous ACh and after Ran + ACh administration. Recording of right atrial monophasic action potentials (MAPs) and programmed stimulation were utilized to determine the duration of atrial repolarization at various cycle lengths and voltage levels of action potential, including 75% of total MAP duration (MAPD75), effective refractory period (ERP), and postrepolarization refractoriness (PRR = ERP - MAPD75) prior to and after Ran. Control stimulation yielded no arrhythmias or maximal nonsustained runs of Afl/AF. Upon ACh, 17 of 19 rabbits exhibited sustained Afl and AF as well as mixed forms of Afl/AF, while 2 animals revealed none or short runs of nonsustained arrhythmias and were excluded from the study. High-frequency burst pacing during the first 30 minutes after Ran + ACh failed to induce any arrhythmia in 13 of 17 rabbits (76%), while 2 animals displayed sustained Afl/AF and 2 other animals nonsustained Afl/AF. At basic stimulation cycle length of 250 milliseconds, Ran prolonged baseline atrial ERP (80 ± 8 vs 120 ± 9 milliseconds, P < .001) much more than MAPD75 (65 ± 7 vs 85 ± 7 milliseconds, P < .001), leading to atrial PRR which was more pronounced after Ran compared with control measurements (35 ± 11 vs 15 ± 10 milliseconds, P < .001). This in vivo study demonstrates that Ran exerts antiarrhythmic activity by suppressing inducibility of ACh-mediated Afl/AF in intact rabbits. Its action may predominantly be related to a significant increase in atrial PRR, resulting in depressed electrical excitability and impediment of arrhythmia initiation.

Effect of ranolazine in preventing postoperative atrial fibrillation in patients undergoing coronary revascularization surgery.

BACKGROUND/OBJECTIVE: Ranolazine is a new anti-ischemic agent approved for chronic angina with additional electrophysiologic properties. The purpose of the present trial was to investigate its effect in preventing postoperative atrial fibrillation (POAF) after on-pump coronary artery bypass graft (CABG) surgery. METHODS: In the current prospective, randomized, (1 active: 2 control), single-blind (outcome assessors), single-centre clinical trial we recruited consecutive eligible patients scheduled for elective on-pump CABG. Participants were assigned to receive either oral ranolazine 375 mg twice daily for 3 days prior to surgery and until discharge, or to receive usual care. Patients were monitored for the development of POAF. RESULTS: We enrolled 102 patients. Significantly lower incidence of POAF was noted in the ranolazine group compared with the control group (3 out of 34 patients, 8.8%, vs 21 out of 68 patients, 30.8%; p< 0.001). Mean values of left atrial diameter and left ventricular ejection fraction between the control and the ranolazine group were not significantly different. CONCLUSION: Our findings suggest a protective role of oral ranolazine when administered in a moderate dose preoperatively in patients undergoing on-pump CABG surgery. Future studies based on a wider sample of patients will eventually support our conclusions.

Why are thoracic operations postponed?

AIM: To investigate and present the reasons that cause the postponement of thoracic surgical operations. METHODS: We retrospectively included in the study all patients submitted to elective thoracic surgery in our department during the 4-year period 2007-2010 and noted all cases of postponement after official inclusion in the operating schedule. RESULTS: 81 out of a total of 542 patients (14.9%) scheduled for elective thoracic operation had their procedure postponed. The reasons were mainly organisatory (in 42 cases, 51.85%), which in order of significance were: shortage in matching erythrocyte units, shortage in anaesthetic/nursing staff and unavailability in operating rooms. The rest of the cases (39, 48.1%) were postponed due to medical reasons, which in descending order of significance were: respiratory infections and exacerbations of COPD, cardiological problems, misregulation of antiplatelet/antithrombotic drugs and infections from other systems (gastrointestinal, urinary, etc.). Elderly male patients planned for major/oncologic surgery were most possible to have their operation postponed for medical reasons. DISCUSSION-CONCLUSIONS: Thoracic operations are postponed owed to organisatory as well as medical reasons, the latter mainly affecting elderly, morbid patients awaiting for major/oncologic surgery.

Ondasetron versus haloperidol for the treatment of postcardiotomy delirium: a prospective, randomized, double-blinded study.

BACKGROUND: To investigate the controlling efficacy of ondasetron and haloperidol in regard to the postcardiotomy delirium. METHODS: We included in this prospective, randomized, double-blinded study 80 patients who developed delirium after heart surgery with the application of heart lung-machine. The patients were divided into two, equally-sized groups, which on detection of delirium received ondasetron 8 mg iv or haloperidol 5 mg iv respectively. The statistical analysis compared the baseline and demographic characteristics of the two groups (age, gender, comorbidities, years of education, type of surgery etc.). RESULTS: Both ondasetron and haloperidol had very good delirium controlling effects, without statistically significant differences. DISCUSSION-CONCLUSIONS: Ondasetron and haloperidol are efficient agents as far as the treatment of postcardiotomy delirium is concerned. As, in addition, ondasetron bares milder side-effects, we believe this could be the agent of choice in patients developing postcardiotomy delirium in the future.

Classic and non-classic forms of mitral valve prolapse.

OBJECTIVE: To investigate the significance of the established distinction between classic and non-classic forms of mitral valve prolapsed (MVP). METHODS: We included in this prospective study all patients examined in our preventive cardiology outpatient clinics during the biannual period October 2004-October 2006. We examined in total 10.818 patients, 238 of whom (2.2%) were diagnosed for MVP. We noted relevant demographic and clinical data (gender, age of diagnosis, symptoms, need for hospitalization) and performed statistical comparisons between patients with the classic and those with the non-classic form. Follow-up controls were performed three years afterwards. RESULTS: Patients with the classic form had an earlier age of first diagnosis, more prominent symptoms, and more frequently diagnosis for other disorders (atrial septal defect, ventricular septal defect, Marfan syndrome, Ehlers-Danlos syndrome) than the rest of the patients; however, there were no significant differences as far as certain major complications (stroke, death, submission to surgery) were concerned. CONCLUSION: The classic form of mitral valve prolapse is more tightly associated with morbid complications, and a more frequent follow-up control in this group of patients may be useful.

Vision impairment during cardiac surgery and extracorporeal circulation: current understanding and the need for further investigation.

The aim of this article was to provide a comprehensive review of current knowledge regarding ocular hemodynamic alterations affecting the retinal neuroglial cells and optic nerve head (ONH) function during cardiac surgery. Literature indicates that visual loss after heart surgery is a rare but devastating complication provoked by two main causes of optic ischaemia and infarction during on-pump cardiac procedures: microembolism and/or hypoperfusion. Retinal ischaemia and ischaemic optic neuropathy are two possible major consequences of extracorporeal circulation in cardiac surgery. The hemodynamic modifications within the vascular beds of retina and ONH during cardiovascular operations have been incompletely studied. Consequently, it is of great interest to investigate the hemodynamic changes during cardiopulmonary bypass within the choroidal, retinal and optic nerve microcirculations as well as other potential causes of vaso-occlusion. Maintaining stable hemodynamic parameters during cardiovascular surgery seems to be the key to prevent visual impairment.

Experimental cardiac hypertrophy induced by oral administration of mineralocorticoid and saline in rats.

We suggest a new, easily applicable way of myocardial hypertrophy induction in rats. Forty randomized age-matched male Wistar rats were divided into 2 groups of 20 each: a control group and an orally administered fludrocortisone/salt group. Myocardial hypertrophy was estimated by measuring body weight, heart-weight-to-body-weight ratio and ventricular free wall thickness. Moderate myocardial hypertrophy without heart failure was established in fludrocortisone/salt group in 4 weeks. Our method is effective and low cost, and it provides a model of hypertrophic heart.

How many lobes do you see?

Accessory fissures represent a variation of the normal lung anatomy. Incomplete development or even the absence of the major or minor fissures can lead to confusion in distinguishing adjacent lobes. This report aims to present a rare intraoperative finding of an anatomic malformation of the right lung in a 19-year old male patient with recurrent pneumothorax who underwent a surgical repair. An accessory fissure which was separating the superior segment of the lower lobe from the basal segments gave to the whole lung the unique image of a four-lobed one. A profound knowledge of the accessory fissures, even if they are incidentally discovered, is of pivotal importance for the thoracic surgeon and leads to optimal operative assessment and strategic planning.

Why are heart operations postponed?

AIM: To investigate the reasons that lead to postponement of cardiac operations, in order to elucidate the problem and help patients through modes of prevention. METHODS-DESIGN: We retrospectively included in the study all patients submitted to elective adult heart surgery in our department during the 4-year period 2007-2010 and noted all cases of postponement after official inclusion in the operating schedule. RESULTS: 94 out of a total of 575 patients (16.34%) scheduled for elective cardiac operation had their procedure postponed. The reasons were mainly organisatory (in 49 cases, 52.12%), which in order of significance were: unavailability in operating rooms, shortage in matching erythrocyte units and shortage in anaesthetic/nursing staff. The rest of the cases (45, 47.88%) were postponed due to medical reasons, which in order of significance were: febrile situations, including infections of the respiratory, gastrointestinal and urinary system, problems with the regulation of antiplatelet and antithrombotic drugs, neurological manifestations such as stroke and transient ischaemic attacks, exacerbation of asthma/chronic obstructive pulmonary disease, arrhythmias, renal problems and allergic reactions to drugs. Patients with advanced age and increased Euroscore values were most possible to have their heart operation postponed. CONCLUSIONS: Heart operations are postponed due to organisatory as well as medical reasons, the latter mainly affecting older, morbid patients who therefore require advanced preoperative care.