Chest X-ray and electrocardiogram in post-cardiac surgery follow-up clinics: should this be offered routinely or when clinically indicated?

OBJECTIVES: Many centres in the UK carry out routine chest X-ray (CXR) and/or electrocardiogram (ECG) when patients attend follow-up clinic after cardiac surgery. Current evidence to support this practice is weak. This study investigated the appropriateness of carrying out these investigations in the absence of clinical indication. METHODS: All patients attending routine 6- to 8-week follow-up clinic after cardiac surgery in this hospital were prospectively reviewed over a 6-month period (October 2011-April 2012). Two groups were identified for comparison. Group A comprised patients who had CXR and/or ECG requested routinely, and those in Group B had the investigations only when clinically indicated. A proforma was designed to screen each patient for cardiac and respiratory symptoms, predischarge CXR abnormalities and the presence of atrial fibrillation/flutter postoperatively. Management alterations based on the findings from the investigations were noted. Patients who had thoracic, major aortic, or heart transplant surgery were excluded from the audit. RESULTS: Three hundred and fifty patients were reviewed: 250 were in Group A and 100 in Group B. No patient had a significant management alteration in the absence of an indication for the tests. There were no differences in outcome between the two groups. In Group A, 111 (45%) patients had CXR and ECG done without indication and no abnormality was detected. In Group B, 52 patients had no indication for either tests and were thus not tested. None of these patients required readmission/intervention following discharge from clinic. Overall, 271 patients had CXR carried out, with only 83 being indicated. This led to a management alteration in 33 patients (12% overall, 40% if indicated). Two hundred and eighty-six patients had ECG carried out with 140 indicated. Management was altered in 122 patients (43% overall, 87% if indicated). The correlation between the clinical indication-based investigation and the resulting change in patient management was found to be significant (Goodman-Kruskal Gamma: 0.99, P = 0.000 for both investigations). CONCLUSIONS: There is a strong correlation between clinical indication for CXR and/or ECG and management alterations. These investigations should be performed during the routine follow-up of adult cardiac surgical patients using a patient-centred approach based on signs and symptoms.

A difficult diagnosis - constrictive pericarditis and its treatment: a case report.

The diagnosis of constrictive pericarditis requires a high degree of clinical suspicion, for the signs and symptoms of this disease can be falsely attributed to other causes. Herein, we present a case of a 70-year old retired farmer whose symptoms of right heart failure were initially attributed to co-existing pneumonia and pulmonary embolism. He was discharged. Three weeks later he presented with worsening breathlessness and ascites. Echocardiography, computed tomography and cardiac catheterization revealed the diagnosis of constrictive pericarditis. He underwent complete pericardectomy and to date has made a good recovery. This case exemplifies the difficulty in diagnosing this condition, the investigation required, and provides a discussion of the benefit and outcomes of prompt treatment.

Preoperative angiotensin-converting enzyme inhibition can cause severe post CPB vasodilation--current UK opinion.

Preoperative use of angiotensin-converting enzyme inhibitors in cardiac surgery patients is thought to cause extreme vasodilatation in post cardiopulmonary bypass period. Opinions are divided as to whether it is beneficial or not to stop it prior to operation. A national survey in the UK was carried out on this issue. Questionnaires were sent to 167 currently practicing UK cardiac surgeons, out of which 105 (62%) replied back. Their responses were analyzed. Among the surgeons who replied to the questionnaires, the majority (63%) were of the opinion that the use of angiotensin-converting enzyme inhibitors leads to vasodilatation resulting in increased usage of fluids, inotropes and vasoconstrictors. However, there was no agreement on the issue of stopping it prior to surgery. Forty one (39%) felt it was beneficial to stop the angiotensin-converting enzyme inhibitors prior to surgery whereas 40 (38%) of them thought it was harmful to stop it. Twenty one (20%) were of the opinion that it made no difference. 39% of respondents practiced stopping the drug prior to planned operation. This national survey revealed differences in management of patients on angiotensin-converting enzyme inhibitors undergoing cardiac surgery. Recommendations from available literature are equally varied, highlighting the need for multicenter randomized trials to address this clinical problem.