Self-reported functional status as a predictor of coronary artery bypass graft surgery outcome in elderly patients.

BACKGROUND: Surgeons have traditionally relied mainly on clinical intuition in the selection of elderly candidates for coronary artery bypass grafting (CABG). The overall increasing number of patients undergoing CABG and limited resources require that a more rational approach be used to screen out candidates who are least likely to benefit from the surgery. HYPOTHESIS: Preoperative functional status is a more sensitive predictor of mortality and poor postoperative functional status than age. PATIENTS AND METHODS: Retrospective preoperative and postoperative geriatric assessment was obtained for 123 patients who had undergone CABG at the Montreal General Hospital. Montreal, Quebec. Preoperative and postoperative health and functional status were assessed using the Canadian version of the Medical Outcomes Study 36-Item Short-Form (SF-36) 1 to 1.5 years following surgery. The questionnaires were compiled according to the method described by Stewart et al and scores were transformed linearly to a 0 to 100 scale. In addition to functional status, the presence of comorbidities and other risk factors known to influence the outcome of CABG were recorded. RESULTS: There was no significant difference in the likelihood of having a poor functional status before or after surgery, or death as an outcome of CABG in the young elderly group versus the old elderly group. Preoperative functional status was found to predict postoperative functional status; however, there was no significant association between preoperative functional status and the presence of comorbidity. The presence of comorbidity did not affect the postoperative functional status, but increased the likelihood of death. CONCLUSION: Functional status was demonstrated to be a significant predictor of CABG outcome. When compared with age, functional status was also found to be a more reliable predictor of CABG outcome, which had not been previously demonstrated. Women were found to be more likely to have a poor preoperative functional status than their male counterparts. This may account in part for the decreased success rate of CABG in elderly women.

Chest wall infarction following bilateral internal mammary to coronary arterial bypass in a patient with a thoracoabdominal aneurysm.

A 69-year-old man with severe peripheral vascular disease and a known thoracoabdominal aortic aneurysm underwent bilateral internal mammary artery (BIMA) to coronary artery bypass grafting and aortic hemiarch replacement. He immediately thereafter developed massive chest wall ischemia and infarction with a severe metabolic acidosis, and subsequently died. Chest wall infarction following BIMA harvesting has not been previously described. Cautious use of internal mammary arterial grafting may be in order in the severe vasculopath with significant thrombo-occlusive thoracoabdominal aortic disease.

Reinfusion of mediastinal blood in CABG patients: impact on homologous transfusions and rate of re-exploration.

BACKGROUND: Reinfusion of mediastinal shed blood after cardiac surgery has been used in some centers to reduce exposure to homologous blood transfusions. The method has not been widely applied mostly because some studies have failed to demonstrate a significant benefit. METHODS: A group of 675 consecutive patients undergoing first-time, isolated coronary artery bypass surgery (CABG) was studied. Prospective data was collected on the first 375 patients receiving autotransfusion (ATS) of mediastinal shed blood. The charts of 338 patients immediately preceding the institution of the ATS program at our institution (NO ATS group) were retrospectively reviewed. Transfusion of homologous blood products and rate of re-exploration for bleeding were closely monitored. RESULTS: The two groups were identical. The net blood loss was significantly less in the ATS group than in the NO ATS group (1013 +/- 431 cc vs 1371 +/- 631 cc, p < 0.0001). Rate of exploration for postoperative bleeding was 1.5% in the ATS group and 5.0% in the NO ATS group (p < 0.01). In the ATS group, 51.9% of patients were not exposed to any homologous blood product (vs 17.8% in the NO ATS group, p < 0.0001). The ATS patients received on the average 2.9 +/- 7.2 units of blood products versus 6.4 +/- 9.7 units in the NO ATS group (p < 0.0001). CONCLUSION: Reinfusion of mediastinal shed blood significantly reduces exposure to homologous blood transfusions and rate of reexploration. The ATS system reduces the number of re-explorations for coagulopathy-related postoperative hemorrhage.

Impact of transfusion of mediastinal shed blood on serum levels of cardiac enzymes.

BACKGROUND: Infusion of shed mediastinal blood using an autotransfusion system is a widely applied technique of blood conservation in cardiac surgery. Serial determinations of serum creatine kinase (CK), its MB isoenzyme (CK-MB), and lactate hydrogenase (LDH) levels have been used to monitor perioperative myocardial injury. We investigated the impact of postoperative autotransfused blood infusion on serum levels of these enzymes. METHODS: We performed a retrospective analysis of postoperative serum CK, CK-MB, and LDH levels of 300 patients who had elective uncomplicated aortocoronary bypass grafting. Shed mediastinal blood samples from 26 patients were analyzed for CK, CK-MB (enzymatic activity and mass), and LDH levels before infusion. RESULTS: High postoperative serum levels of CK and LDH were observed after infusion of autotransfused blood. Shed mediastinal blood contained extremely high levels of these enzymes, particularly from patients who had internal mammary artery dissection. There was a strong correlation (r = 0.96) between measured CK-MB enzyme activities and those calculated from the CK-MB mass units. CONCLUSIONS: Infusion of autotransfused blood containing high concentrations of CK and LDH results in elevated serum levels of these enzymes. Hemolysis, frequently present in shed blood, does not interfere with the routine biochemical assays for CK and CK-MB enzyme activities. Caution should be taken when postoperative cardiac enzyme levels are used to determine myocardial injury after aortocoronary bypass grafting if autotransfusion is used as a method of blood conservation.

Atrial myxomas in young children: an alternative surgical approach.

A case report and a brief review of the literature on atrial myxomas in young children (5 years and younger) are presented. Right atrial myxomas are predominant in this age group in contrast to older children and adults. The echocardiogram alone can provide clear anatomic information for the operation. For large left atrial myxomas, wide exposure through a transverse biatrial incision is recommended to avoid tumor manipulation and facilitate en bloc resection.

Perioperative care of the elderly patient.

Surgical risk increases with age, primarily from loss of cardiac and pulmonary reserve. Complications are tolerated poorly by the elderly, emphasizing the importance of their prediction and prevention. Surgical risk in this population is significant, but with careful preoperative assessment and perioperative management acceptable morbidity and mortality are possible. This review proposes a general approach to the elderly surgical patient and applies it to the most significant sources of morbidity and mortality: pulmonary and cardiac complications. Risk assessment based on validated tools is utilized, and perioperative management recommendations based on the state of the art are examined. In addition, pulmonary embolism and postoperative confusion are examined separately with the same overall strategy.

Evaluation of pulmonary function in laparoscopic cholecystectomy.

Historically, values of pulmonary function tests, when taken on the day after open upper abdominal surgery and cholecystectomy, show decreases of 45% to 60% compared with preoperative determinations. In a group of 54 consecutive patients in whom many pulmonary function parameters were studied, forced vital capacity (FVC) and forced expiratory volume in 1 s (FEV1), measured the morning after laparoscopic cholecystectomy, revealed a 22% decrease (3.31/2.59 L) and a 21% decrease (2.68/2.11 L), respectively, on average compared with preoperative values, demonstrating better pulmonary function after laparoscopic cholecystectomy. Furthermore, there was no difference between patients above or below 60 years of age and between smokers and nonsmokers. Improved pulmonary function after laparoscopic cholecystectomy may account for the observed reduced rate of pulmonary complications after laparoscopic cholecystectomy.